Operative Note (Plastic Surgery - General)

Date of Procedure: [Date]

Time: [Start time and/or completion time]

Urgency: [elective / urgent / emergent]

Surgical Team and Anesthesia

Primary Surgeon: [Name(s) and role(s) if multiple surgeons]

Assistants: [Name(s) and role(s): co-surgeon / resident / PA / NP / RNFA]

Anesthesia Type: [general / regional / MAC / local / combination]

Anesthesia Personnel: [Anesthesiologist / CRNA / Anesthesia resident / SRNA]

Preoperative Diagnosis

• [Diagnosis with laterality and anatomic site]
• [Additional diagnosis if applicable]

Postoperative Diagnosis

(May state "same as preoperative" only if explicitly confirmed. If procedure was aborted, state the reason.)

• [Final diagnosis with laterality and anatomic site]
• [Additional diagnosis if applicable]

Procedure(s) Performed

(List in order performed. For combined cases, clearly delineate the plastic surgery component(s).)

• [Procedure name, laterality, site, approach (open / endoscopic / intraoral / transconjunctival / etc.)]
• [Additional procedure if applicable]

Indications

[Brief rationale for surgery] (3–6 sentences covering diagnosis, symptom or defect description, relevant prior management, and for reconstruction: etiology, functional deficit, and staged plan if applicable. Include key risk context only if it directly affected technique selection.)

Findings

(Document key findings that affected operative conduct. Group by site if multiple. Label uncertain findings as "suspected" or "appears consistent with.")

• [Tissue quality: radiated / scarred / infected / ischemic / healthy]
• [Defect dimensions and involved layers]
• [Critical structures identified: nerves / vessels / tendons / bone / cartilage and their condition]
• [Margin assessment if performed: grossly clear / frozen section result]
• [Implant/capsule findings if applicable: capsule quality, seroma, rupture, contamination]
• [Other pertinent findings]

Procedure in Detail

(Chronological narrative from incision to closure. Use H3 subheadings only if multiple distinct procedures or sites warrant separation. Do not assume or auto-populate values for antibiotics, tourniquet time, drains, or implants without explicit information.)

[Patient positioning, preparation, and pre-incision markings]

[Incision type and location, dissection planes, anatomical landmarks, identification and protection of critical structures, tourniquet use if applicable]

[Resection, debridement, release, or excision details with extent and indications]

[Reconstruction specifics as applicable: flap design/type/dimensions/pedicle/perfusion assessment; graft donor site/thickness/meshing/fixation; free flap recipient vessels/anastomosis technique/ischemia time/perfusion verification; breast reconstruction pocket type/ADM or mesh/implant placement and volumes; hand surgery repair method/suture type/tensioning; craniofacial osteotomies/fixation]

[Hemostasis methods and agents if clinically meaningful]

[Layered closure description with materials and suture sizes]

[Dressings, splints, compressive garments, NPWT with settings if applicable]

Specimens

(If no specimens sent, omit this section or state "None" only if explicitly confirmed.)

• [Specimen name] – [Site, laterality]; [Orientation method if used]; [Destination: permanent / frozen / culture]

Implants/Devices/Materials

(Include all implants placed and removed/exchanged: implants, ADM/mesh, fixation hardware, nerve conduits, tendon anchors, tissue expanders, dermal substitutes. If none, omit or state "None" only if confirmed.)

• Placed: [Item] – [Manufacturer, product, model]; [Size]; [Laterality, site, pocket]; [Serial/Lot/UDI if available]
• Removed/Exchanged: [Item] – [Manufacturer, product]; [Reason if relevant: rupture / infection / capsular contracture]

Drains

(If none, omit or state "None" only if confirmed.)

• [Drain type, size (Fr)] – [Number]; [Anatomic location]; [Suction method: bulb / wall / gravity]; [NPWT pressure settings if applicable]

Estimated Blood Loss

[Numeric estimate in mL / minimal] (If unknown at documentation time, state explicitly rather than entering zero.)

Counts

[Sponge, needle, and instrument counts correct / Discrepancy noted with actions taken and resolution] (If any item intentionally retained, document what, why, and how communicated.)

Complications

[None / None apparent / Description of unplanned intraoperative event and immediate management] (Distinguish expected procedural steps from unplanned events.)

Disposition

[Patient condition at conclusion: stable / intubated / etc.] to [Destination: PACU / ICU / floor]; [Key supports if applicable: ETT, pressors, etc.]

(For flaps or critical reconstructions: [Immediate perfusion status: Doppler signal / capillary refill / temperature]; [Monitoring plan and frequency])

Postoperative Plan

• [Wound care and dressing change timing]
• [Drain care and removal criteria]
• [Activity restrictions: elevation / splint precautions / weight-bearing / ROM limits and duration]
• [Antibiotics: agent and duration] (Only if surgeon-directed)
• [DVT prophylaxis] (Only if surgeon-directed or non-routine)
• [Special monitoring: flap check frequency and parameters] (Only if applicable)
• [Follow-up timing and return precautions]