Breast Implant Removal/Exchange Operative Note

Date of Procedure: [Date]

Patient: [Full name]

MRN: [Medical record number]

Surgeon: [Primary surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)] (Omit if none)

Facility: [Facility name]

Anesthesia: [general / MAC / local / regional / combined]

Pre-incision Verification: Site marking and time-out performed per protocol

Preoperative Diagnosis

• [Right breast diagnosis with Baker grade/stage if applicable]
• [Left breast diagnosis with Baker grade/stage if applicable]

(List each distinct diagnosis separately with explicit laterality. Specify suspected vs confirmed rupture.)

Postoperative Diagnosis

• [Right breast updated diagnosis]
• [Left breast updated diagnosis]

(Reflect intraoperative findings. If malignancy is a consideration without pathologic confirmation, state "pathology pending.")

Procedures Performed

• [Right breast: procedure(s) performed]
• [Left breast: procedure(s) performed]

(Every unilateral procedure must specify Right or Left. Include capsulectomy extent, plane changes, mastopexy, ADM use as applicable.)

Indications

[Indication for surgery including symptoms, functional/cosmetic concerns, and whether revision of cosmetic augmentation or reconstruction] (Include one to two sentences on prior interventions if relevant.)

Operative Findings

Right Breast

• Pocket/plane at start: [subglandular / subpectoral / dual-plane / prepectoral]
• Capsule: [Thickness, calcifications, discoloration, suspicious areas]
• Contracture grade: [Baker I / II / III / IV] (Omit if not assessed)
• Fluid/seroma: [Volume in mL and character] (Omit if none)
• Implant status: [intact / ruptured—intracapsular / ruptured—extracapsular]
• Pocket abnormalities: [Malposition, animation deformity, other findings] (Omit if none)

Left Breast

• Pocket/plane at start: [subglandular / subpectoral / dual-plane / prepectoral]
• Capsule: [Thickness, calcifications, discoloration, suspicious areas]
• Contracture grade: [Baker I / II / III / IV] (Omit if not assessed)
• Fluid/seroma: [Volume in mL and character] (Omit if none)
• Implant status: [intact / ruptured—intracapsular / ruptured—extracapsular]
• Pocket abnormalities: [Malposition, animation deformity, other findings] (Omit if none)

Global Findings

[Bilateral observations: hemostasis status, chest wall integrity, absence of gross infection, other relevant findings]

Removed Implant(s)

• Side: [R / L]; Type: [silicone implant / saline implant / tissue expander]; Manufacturer/Model: [Name or unknown]; Size: [cc]; Surface: [smooth / textured]; Shape: [round / anatomic]; Serial/Lot/UDI: [Value / recorded in implant log / stickers attached to chart—addendum to follow]; Plane at removal: [subglandular / subpectoral / prepectoral]; Condition: [intact / ruptured—intracapsular / ruptured—extracapsular]; Saline fill: [Aspirated volume in mL] (Include for saline implants only)

(Create separate entry for each removed implant. Do not fabricate identifiers—reference implant log or addendum if unavailable at dictation.)

New Implant(s) Placed

• Side: [R / L]; Manufacturer/Model: [Name/model]; Type: [implant / expander]; Size: [cc]; Surface: [smooth / textured]; Shape: [round / anatomic]; Serial/Lot/UDI: [Value]; Final plane: [subglandular / subpectoral / prepectoral]; Final fill volume: [mL] (For saline or expanders); Insertion technique: [no-touch/funnel / standard]

(Omit this entire section for explantation-only cases.)

Capsule Management

• Right: [no capsulectomy / partial capsulectomy / total capsulectomy / total intact capsulectomy / en bloc capsulectomy]; [capsulotomy / capsulorrhaphy / plane change if performed]. Rationale: [One-line explanation for chosen approach]
• Left: [no capsulectomy / partial capsulectomy / total capsulectomy / total intact capsulectomy / en bloc capsulectomy]; [capsulotomy / capsulorrhaphy / plane change if performed]. Rationale: [One-line explanation for chosen approach]

(Use "en bloc" only if performed for suspected or established capsular malignancy with margin of uninvolved tissue.)

Description of Procedure

Preparation and Positioning: [Patient positioning, prophylaxis measures, prep and drape technique]

Incision Approach: [inframammary fold / periareolar / prior scar / other]

Right Breast

[Dissection to pocket, capsule entry, seroma management if present]

[Implant removal technique; describe gel removal and pocket debridement if ruptured]

[Capsule management technique, extent, areas left in situ with justification, hemostasis method]

[Pocket modifications: capsulotomy, capsulorrhaphy, plane change, ADM/mesh if used; irrigation solution]

[New implant placement if applicable: sizer use, selection rationale, insertion technique, final position]

[Drain placement if used: type and location; layered closure with suture materials; dressing/garment applied]

Left Breast

[Dissection to pocket, capsule entry, seroma management if present]

[Implant removal technique; describe gel removal and pocket debridement if ruptured]

[Capsule management technique, extent, areas left in situ with justification, hemostasis method]

[Pocket modifications: capsulotomy, capsulorrhaphy, plane change, ADM/mesh if used; irrigation solution]

[New implant placement if applicable: sizer use, selection rationale, insertion technique, final position]

[Drain placement if used: type and location; layered closure with suture materials; dressing/garment applied]

[Intraoperative events: unexpected findings, conversion from exchange to removal-only, complications and management] (Omit if none)

Specimens

• [Right / Left]: [Specimen source] → [histopathology / cytology / microbiology / gross only]
• [Explanted implants]: [sent to pathology / returned to patient per policy]

(For late seroma or concern for BIA-ALCL, note fluid sent for cytology with CD30 immunophenotyping and capsule sent for histopathology.)

EBL, Drains, Counts, Complications

EBL: [mL value / minimal]

Drains:

• [Right: drain type, location, secured with suture type] (Omit if no drain placed)
• [Left: drain type, location, secured with suture type] (Omit if no drain placed)

Counts: [Sponge, needle, and instrument counts correct / discrepancy with resolution]

Complications: [None / description of event, suspected cause, management, and outcome] (Always document—state "None" if none)

Disposition and Plan

Condition: [stable / transferred to PACU / other]

• [Drain care and removal criteria]
• [Pain management plan]
• [Activity restrictions and garment instructions]
• [Incision care and showering guidance]
• [Follow-up timing]
• [Pathology follow-up plan] (Include if specimens sent; if malignancy workup pending, note reconstruction plan staged pending results)