Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:   02/20/10
PREOPERATIVE DIAGNOSIS: Status post excision basal cell carcinoma left lower lid. 
POSTOPERATIVE DIAGNOSIS: Status post excision basal cell carcinoma left lower lid.
PROCEDURE:
Reconstruction of left lower lid with full-thickness lid repair.
SURGEON: Harry Richard, M.D.
ANESTHESIA: Local with sedation.  
COMPLICATIONS: None. 

JUSTIFICATION FOR PROCEDURE:  The patient had a previously biopsied basal cell carcinoma of the left lower lid excised by his primary care doctor earlier in the day.  This resulted in a full-thickness lid defect of the temporal 1/3 of the lid.    

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought to the Operating Room. 

A 50/50 mixture of Xylocaine 2.0% with epinephrine mixed with Marcaine 0.75% with epinephrine was injected into the left lower lid.  The face was prepped and draped in the usual sterile fashion.  There was a defect of the full-thickness lid.  This defect was created into a triangle by excising inferiorly at the base of the defect with Stevens scissors.  A 6-0 silk suture was then passed through the lid margin including tarsus, both the medial and temporal edges to oppose the two edges of the lid.  Deep 6-0 Vicryl sutures were then placed to close the deep tissues.  The skin was then closed with several more 6-0 black silk sutures which were tied down under the skin.  At the end of the procedure, the lid was in good position.  The patient tolerated the procedure well and left the Operating Room in good condition.