Excision of gynaecomastia (Webster subareolar mastectomy)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• haematoma needing return to theatre
• seroma needing aspiration
• saucer (donut) deformity or nipple inversion
• loss of sensation or necrosis of the nipple and areola
• asymmetry and contour irregularity
• visible periareolar scar
• residual tissue or recurrence
• wound infection

Pre-operative details for this operation

1. SideBilateralRightLeft
2. GradeSimon 1Simon 2aSimon 2bSimon 3and whether mainly glandular, fatty or mixed
3. Duration and cause looked formonths present, drugs, anabolic steroids, liver or kidney disease, testes examined, hormone tests if done
4. ImagingUSG or mammogram: disc of subareolar tissue, no suspicious mass
5. Standing markingsmidline, sternal notch, NAC, inframammary fold, border of pectoralis major, area of excess tissue
6. Clinical photographs takenYes, with consent

Anaesthesia and position

1. AnaesthesiaGeneralLocal with sedation (small unilateral)
2. PositionSupine, arms abducted
3. Infiltrationsolution and volume, if used (e.g. wetting solution before liposuction)

Operative findings

1. Tissue removedeach side: glandular / fatty / fibrous, size and weight
2. Disc under the NACfirm disc of gland, any discrete lump
3. Skin excess after excisionNoneMild, expected to retractMarked

Procedure (steps)

1. IncisionInferior hemi-periareolar (Webster)TransareolarSmall access incision for pull-throughWise / vertical pattern (skin excess)arc and length
2. LiposuctionNot doneSuction-assistedPower-assistedUltrasound-assistedport site, wetting solution volume, aspirate volume each side
3. Areolar skin flap raisedin a deep enough plane to keep areolar blood supply
4. Gland dissected off skin and pectoral fasciascissors / cautery, fat over the pectoral fascia kept
5. Tissue left under the NACthickness left, to prevent saucer deformity
6. Gland removedweight each side, marked for side
7. Contour and symmetry checkededges feathered if needed
8. Haemostasis and washcautery, saline irrigation

Closure, drains and dressing

1. DrainNoneSuction drain each side (size)exit site
2. Subcutaneous layere.g. polyglactin 910 (Vicryl) 3-0
3. Skine.g. subcuticular poliglecaprone (Monocryl) 3-0, or polypropylene 3-0
4. CompressionCompression dressingCompression garment
5. Nipple and areola colour at endPink both sidesDusky (action taken)

Specimens and implants

1. Breast tissue sent for HPEYes, right and left in separate labelled jarsweight each side

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Watch for haematomaswelling, tense chest, drain filling with blood: inform at once
2. Drainschart each side, remove when under 20 ml in 24 hours for two days
3. Compression garmentday and night for 3 weeks except bath, total 4 to 6 weeks
4. Analgesiadrug, dose, frequency
5. Diet and mobilisationorally when awake, walk same day
6. Bathshower from POD 1 if dressing allows
7. Arm movementas advised by the surgeon, record the plan
8. Follow-upwound check and HPE report at about 2 weeks

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery