Mastopexy/Breast Lift Operative Note

(Use consistent laterality labels throughout as "Right Breast (RB)" and "Left Breast (LB)". Never leave required fields blank—use "None" or "Not applicable" where appropriate. If specific device identifiers are not available at dictation, indicate "see implant log". Omit optional subsections entirely if not performed.)

Date of Procedure: [Date]

Start Time / End Time: [Start time] / [End time]

Location: [Facility and OR number]

Preoperative Diagnosis: [Diagnosis with laterality]

Postoperative Diagnosis: [Diagnosis with laterality] (State if changed intraoperatively)

Procedure(s) Performed: [Procedure(s) with laterality and pattern/pedicle]

Surgeon: [Name, credentials]

Assistant(s): [Name(s) / None]

Anesthesia Type: [General endotracheal / General LMA / MAC / Local with sedation]

Anesthesia Provider: [Name, credentials]

Estimated Blood Loss: [mL]

Drains: [Type, size, laterality / None]

Specimens: [Description, laterality, weight / None]

Implants/Devices: [Product name, manufacturer, size, lot/serial number, laterality / None] (If identifiers not available at dictation, write "see implant log")

Complications: [None / Description]

Counts: [Correct / Discrepancy with description and resolution]

Disposition: [Destination, condition, airway status]

Indications

[Brief statement of indication and surgical goals] (State the reason for surgery and intended outcomes: lift, reshape, improve ptosis, adjust NAC position, address asymmetry, restore upper pole fullness if auto-augmentation planned. Include relevant history only if provided: prior breast or implant surgery, significant weight changes, tobacco use that influenced planning, baseline asymmetry that informed technique selection.)

Consent and Time-Out

[Consent and time-out confirmation] (Document informed consent obtained for mastopexy and any adjuncts such as fat grafting, implant work, or mesh/ADM. Confirm procedural time-out was performed verifying correct patient, procedure, and laterality.)

Preoperative Markings

[Confirmation markings performed preoperatively with patient upright] (Be explicit about pattern and pedicle; avoid generic phrasing such as "marked in standard fashion".)

Right Breast (RB)

• Skin pattern: [Wise/inverted-T / Vertical / Circumareolar]
• Pedicle design: [Superior / Superomedial / Medial / Inferior / Central]
• Planned NAC position method: [Method used to determine target position]
• Areolar template size: [mm]
• Key measurements: [Sternal notch-to-nipple, nipple-to-IMF, other measurements if used]

Left Breast (LB)

• Skin pattern: [Wise/inverted-T / Vertical / Circumareolar]
• Pedicle design: [Superior / Superomedial / Medial / Inferior / Central]
• Planned NAC position method: [Method used to determine target position]
• Areolar template size: [mm]
• Key measurements: [Sternal notch-to-nipple, nipple-to-IMF, other measurements if used]

(Note any planned asymmetric approach if applicable.)

Operative Findings

• [Degree of ptosis and breast size/shape]
• [Baseline asymmetry: volume, NAC height, IMF level] (Only include if present)
• [Skin quality: striae, elasticity, redundancy] (Only include if relevant to technique)
• [Parenchymal quality: density, deflation, glandular distribution] (Only include if relevant)
• [Prior scars and locations] (Only include if present)
• [Unexpected findings] (Only include if present)

Procedure

Positioning and Preparation

[Patient positioning, arm position, pressure point protection] [Antibiotic prophylaxis: drug, dose, timing relative to incision] [DVT prophylaxis method] [Skin preparation and sterile draping]

Incisions and De-epithelialization

[Incision pattern performed] (Note if it differed from preoperative plan.) [De-epithelialization of pedicle and periareolar area] [Any intraoperative pattern adjustments or tailor-tacking]

Pedicle Creation and NAC Management

(If technique was bilaterally identical, state this and summarize once; otherwise document RB and LB separately.)

Right Breast (RB)

• Pedicle type and creation: [Pedicle type, dissection plane, perforator preservation]
• NAC management: [Transposition method, areolar reduction if performed, final areolar diameter]
• NAC perfusion after transposition: [Color, capillary refill, dermal edge bleeding]

Left Breast (LB)

• Pedicle type and creation: [Pedicle type, dissection plane, perforator preservation]
• NAC management: [Transposition method, areolar reduction if performed, final areolar diameter]
• NAC perfusion after transposition: [Color, capillary refill, dermal edge bleeding]

Parenchymal Reshaping

(If no parenchymal reshaping performed, state: "Only skin envelope tightening performed without parenchymal work" and omit the bullets below.)

• Pillar suturing/plication: [Which pillars, technique, suture type if relevant]
• Auto-augmentation flap: [Source, rotation/advancement, fixation points] (Only include if performed)
• Mesh/ADM placement: [Device name, manufacturer, size, fixation points, laterality, lot/serial] (Only include if used)
• Parenchymal excision: [RB weight, LB weight] (Include weights when available)

NAC Positioning and Inset

[Final NAC position relative to breast meridian and IMF] [Areolar template size used] [Inset technique and key sutures] [Symmetry confirmation or revisions performed]

Symmetry Assessment

[Symmetry assessment performed] (Note if patient was sat upright or table flexed.) [Parameters evaluated: NAC height and shape, breast projection, upper pole fullness, IMF symmetry, scar line alignment] [Any accepted asymmetry with rationale]

Hemostasis and Closure

[Hemostasis method] [Closure by layer: deep parenchymal, deep dermal, subcuticular, NAC inset] [Suture materials if clinically relevant] [T-junction management if Wise pattern] [NAC perfusion reassessed at closure] (Include perfusion reassessment if any concern arose during the case.) [Drains placed and secured if used]

Dressings and Support

[Dressings applied] [External support: surgical bra or compression wrap] [Special protections: bolster, nipple shields, or none]

Postoperative Plan

• Dressing care and showering: [Instructions and timing]
• Bra/compression: [Type and duration]
• Drain care: [Output log instructions and removal criteria] (Only include if drains placed)
• Activity restrictions: [Lifting limits, arm motion guidance, return to work/exercise timeline]
• Return precautions: [Signs of hematoma, infection, wound dehiscence, NAC ischemia, DVT/PE]
• Medications: [Antibiotics if prescribed, analgesia plan, other medications]
• Follow-up: [Timing of postoperative visits]

Technique Variance or Complications

(Only include this section if the operative plan changed intraoperatively or a complication occurred; otherwise omit entirely.)

• Description: [What changed or occurred]
• Reason: [Why the change or complication happened]
• Actions taken: [Corrective steps and intraoperative management]
• Impact on aftercare: [Postoperative implications and additional instructions]