Maxillofacial Surgery Operative Notes

Operative Note – Maxillofacial Surgery Date: 1 November 2024 Location / Service Center: Cintocare Procedure Performed: - Open reduction and internal fixation of left mandibular angle fracture ICD-10 code: - S02.61XA Surgical Team: - Primary Surgeon: Dr. Thomas Kelly - Assistant: Dr. Sarah Jenkins Anaesthesia and Positioning: - General anaesthesia - Orotracheal intubation - 2% Lidocaine with 1:100,000 Epinephrine, 3.6 ml Surgical Approach and Technique: - A standard submandibular incision was made on the left side, approximately 2 cm inferior to the mandibular border. Dissection was carried through subcutaneous tissue and platysma. The facial artery and vein were identified and ligated. The fracture site at the left mandibular angle was exposed. Reduction was achieved using arch bars and intermaxillary fixation. A 2.0 mm titanium miniplate with four screws was applied to the inferior border of the mandible, followed by a second 2.0 mm miniplate superiorly. Final occlusion was verified. Wound closure was performed in layers. Findings and Intraoperative Observations: - Displaced, comminuted fracture of the left mandibular angle. No significant neurovascular injury observed intraoperatively. Adequate reduction and stable fixation achieved. Specimens and Devices: - Two 2.0 mm titanium miniplates with eight titanium screws (four per plate). Postoperative Instructions: - Follow-up appointment scheduled for 2 weeks post-op with Dr. Thomas Kelly for suture removal and clinical assessment. - Medications: Amoxicillin 500mg TDS for 7 days, Ibuprofen 400mg TDS PRN for pain, Chlorhexidine mouthwash BID for 14 days.