Blepharoplasty Operative Note

Operative Note: Blepharoplasty

Procedure Date: [Date]

Facility/Location: [Facility name and location]

Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) / None]

Anesthesia: [local only / local with sedation (MAC) / general]

Preoperative Diagnosis: [Diagnosis with explicit laterality]

Postoperative Diagnosis: [Diagnosis with explicit laterality]

Procedure(s) Performed: [List each procedure with explicit laterality and upper vs lower designation, e.g., "Upper eyelid blepharoplasty, right" or "Lower eyelid blepharoplasty, bilateral, transconjunctival approach"]

Procedure Start Time: [Start time]

Procedure End Time: [End time]

Indication and Pertinent Preoperative Findings

[Indication: functional / reconstructive / cosmetic]. [Key clinical findings driving the surgical plan]. (For functional cases, include findings supporting medical necessity such as dermatochalasis severity, visual field impact, and symptomatic complaints. Include relevant periocular findings: lid crease position, fat pad prominence, lid laxity, ocular surface risk factors. If a detailed preoperative examination is documented in a separate clinic note, reference that note by date rather than duplicating findings.)

Consent and Safety Verification

Informed consent obtained with risks, benefits, and alternatives discussed. Surgical site marked. Time-out performed confirming correct patient, procedure(s), and laterality.

Procedure Description

Patient positioned supine. Standard prep and drape performed. [Local anesthetic agent, concentration, epinephrine status, approximate total volume]. Corneal protection: [lubricating ointment / corneal shields placed / other method]. Incision markings made preoperatively with patient upright: [yes / no].

Upper Eyelid Blepharoplasty

(Include this section only if upper eyelids were addressed. Document each side separately with explicit laterality.)

Right Upper Eyelid: (Include only if performed)

• Incision design: [crease-based / other]; [ellipse configuration]; lateral extension: [none / minimal / to lateral canthus / beyond lateral orbital rim]
• Skin excision approach: [skin-only / skin-muscle flap]; approximate amount removed: [measurement or description]
• Orbicularis management: [preserved / strip excision]
• Septum: [opened / preserved]
• Fat management: medial pad [excised / sculpted / repositioned / not addressed]; central pad [excised / sculpted / repositioned / not addressed]
• Lacrimal gland: [normal position / prolapsed — repositioned and secured / prolapsed — observed]
• Hemostasis: [method]
• Crease reformation: [performed with technique / not performed]
• Closure: [suture type, running vs interrupted, skin adhesive if used]

Left Upper Eyelid: (Include only if performed)

• Incision design: [crease-based / other]; [ellipse configuration]; lateral extension: [none / minimal / to lateral canthus / beyond lateral orbital rim]
• Skin excision approach: [skin-only / skin-muscle flap]; approximate amount removed: [measurement or description]
• Orbicularis management: [preserved / strip excision]
• Septum: [opened / preserved]
• Fat management: medial pad [excised / sculpted / repositioned / not addressed]; central pad [excised / sculpted / repositioned / not addressed]
• Lacrimal gland: [normal position / prolapsed — repositioned and secured / prolapsed — observed]
• Hemostasis: [method]
• Crease reformation: [performed with technique / not performed]
• Closure: [suture type, running vs interrupted, skin adhesive if used]

Lower Eyelid Blepharoplasty

(Include this section only if lower eyelids were addressed. Document each side separately with explicit laterality.)

Right Lower Eyelid: (Include only if performed)

• Approach: [transconjunctival preseptal / transconjunctival retroseptal / transcutaneous subciliary]
• Skin management: [none / pinch excision with amount]
• Orbicularis management: [preserved / tightened / partial excision] (if applicable)
• Fat management: medial pad [excised / repositioned / not addressed]; central pad [excised / repositioned / not addressed]; lateral pad [excised / repositioned / not addressed]
• Arcus marginalis release: [performed / not performed]; fat transposition over orbital rim: [yes / no]
• Lid laxity: [normal / lax — canthal support performed (see below) / lax — canthal support not indicated]
• Closure: [conjunctival left to heal by secondary intention / conjunctival suture / skin closure technique and suture type]

Left Lower Eyelid: (Include only if performed)

• Approach: [transconjunctival preseptal / transconjunctival retroseptal / transcutaneous subciliary]
• Skin management: [none / pinch excision with amount]
• Orbicularis management: [preserved / tightened / partial excision] (if applicable)
• Fat management: medial pad [excised / repositioned / not addressed]; central pad [excised / repositioned / not addressed]; lateral pad [excised / repositioned / not addressed]
• Arcus marginalis release: [performed / not performed]; fat transposition over orbital rim: [yes / no]
• Lid laxity: [normal / lax — canthal support performed (see below) / lax — canthal support not indicated]
• Closure: [conjunctival left to heal by secondary intention / conjunctival suture / skin closure technique and suture type]

Canthopexy/Canthoplasty

(Include this section only if canthal procedure performed.)

Laterality: [right / left / bilateral]

Procedure: [suture canthopexy / lateral tarsal strip canthoplasty / other technique]

• Indication: [laxity / negative vector / ectropion prophylaxis / other]
• Technique: [brief description of steps performed]
• Fixation: [suture type] secured to [periosteum at Whitnall's tubercle / lateral orbital rim / other fixation site]
• Lid position assessment: [good apposition / appropriate tension / symmetric]

Concurrent Procedures

(Include only if additional procedures performed.)

• [Procedure type] — [laterality] — [brief technique description]

Findings, Specimens, and Materials

• Intraoperative findings: [tissue characteristics, scarring, asymmetry, unexpected findings, or "unremarkable"]
• Tissues removed or altered: [skin, muscle, fat by compartment — specify excised vs repositioned]
• Specimens to pathology: [type, site, side, and labeling / None]
• Implants or devices: [type and location / None]

EBL and Complications

Estimated Blood Loss: [volume in mL / minimal]

Complications: [None / description with management and outcome]. (If any of the following occurred, document specifically: suspected globe injury, orbital hemorrhage or compartment concern, extraocular muscle involvement, corneal abrasion.)

End of Procedure and Disposition

• Hemostasis: adequate
• Corneal shields: [removed and confirmed / not used]
• Patient condition: [stable / returned to baseline]
• Disposition: [PACU / recovery area / direct discharge]
• Vision check: [performed at end of case with result / deferred to recovery / to be assessed when patient fully alert]
• Recovery team instructions: [specific monitoring instructions if any]

Postoperative Precautions

Return precautions reviewed with patient, including urgent contact for: vision change, severe or worsening pain, proptosis, tense orbital swelling, uncontrolled bleeding, or new diplopia. [Reference to standardized postoperative instruction sheet if provided.]