Facelift/Neck Lift Operative Note

(General generation rules: Omit sections for components not performed. Do not infer values for EBL, drains, specimens, or complications—include only if explicitly dictated. For bilateral procedures, describe both sides together unless asymmetric technique/findings require separate right/left documentation. SMAS technique documentation is required for any facelift—prompt if not dictated.)

Patient: [Patient full name], [DOB], [MRN]

Date of Surgery: [Date of surgery]

Facility: [Facility name]

Primary Surgeon: [Surgeon name, credentials]

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

Anesthesia: [general / MAC with local / local] provided by [Anesthesia provider and credentials]

Diagnoses and Procedures

Preoperative Diagnosis: [Clinical descriptors of facial/cervical aging] (Use concise clinical terms; include severity if stated)

Postoperative Diagnosis: [Diagnosis] (Usually same as preoperative; document unexpected findings if different)

Procedures Performed: [Comprehensive list of procedures with specific technique descriptors]

Indication: [Brief statement of patient concerns/goals and indication for surgery; confirmation of informed consent]

Intraoperative Summary

• Findings: [High-yield anatomic observations with severity and specifics as stated]
• EBL: [Estimated blood loss in mL or "minimal"] (Do not infer; must be explicitly dictated)
• Specimens: [Specimen(s) sent with description and destination] (Omit if none)
• Drains: [Type, size, number, locations, exit sites] (Omit if none)
• Complications: [Intraoperative complications or "None"]
• Counts: [correct / incorrect] (If incorrect, document reconciliation actions)
• Disposition: [Destination and patient condition on transfer]

Procedure Details

(Document in chronological order. For bilateral procedures, describe together if symmetric; if asymmetric, document right and left separately with explicit differences.)

Preoperative Marking and Verification: [Incision plan marked in upright position: temporal extension, pretragal vs posttragal approach, lobule contour strategy, postauricular extension, hairline considerations, submental incision if planned]. [Time-out/verification completed with patient, procedure, site, and laterality confirmed].

Positioning and Preparation: [Patient position]. [Skin prep solution and areas prepped/draped]. [Local anesthetic/tumescent infiltration: solution composition, concentration, total volume, and planes infiltrated].

Incisions and Flap Elevation: [Incisions executed by anatomic location: temporal, preauricular, tragal, lobule, postauricular, hairline extension, submental as applicable]. [Dissection plane: subcutaneous / sub-SMAS / deep plane]. [Extent of undermining using anatomic landmarks]. [Hemostasis technique]. (If bilateral with asymmetric findings, specify side-specific details.)

SMAS Management: [Specific SMAS technique: plication / imbrication / SMASectomy / extended SMAS flap / deep-plane dissection / MACS lift / skin-only without SMAS modification]. [Vectors of suspension and fixation points]. [Suture material and configuration]. (Required for any facelift; if not dictated, prompt for this information.)

Neck Lift / Platysma Management: [Submental access and neck flap elevation]. [Liposuction details: cannula size, planes treated, total aspirate volume]. [Fat management: supraplatysmal/subplatysmal excision; adjunct maneuvers]. [Platysma technique: midline corset platysmaplasty extent, lateral suspension, fixation points, sutures]. (Include only if neck work performed; omit section entirely if not.)

Hemostasis and Symmetry: [Irrigation performed]. [Hemostasis confirmed; hemostatic agents or sealants if used]. [Symmetry assessment with standardized head position]. [Skin redraping with conservative trimming approach].

Closure: [Closure by anatomic region and layer: SMAS if incised, deep dermal, skin]. [Techniques for complication prevention: lobule inset strategy, tragal approach, tension-free skin closure, hairline preservation]. [Suture types/sizes for key cosmetic areas].

Dressings: [Topical ointment, adhesive strips, compressive wrap/garment, chin strap, drain dressings, bolsters] (Include only those used)

Postoperative Plan

• Head elevation and activity: [Restrictions and instructions]
• Drain care: [Output monitoring and removal criteria] (Include only if drains placed)
• Wound care: [Incision care, bathing/shower guidance, garment use]
• Medications: [Antibiotics if prescribed, analgesia, other medications]
• Follow-up: [Timing of first and subsequent visits]
• Return precautions: [Expanding hematoma, persistent bleeding, respiratory difficulty, severe unilateral pain, asymmetric swelling, facial weakness, fever]

Attestation

[Surgeon signature], [Date/Time]