Liposuction Operative Note

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Surgery: [YYYY-MM-DD]

Start Time: [HH:MM]

End Time: [HH:MM]

Facility: [Facility name]

Surgeon: [Surgeon full name, credentials]

Assistant(s): [Assistant name(s) and role(s)]

Anesthesia Type: [general / MAC / tumescent-local / combination] (If combination, specify details.)

Preoperative Diagnosis

[Specific clinical diagnosis with laterality where applicable]

Postoperative Diagnosis

[Diagnosis] (Usually same as preoperative; if different, state what changed and why.)

Procedure(s) Performed

• [Procedure with anatomic area(s), laterality, and modality if applicable]
• [Additional procedure] (Repeat as needed. List fat grafting separately from liposuction if performed.)

Indications

[Brief statement connecting patient concerns and diagnosis to procedure selection and goals] (2–4 sentences. For cosmetic cases, document goals discussed. Do not reproduce full preoperative consultation.)

Findings

[Adiposity distribution by area, baseline asymmetry, skin quality and elasticity, fibrosis or scarring from prior procedures if present, and any unexpected findings affecting technique]

Tumescent Infiltration

Technique: [tumescent / superwet / wet / dry]

Solution Composition: [Carrier fluid (NS/LR), lidocaine concentration (%), epinephrine concentration, additives if used] (If multiple formulations were used for different areas, list each separately.)

Patient Weight: [Weight in kg]

Total Lidocaine Dose: [Total mg] ([mg/kg])

Total Epinephrine Dose: [Total amount with units]

Per-Area Infiltration:

• [Area with laterality]: [volume mL]
• [Area with laterality]: [volume mL]

Total Infiltrate Volume: [mL]

(If exact dose calculations are pending at documentation, state "Pending final reconciliation; addendum to follow.")

Technique

Access Incisions: [Location(s) and laterality of incision sites]

Modality: [SAL / PAL / UAL / LAL / WAL / combination] (For energy-assisted devices, include device name and settings used.)

Cannulas: [Diameter(s) in mm and approach for each: deep debulking vs superficial contouring/feathering]

Area-by-Area Aspirate Volumes

• [Area with laterality]: Total aspirate [mL]; Estimated fat [mL] (if decanted); Cannula [mm]
• [Area with laterality]: Total aspirate [mL]; Estimated fat [mL] (if decanted); Cannula [mm]

Total Aspirate Volume: [mL]

Estimated Blood Loss: [mL]

(If total aspirate exceeds 5000 mL, this constitutes large-volume liposuction; explicitly document the postoperative monitoring plan in Disposition.)

Fat Grafting

(Include this section only if fat was harvested for grafting, sent to pathology, or otherwise retained. Omit entirely if not applicable.)

Donor Site(s): [Anatomic location(s)]

Processing: [Decanting / washing / centrifugation with parameters / filtration]; Final volume available: [mL]

Recipient Site(s):

• [Recipient area with laterality]: Plane(s) [subcutaneous / intradermal / other]; Cannula [size]; Volume injected [mL]; Technique [multi-plane / small aliquots / fanning]
• [Additional recipient area] (Repeat as needed.)

(For gluteal fat grafting: Explicitly document that injection was performed in the subcutaneous plane only and whether ultrasound guidance was used to confirm cannula position.)

Contour Assessment

[Patient positioning used for assessment, method of assessment, and any intraoperative adjustments made based on assessment]

Closure and Dressings

Incision Closure: [Sutures with type and size / steri-strips / left open for drainage]

Dressings: [Type applied]

Compression: [Garment or binder placed and coverage area]

Drains: [None / Present: type, location, and securement]

Specimens

[None sent to pathology / List specimens with site labels]

Complications

[None / Description of event, immediate management, impact on procedure completion, and postoperative monitoring needs]

Patient Condition and Disposition

Condition: [stable / hemodynamically stable]

Disposition: [PACU / Phase II recovery / Admitted for overnight monitoring]

Postoperative Plan:

• [Pain management approach]
• [Antibiotic plan] (If applicable.)
• [VTE prophylaxis: SCDs, chemoprophylaxis] (If applicable.)
• [Compression garment instructions]
• [Follow-up timing]

(For large-volume cases exceeding 5000 mL total aspirate: Explicitly document overnight monitoring parameters including vital sign frequency, urine output targets, fluid balance monitoring, and escalation criteria.)