Patient Instructions (Postoperative Plastic Surgery)

Document Header

Patient Name: [Patient full name]

Procedure: [Patient-friendly procedure name (clinical term if helpful)]

Date of Surgery: [MM/DD/YYYY]

Surgeon: [Surgeon name and credentials]

Facility: [Hospital or surgical center name]

Contact Information

Plastic Surgery Clinic (business hours): [Clinic phone]

After-hours/On-call: [After-hours phone or paging instructions]

Emergencies: If this is an emergency, call 911 or go to the nearest Emergency Department.

(If any contact information is unavailable, insert: "Call the main clinic number on your discharge paperwork or check your patient portal.")

Quick Start: What to Do Today

• ☐ Keep your current dressing [in place until instructed / change on MM/DD at HH:MM / change every X hours]. (Select one option based on orders.)
• ☐ Start your medications at [time today / tomorrow morning]. Take them exactly as listed below.
• ☐ Move carefully. Walk short distances every few hours while awake. [No lifting over X lb/kg]. (Include lifting limit only if specified.)
• ☐ Sleep [on your back / with head elevated / on your side / in a recliner]. Use extra pillows as needed. (Include only if positioning is ordered.)
• ☐ Empty your drain(s) [at least twice daily / every X hours / when half full]. Write down the amount and color each time. (Include only if drains are present.)
• ☐ Your follow-up: [Date/Time at Location] or [Call the clinic within X business days to schedule].
• ☐ Call now for fever, worsening redness, sudden swelling, bleeding that will not stop, or trouble breathing.

Wound and Drain Care

Your incision(s): You have a [dressing type] over your incision(s). Keep it clean and dry.

• Keep the dressing in place until your surgeon's office instructs you otherwise. (If a specific change schedule is ordered, state it here instead.)
• Wash your hands with soap and water before and after any wound care.
• Showering: [You may shower starting MM/DD / Do not shower until the clinic clears you]. Let water run gently over the area. Do not scrub the incision.
• Pat dry with a clean towel. Do not rub.
• No baths, hot tubs, pools, or soaking until your surgeon clears you.
• Do not use peroxide, alcohol, ointments, or creams unless instructed.
• Do not pick at scabs or closures.

Closure type: [sutures (stitches) / staples / steri-strips (paper tape) / skin glue / splint or cast] (Include only the types that apply.)

• Sutures or staples: Leave in place. The clinic will remove them at your follow-up. (Include only if present.)
• Steri-strips: Keep dry. They will curl and fall off on their own. Do not pull them off. (Include only if present.)
• Skin glue: It will flake off over 1–2 weeks. Do not peel it. Keep it dry and out of sun. (Include only if present.)
• Splint or cast: Keep dry and on at all times unless told otherwise. (Include only if present.)

Drain care (Include this subsection only if drains are present.)

• You have a [drain type, e.g., Jackson-Pratt] drain in [location]. Keep the bulb compressed to maintain suction.
• Empty the drain [at least twice daily / every X hours / when half full].
• To re-establish suction: Open the cap, squeeze the bulb flat, then close the cap while still squeezing.
• Record each emptying in the log below. Bring this log to your follow-up visit.

Date	Time	Drain #	Amount (mL)	Color/Notes

Medications

(Populate from the reconciled discharge medication list only. Do not infer medications from narrative text.)

Medication	Purpose	Dose	When to Take	Key Warnings
[Name, strength]	[Pain / swelling / nausea / antibiotic / stool softener]	[Number of tablets + total mg per dose]	[Every X hours / With food / Start at HH:MM on MM/DD]	[Key warnings]
[Name, strength]	[Purpose]	[Dose]	[Schedule]	[Key warnings]

Pain plan:

• Use non-opioid medicine first: [acetaminophen and/or ibuprofen if allowed]. (Include only if ordered.)
• Use opioid medicine for breakthrough pain if still severe. (Include only if an opioid is prescribed.)

(If any product contains acetaminophen: Do not take more than 4,000 mg of acetaminophen in 24 hours from all sources.)

(If an opioid is prescribed, include: No alcohol. Do not drive or operate machinery. Risk of drowsiness and falls. Store locked and away from children. Dispose of leftovers at a pharmacy take-back site.)

Allergies: [List drug allergies and reactions / No known drug allergies]

Home medications: (Include only if explicit orders are documented.)

• Resume: [Home medications to restart]
• Hold: [Medications to hold and for how long]

Activity and Recovery

What is normal: Some pain, swelling, and bruising near the surgical site. Possible numbness or tightness. Fatigue for a few days. These usually improve over time.

Activity:

• Allowed: Gentle walking several times a day. Light daily tasks. Deep breathing exercises.
• Avoid: Lifting more than [X lb/kg]. Pushing or pulling heavy items. Straining. High-impact exercise. No driving for 24 hours after anesthesia. No driving while taking opioid pain medicine. No smoking or vaping. No alcohol while taking opioids or certain antibiotics.
• Ask first: [Returning to gym / Sexual activity / Travel / Sports / Compression garments]

Positioning: Sleep [on your back / with head elevated / on your side] as instructed. (Include only if specific positioning is ordered.)

Work and activities: [Return to work in X days/weeks / Discuss at your follow-up visit]

If you are unsure whether something is normal, call the clinic.

When to Call for Help

Call 911 or go to the ER now: Trouble breathing, chest pain, fainting, severe dizziness, sudden one-sided leg swelling with pain, coughing up blood, uncontrolled bleeding, severe allergic reaction (face/lip/tongue swelling, trouble breathing).

Call your surgeon now (urgent): Fever above [100.4°F / 38°C], redness or swelling that is getting worse quickly, warmth spreading from the incision, foul-smelling or thick drainage, severe pain not controlled by your medicines, new or worsening asymmetric swelling, persistent vomiting, drain that will not hold suction or falls out.

Call during business hours or send a portal message: Questions about medicines, mild side effects, stable dressing or wound questions, return-to-work forms.

Clinic (business hours): [Clinic phone] | After-hours/On-call: [After-hours phone]

Follow-Up

Visit Type	Date/Time	Location
[Post-op visit]	[MM/DD/YYYY HH:MM]	[Clinic location]

• Bring your medication list.
• Bring your drain log. (Include only if drains are present.)

[Call the clinic within X business days to schedule your post-op visit.] (Include only if no appointment is scheduled.)

Pending results: [Pathology / cultures / imaging] — the clinic will contact you when results are available. (Include only if results are pending.)

(Omit any section or line that does not apply to this patient or procedure.)