Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:   03/08/10
PREOPERATIVE DIAGNOSIS: Dermatochalasis OU.     
POSTOPERATIVE DIAGNOSIS: Dermatochalasis OU.  
OPERATIVE PROCEDURE: Bilateral upper lid blepharoplasty. 
SURGEON: Harry Richard, M.D.
ANESTHESIA: Local with Monitored Anesthesia Care. 
COMPLICATIONS: None. 


HISTORY OF PRESENT ILLNESS:
  Patient was taken from the preoperative area to the Operating Room and placed in the supine position.  A time-out was taken and surgery was verified.  Patient was then prepped and draped in the usual sterile fashion for ocular plastic surgery.  A skin marker was then used to delineate the left upper lid crease along its lateral border.  This was also done on the right upper lid.  Green’s forceps were then used to grasp the tissue superior to the lid crease.  The appropriate amount was grasped for planned removal.  This area was then marked along the superior edge.  The inner aspects of the markings were then joined and the lateral aspects of the markings were also joined.  Close attention was paid to insure that no lagophthalmos was created.  At this point, lidocaine 2.0% with epinephrine was then injected locally under the premarked skin area, on the left upper lid as well as the right upper lid.  Cool compresses were placed on the lids.  Attention was first paid to the left side where a #15 blade was then used to incise the skin along the area that was premarked.  The skin was then initially removed using  Westcott, and 0.12 and then with a Bovie.  Hemostasis was achieved using the Bovie cautery as well.  Then 6-0 Prolene suture was then used to close the incision with a running subcuticular stitch pattern.  The ends were bolstered with small pieces of rubber band and tied to the Prolene suture. The wound was noted to be well approximated.  No lagophthalmos was appreciated.  The same technique was performed on the right upper lid with no lagophthalmos appreciated as well.  Maxitrol and cold compresses were placed.  Patient tolerated the procedure without any complications.  Patient was instructed to take oral antibiotics and Topical TobraDex and follow up in one week with Dr. Lazcano in the eye clinic.