advancement flap

LaceyCanon

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Conway, AR
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Can anyone help with this procedure, I asked the doc if the raising of the skin flaps was an advancement flap and all he did was do an addendum to his note stating it was a complex repair.

lOPERATIVE FINDINGS:
A 3 cm leg cyst was excised and closed primarily.* A 2 cm left shoulder cyst was excised and closed primarily and a 3 cm back skin cyst was excised and closed primarily.* The back wound was a 15 x 5 x 3 cm lesion, which involved the underlying fascia and latissimus muscle.* This was completely excised.* Skin flaps were raised and then a complex 15 cm closure performed.

HISTORY:
The patient is a 43-year-old male who presents with initially an infected sebaceous cyst on his back.* He underwent an I and D.* Initially, wet to dry dressings were started.* He eventually required debridement in clinic.* Pathology from this showed a benign proliferating epidermal cyst, which is more likely to develop carcinomatous changes.* We discussed close monitoring as we allowed this wound to heal.* However, an adjacent sebaceous cyst has become infected and also turned into an abscess and ruptured into the initial wound creating a much larger complex wound.* He has another adjacent back cyst as well as a cyst on his shoulder and left knee that he would like excised at the same setting.

DESCRIPTION OF PROCEDURE:
Written informed consent was obtained.* All planned lesions were marked with the patient awake, he was then taken from the preop staging area to the operating suite.* General endotracheal anesthesia was introduced.* He was then transferred to the operating room table in the prone position.* All pressure points were padded appropriately.* The left shoulder, back and left leg about the lateral portion of the knee were prepped and draped in normal sterile fashion.* Time-out was called.* I started with the left leg excision and a longitudinal ellipse was made with a 15 blade scalpel over the lesion.* The lesion was then excised with a scalpel.* Hemostasis was obtained at the base with electrocautery.* The wound was then irrigated with peroxide followed by saline.* Hemostasis ensured and then closed with interrupted 3-0 Vicryl sutures followed by Mastisol, Steri-Strips and Medipore dressing.* We turned our attention next to the left shoulder and local anesthetic was used and then a 3 cm x 1 cm ellipse of skin incised with a 15 blade scalpel.* A 2 cm skin cyst was then completely excised using a scalpel and electrocautery.* I then irrigated the wound thoroughly with peroxide followed by saline.* Hemostasis ensured with cautery and then the wound closed with interrupted 3-0 Vicryl sutures.* The wound was dressed with Mastisol, Steri-Strips, and a Medipore dressing.* We then turned our attention to the final back skin cyst.* This was excised again with a 3 cm x 1 cm ellipse after first anesthetizing the skin.* The incision was made as above and the cyst excised in total.* The wound was irrigated with peroxide and saline followed by hemostasis using cautery and then closed with interrupted 3-0 Vicryl sutures, Mastisol, and Medipore dressing.* We finally turned our attention to the largest wound, a 15 x 5 cm ellipse was incised for complete excision of the infected and sebaceous cyst.* This was performed with a 10 blade scalpel.* I then used cautery to deepen the incision to the underlying fascia as we excised the mass.* The midportion mass that had ruptured below the fascia and into the latissimus muscle.* This was taken with the specimen.* Once the specimen was completely excised, it was marked with a short stitch superior and a long stitch lateral.* I then used skin rakes to raise superior and inferior skin flaps approximately 5 cm to close the wound under no tension. I then irrigated the wound thoroughly with peroxide.* We then irrigated with saline and then ensured hemostasis with electrocautery.* We then closed in layers 1st with interrupted 3-0 Vicryl sutures for the subcutaneous tissues and deep dermis.* The skin was then closed with interrupted 2-0 nylon vertical mattress sutures.* This gave a 15 cm complex transverse closure.* We did use approximately 30 mL of local anesthetic for the wound.* The wound was then dressed with a Medipore dressing.* The patient was transferred back to the supine position, awoken from anesthesia and taken to the recovery room in stable condition.* All lap, sponge, instrument, and needle counts were correct prior to completion of our case
 
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