Breast Augmentation Operative Note

Date of Procedure: [Date]

Preoperative Diagnosis: [Preoperative diagnosis with explicit laterality]

Postoperative Diagnosis: [Postoperative diagnosis with explicit laterality] (State "same" only if truly unchanged.)

Procedure(s) Performed: [Standardized procedure name(s) with explicit laterality; list implant augmentation and fat grafting as separate procedures if both performed]

Surgeon: [Primary surgeon name, credentials]

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

Anesthesia: [general endotracheal / general LMA / MAC with local / local only] (Include adjunct blocks if performed.)

Indication and Findings

[Brief clinical context and indication for augmentation in 1–3 sentences, including goals and relevant constraints.]

Operative findings: [Breast tissue characteristics, soft-tissue envelope, skin quality, asymmetry addressed, chest wall features, capsule characteristics if revision, and other relevant intraoperative findings.]

Synoptic Summary

• EBL: [Estimated blood loss in mL] (Provide numeric estimate even if minimal.)
• Drains: [Type/size, location, laterality / None]
• Specimens: [Specimen description with laterality and label as submitted / No specimens]
• Complications: [Event, severity, intraoperative management, and patient status / None]
• Counts: [Sponge/sharps/instruments correct / Discrepancy occurred — reconciliation actions and outcome]

Consent and Safety Verification

[Informed consent obtained with discussion of risks, benefits, and alternatives.] [Surgical site marking verified and time-out completed confirming patient identity, procedure, laterality, and implants/devices.]

Operative Technique

Setup: [Patient positioning, padding, warming measures; skin prep agent and draping; incision markings confirmed.] [Local infiltration agent(s), concentration(s), and total volume per site if used.] (Include local details especially if large total doses.)

Right Breast: [Incision/approach.] [Dissection path to pocket.] [Pocket plane/type with dual-plane subtype if applicable.] [Pocket boundary adjustments as performed.] [Capsule work if revision.] [Hemostasis method.] [Pocket irrigation solution and additives.]

Left Breast: [Incision/approach.] [Dissection path to pocket.] [Pocket plane/type.] [Pocket boundary adjustments.] [Capsule work if revision.] [Hemostasis method.] [Pocket irrigation solution and additives.] (Mirror Right Breast structure for direct comparison; document any differences in technique or findings.)

Sizing and Symmetry Assessment: [Sizers used per side with volumes (cc) and rationale for final selection.] [Patient position during assessment.] [Symmetry checks performed: IMF alignment, nipple-to-IMF distance, medial fullness, lateral contour, upper pole fullness, base width.] [Pocket adjustments performed after assessment.]

Implant Details and Placement

(For fat-only cases, state "Implants: none" and omit remainder of section.)

Right Breast Implant:

Field	Value
Laterality	Right
Manufacturer	[Manufacturer]
Product line/Model/Style	[Product line/Model/Style]
Implant type	[silicone gel / saline] [smooth / textured] [round / anatomic]
Size (cc)	[Volume]
Profile	[Profile]
Catalog number	[Catalog number]
Lot number	[Lot number]
Serial number	[Serial number]
UDI	[UDI]

Left Breast Implant:

Field	Value
Laterality	Left
Manufacturer	[Manufacturer]
Product line/Model/Style	[Product line/Model/Style]
Implant type	[silicone gel / saline] [smooth / textured] [round / anatomic]
Size (cc)	[Volume]
Profile	[Profile]
Catalog number	[Catalog number]
Lot number	[Lot number]
Serial number	[Serial number]
UDI	[UDI]

Placement technique: [Pocket plane confirmed.] [No-touch technique if used.] [Insertion method and orientation.] [Final position check and hemostasis re-confirmed.]

Autologous Fat Grafting

(For implant-only cases, state "Fat grafting: not performed" and omit remainder of section.)

Donor Site and Infiltration: [Donor site(s).] [Tumescent solution composition and total volume by site (mL).]

Harvesting: [Liposuction method, cannula size, total lipoaspirate volume (mL).]

Processing: [Processing method and final processed fat volume available (mL).]

Injection — Right Breast: [Total fat injected (cc).] [Planes/regions injected.] [Access sites and closure.] [Limitations encountered.] [Rationale if intentionally asymmetric.]

Injection — Left Breast: [Total fat injected (cc).] [Planes/regions injected.] [Access sites and closure.] [Limitations encountered.] [Rationale if intentionally asymmetric.]

Closure and Dressings

[Hemostasis confirmed.] [Layered closure for each side with suture types/sizes for each layer.] [Drain details if placed: type, laterality, exit site, securing method.] [Dressings applied and support garment/bra.] [For fat grafting: donor site entry closure and compression garment.]

Disposition

• Condition: [Patient status on transfer, airway status, pain control]
• Destination: [PACU / recovery area / home]
• Immediate Plan: [Activity restrictions, antibiotic/analgesic plan, drain care if applicable, follow-up timing]

(Meta-instructions: For EBL, drains, specimens, complications, and counts, never leave blank—use "None," "No specimens," or document events as applicable. Record all implant identifiers exactly as provided; do not infer or carry forward from prior records. Maintain explicit laterality throughout. Use objective measurements. If a complication occurred, document the event, severity, immediate management, and patient condition at transfer.)