Breast Reconstruction Operative Note

Date of Operation: [Date]

Facility/Location: [Facility and OR number]

Primary Surgeon: [Name, credentials]

Assistant(s): [Names and roles] (Omit if none.)

Anesthesia Type: [general / regional / MAC] (Include airway management and regional blocks if applicable.)

Preoperative Diagnosis: [Diagnosis with laterality]

Postoperative Diagnosis: [Diagnosis with laterality] (State "Same" if unchanged.)

Procedure(s) Performed: [Procedure title(s) with laterality and stage (e.g., Stage 1 / Stage 2 / Revision)]

Indication: [Brief statement of medical necessity for reconstruction] (1–2 sentences.)

Safety and Compliance

• Informed consent: [Verified with patient / surrogate]
• Operative site marking: [Marked / Not applicable]
• Time-out: [Completed confirming patient, procedure, laterality, and implants/materials]
• Antibiotic prophylaxis: [Agent, dose, timing / See anesthesia record]
• VTE prophylaxis: [Mechanical / Chemical / Both] [timing]

Intraoperative Summary

• Laterality: [Right / Left / Bilateral]
• Reconstruction Timing: [Immediate / Delayed / Delayed-immediate]
• Reconstructive Approach: [Implant-based / Autologous / Hybrid]
• Implant Plane/Pocket: [Prepectoral / Subpectoral / Dual-plane] (Include only if implant used.)
• Flap Type: [DIEP / MS-TRAM / SIEA / PAP / TUG / Latissimus pedicled / Other] (Include only if autologous.)
• Estimated Blood Loss: [mL]
• Drains Placed: [Number and locations]
• Specimens: [List / None]
• Complications: [None / List with brief management]
• Disposition: [Destination and condition]

Findings

(Document only clinically significant findings that influenced surgical decisions. Omit normal/expected findings.)

• [Mastectomy skin flap quality and perfusion]
• [Pocket or capsule condition]
• [Radiation changes or fibrosis]
• [Recipient vessel quality] (Autologous cases.)
• [Perfusion assessment results if performed]
• [Other findings that altered operative plan]

Counts and Hemostasis

[Sponge, needle, and instrument counts correct at case end. Hemostasis achieved.]

Wound Classification: [Class I / II / III / IV] (Include if required by facility.)

Specimens

(Omit this section entirely if no specimens were taken.)

• [Specimen name]: [Pathology / Research]; [Orientation/marking if applicable]

Implants, Devices, and Biologics

(Omit this section if no implants, expanders, ADM/mesh, or microvascular devices were used. Do not infer device identifiers—document from implant stickers or UDI scan. If unavailable, state "See implant log/UDI scan" or "Addendum pending.")

Right

• Tissue Expander or Permanent Implant
  • Device type: [Tissue expander / Permanent implant]
  • Manufacturer and product: [Manufacturer, product line]
  • Model/catalog number: [Number]
  • Size and profile: [cc], [Profile]
  • Serial/Lot/UDI: [Identifier(s) / See implant log / Addendum pending]
  • Placement plane: [Prepectoral / Subpectoral / Dual-plane]
  • Expander fill: Initial [cc]; End of case [cc] (Include only for expanders.)
• ADM/Mesh/Biologic Scaffold
  • Product and source: [Product name], [Human / Porcine / Bovine / Synthetic]
  • Dimensions: [Size]
  • Lot/tracking number: [Identifier / See implant log / Addendum pending]
  • Configuration: [Sling / Wrap / Anterior coverage]
  • Fixation: [Method and anchor points]
• Microvascular Devices (Free flap cases only.)
  • Venous coupler: [Brand], [Size mm]
  • Implantable Doppler: [Device and location] (If placed.)

Left

• Tissue Expander or Permanent Implant
  • Device type: [Tissue expander / Permanent implant]
  • Manufacturer and product: [Manufacturer, product line]
  • Model/catalog number: [Number]
  • Size and profile: [cc], [Profile]
  • Serial/Lot/UDI: [Identifier(s) / See implant log / Addendum pending]
  • Placement plane: [Prepectoral / Subpectoral / Dual-plane]
  • Expander fill: Initial [cc]; End of case [cc] (Include only for expanders.)
• ADM/Mesh/Biologic Scaffold
  • Product and source: [Product name], [Human / Porcine / Bovine / Synthetic]
  • Dimensions: [Size]
  • Lot/tracking number: [Identifier / See implant log / Addendum pending]
  • Configuration: [Sling / Wrap / Anterior coverage]
  • Fixation: [Method and anchor points]
• Microvascular Devices (Free flap cases only.)
  • Venous coupler: [Brand], [Size mm]
  • Implantable Doppler: [Device and location] (If placed.)

Drains

• Right breast: [Type (JP/Blake)], [Size], [Location], [Number]
• Left breast: [Type], [Size], [Location], [Number]
• Donor site: [Type], [Size], [Location], [Number] (Autologous cases only.)

Complications

[None] (Or list each complication with what occurred, immediate management, and outcome. For suspected events, document observations and actions without labeling as definitive complication.)

Procedure Description

(Narrate in chronological order. Use side-specific subheadings for bilateral cases.)

Positioning and Preparation

[Patient position]. [Areas prepped and draped in standard sterile fashion]. [Regional blocks if performed by surgeon: agent, concentration, volume].

Immediate Reconstruction Handoff

(Include only for immediate reconstruction.) [Handoff from ablative team including mastectomy pocket condition, hemostasis status, and skin viability assessment].

Implant-Based Reconstruction

(Include if implant-based or hybrid reconstruction.)

[Pocket assessment and preparation: plane selection, capsulotomy/capsulectomy/capsulorrhaphy as performed, hemostasis, irrigation].

[ADM/mesh placement: preparation, configuration, fixation technique] (If used.)

[Device placement: sizer use, expander or implant placement, fill volumes for expanders, port position confirmation, pocket closure technique].

[Drain placement, layered closure technique, skin closure method, dressings, support garment].

Autologous Reconstruction

(Include if autologous or hybrid reconstruction.)

Donor Site Harvest

[Flap design and type], [perforator selection], [pedicle dissection], [donor site closure including mesh with identifiers if used], [umbilical transposition for abdominal flaps], [donor site drains].

Recipient Site Preparation

[Vessel choice (internal mammary/thoracodorsal)], [exposure technique], [vessel quality assessment].

Microvascular Anastomosis

(Required for free flap cases.)

Ischemia time: [Start time] to [Reperfusion time]; Total: [minutes].

[Arterial anastomosis: hand-sewn or device-assisted, suture]. [Venous anastomosis: coupler size, number of anastomoses]. [Revisions if performed]. [Intraoperative anticoagulation if given].

Flap Inset and Shaping

[De-epithelialization], [skin paddle retention if applicable], [perfusion assessment result], [shaping technique], [breast pocket drains].

Adjunct Procedures

(Include relevant items as applicable.)

Latissimus dorsi flap: [Harvest details, tunneling/inset, donor drain, associated implant if used].

Fat grafting: [Harvest site], [processing], [volume injected per breast], [injection planes].

Contralateral symmetry procedure: [Mastopexy / Reduction / Augmentation], [technique], [specimens].

Nipple-areola reconstruction: [Technique].

Scar revision: [Location and technique].

Negative pressure incisional therapy: [Device and settings].

Postoperative Plan

• Disposition: [PACU to floor / PACU to ICU / Outpatient], [condition]
• Activity: [Mobilization plan], [arm restrictions if applicable]
• Diet: [Per ERAS pathway / Per anesthesia]
• Pain management: [Multimodal regimen per protocol]
• Antibiotics: [Regimen and duration]
• VTE prophylaxis: [Agent], [timing], [duration]
• Drain care: [Output recording], [removal criteria]
• Flap monitoring: [Frequency], [parameters (Doppler, color, capillary refill, temperature)], [escalation protocol] (Free flap cases only.)
• Wound surveillance: [Hematoma/seroma monitoring], [mastectomy skin assessment] (Implant-based cases.)
• Follow-up: [Timing], [triggers for earlier evaluation]

Signature

[Electronic signature, credentials]

[Date and time]