Operative Report Sample:
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|DATE OF OPERATION:||
|PREOPERATIVE DIAGNOSIS:||Bilateral ectropion with recurrent ptosis of the left eye.|
|POSTOPERATIVE DIAGNOSIS:||Bilateral ectropion with recurrent ptosis of the left eye.|
||Bilateral ectropion repair with upper blepharoplasty of the left eye.|
|SURGEON:||Harry Richard, M.D.|
|ANESTHESIA:||Local with monitored anesthesia care.|
|SPECIMEN:||Skin fat excised.|
|ESTIMATED BLOOD LOSS:||Less than 5 cc.|
DESCRIPTION OF THE PROCEDURE: The patient was taken to the Operating Room and was placed in a recumbent position. A time out was conducted in which the patient’s identity, surgical eyes and procedure was verified by the surgeon, circulating nurse and scrub nurse. Using a Colorado needle, an initial incision in the lower eyelid margin on the premarked skin area was performed. The skin was undermined and bleeding vessels were carefully cauterized with a held cautery. The spectrum was opened and excess fat was removed and a lateral tarsorrhaphy was performed as well. The skin was closed with 6-0 plain suture. On the left upper eyelid, we also used a Colorado needle to make an initial elliptical incision on the premarked area of the skin. The skin was removed and it was closed with 6-0 Prolene suture. At the endo f the procedure, we gave 1 gm of Ancef and 8 mg of Decadron intravenously. The patient was sent to the Recovery Room without any complications where he received postoperative instructions and follow up appointments.