Cutaneous Reconstruction Operative Note (Flap/Graft)

Date: [Procedure date]

Patient: [Patient name, MRN, DOB]

Location: [Clinic procedure room / ASC / OR]

Surgeon: [Operating surgeon name]

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

Related Case: [Reference to same-day Mohs case or prior excision note / N/A]

Preoperative Diagnosis

[Indication for reconstruction] (State post-Mohs or post-excision defect with recipient site, laterality, and cosmetic subunit when relevant. Note functional or anatomic constraints influencing reconstruction choice.)

Postoperative Diagnosis

[Diagnosis] (Typically mirrors preoperative diagnosis; update only if intraoperative findings differ.)

Procedure(s) Performed

[Standardized procedure name(s)] (For flaps: specify type such as advancement, rotation, transposition, bilobed, rhombic, V-Y, or island pedicle with recipient site. For grafts: specify FTSG, STSG, or composite with recipient and donor sites.)

Anesthesia

[Anesthesia type] with [agent(s), concentration(s), volume(s), additives] (If administered by another provider, note provider. Do not infer agents, concentrations, or volumes not stated. If missing, insert [COMPLETION REQUIRED: Anesthesia details].)

Consent and Safety Verification

Written informed consent obtained. Time-out performed confirming patient, procedure, site, and laterality.

Operative Data Summary

• Defect origin: [Mohs / excision]
• Recipient site: [Anatomic location with laterality and subunit]
• Defect dimensions: [Length × width in cm] (If missing, insert [COMPLETION REQUIRED: Defect dimensions])
• Defect depth: [Subcutaneous fat / perichondrium / periosteum / muscle / other]
• Reconstruction type: [Local flap / skin graft / combined] (If missing, insert [COMPLETION REQUIRED: Reconstruction type])

If local flap performed: (Omit this block if flap not performed.)

• Flap type: [Advancement / rotation / transposition / bilobed / rhombic / V-Y / island pedicle / other]
• Flap dimensions: [Length × width in cm or mobilized area]
• Undermining plane: [Subcutaneous / sub-SMAS / subperiosteal / other]

If skin graft performed: (Omit this block if graft not performed.)

• Graft type: [FTSG / STSG / composite]
• Graft dimensions: [Length × width in cm or area]
• Donor site: [Anatomic location]
• Donor closure: [Primary closure / secondary intention / other]
• Bolster applied: [Yes with type / no]

• Hemostasis: [Pressure / electrocautery / topical agents / combination]
• Closure: [Layered / single-layer] with [suture material by layer]
• Dressing: [Materials applied]
• EBL: [Volume in mL / minimal]
• Complications: [None / description]
• Specimens: [None / description]

Operative Description

[Positioning, preparation, and draping] (State patient positioning, skin preparation solution, and sterile draping.)

[Defect assessment and reconstruction rationale] (Restate location and measurements. Comment on tissue laxity, tension vectors, proximity to free margins. Briefly justify reconstruction choice.)

Local flap technique: (Include only if flap performed.)

[Flap design and execution] (Describe flap design and orientation, incision and elevation plane, extent of undermining, hemostasis method, flap inset, layered closure with suture types and sizes, management of standing cones or Burow triangles if performed, and assessment of flap perfusion.)

Skin graft technique: (Include only if graft performed.)

[Graft harvest and placement] (Describe recipient bed preparation, donor site harvest with location and technique, donor closure, graft preparation including defatting or fenestration if performed, graft placement and fixation, and bolster application if used.)

[Dressing application] (Detail nonadherent layer, absorbent layer, and pressure wrap or protective covering as applied.)

Postoperative Condition

[Patient tolerance and immediate status] (Document patient tolerance, stability, immediate wound status including hemostasis and flap perfusion or graft security, and disposition.)

Postoperative Plan

• Dressing care: [When to remove outer dressing; for grafts, keep bolster intact until follow-up]
• Wound care: [Cleansing method, ointment, rebandaging instructions]
• Activity: [Restrictions on lifting, exercise, pressure; sleeping position if relevant]
• Warning signs: [Increasing redness, warmth, drainage, fever; for flaps/grafts: dusky color, expanding necrosis, increasing pain]
• Medications: [Drug, dose, route, frequency, duration if prescribed / none]
• Pain management: [Acetaminophen and/or NSAID guidance]
• Follow-up: [Appointment timing, suture removal schedule, bolster removal for grafts]
• Contact: [After-hours contact information]

Signature

[Surgeon signature with date and time]