Plastic Surgery Consultation Note (Aesthetic Surgery)

Date: [Date]

Time: [Time]

Location: [Clinic location]

Patient Name: [Full name]

DOB: [DOB]

MRN: [MRN]

Encounter Type: [New Patient Consultation – Aesthetic Plastic Surgery]

Surgeon: [Surgeon name]

Referring Source: [Self-referred / Referring provider name]

Chaperone Present: [Name and role / Declined / Not applicable]

Chief Complaint

[Primary aesthetic concern(s) in patient's own words] (One to two lines; include brief direct quote if provided; list multiple concerns in patient-stated priority order; note any specific requested procedures.)

History of Present Illness

[Patient's aesthetic goals, definition of success, and priorities if multiple goals exist] (Include why the patient is seeking consultation now—event-driven timeline, aging progression, post-pregnancy, post-weight loss, etc.)

[Trade-offs and preferences] (Scar tolerance, downtime tolerance, implant aversion, anesthesia preferences, budget sensitivity. Note unacceptable trade-offs.)

[Prior treatments and consultations] (Prior procedures, injectables, or energy-based treatments to the area(s) of concern with outcomes; prior consultations and what the patient liked or disliked about previous recommendations.)

[Functional symptoms] (For rhinoplasty, blepharoplasty, breast reduction—document presence or explicit absence of relevant functional symptoms.)

[Expectation assessment] (Patient response to goal photos, filtered images, or celebrity references if reviewed; comment on expectation realism. If BDD screening performed, note tool, result, and action taken.)

[Motivation and psychosocial context] (Self-driven vs external pressure; psychosocial considerations affecting candidacy.)

[Logistical constraints] (Work, childcare, travel, or support system factors affecting planning.)

Relevant History

Past Medical History: [Conditions affecting surgical candidacy, anesthesia safety, or healing] (Cardiopulmonary disease, diabetes, hypertension, autoimmune/connective tissue disease, bleeding/clotting disorders, VTE history, OSA, keloid/hypertrophic scarring, relevant psychiatric diagnoses. If not obtained, state "Not obtained" with reason.)

Past Surgical History: [Prior aesthetic and reconstructive procedures with outcomes, complications, anesthesia complications, difficult airway history] (If unknown, document "Unknown.")

Medications and Supplements: [Current medications and supplements] (Highlight anticoagulants, antiplatelets, hormonal therapy, GLP-1 agonists, immunosuppressants, steroids, isotretinoin, supplements affecting bleeding/healing.)

Allergies: [Medications, latex, adhesives, skin prep agents, suture materials with reaction type]

Social History: [Nicotine use with quantification and cessation status, cannabis, alcohol, occupation/activity level relevant to recovery]

Family History: [VTE, malignant hyperthermia, bleeding disorders, keloid tendency] (If none relevant, state "No relevant family history.")

Review of Systems

[Targeted ROS pertinent to perioperative safety and surgical planning] (Focus on cardiopulmonary symptoms, bleeding/bruising tendency, skin healing concerns, psychiatric symptoms. May state: "ROS limited to items relevant to perioperative safety and surgical planning.")

Physical Examination

Vitals: [Vital signs, BMI if relevant to surgical planning]

General: [General appearance and skin quality]

(Include only examined regions. Document objective findings with interpretation for surgical options/limitations. Explicitly note asymmetries. For bilateral structures, document right and left separately. For measurements, state patient position, method, and tools used.)

Face

• [Facial proportions and symmetry; skeletal vs soft tissue contributions]
• [Skin quality and texture; photoaging features]
• [Aging pattern: volume loss, descent, laxity]
• [Clinical interpretation and implications for surgical/non-surgical options]

Nose

• [Skin-soft tissue envelope thickness]
• [Dorsum profile; tip definition, projection, rotation]
• [Alar base width; columellar show]
• [External/internal valve assessment if functional evaluation performed]
• [Clinical interpretation and implications for rhinoplasty options]

Periorbital

• [Brow position; lid crease; dermatochalasis]
• [Fat herniation; lid laxity; dry eye relevance]
• [Clinical interpretation and implications for blepharoplasty/adjuncts]

Lower Face and Neck

• [Skin laxity; jowling; platysmal bands]
• [Submental fat; cervicomental angle]
• [Clinical interpretation and implications for facelift/neck procedures]

Breast

• [Size, shape, symmetry; chest wall asymmetry]
• [Ptosis grade with grading system used]
• [Base width; areolar dimensions; IMF position]
• [Skin quality; striae; prior scars; implant findings if present]
• [Right vs Left measurements with method and position]
• [Clinical interpretation and implications for augmentation/reduction/mastopexy]

Abdomen and Trunk

• [Adiposity distribution; lipodystrophy zones; skin laxity; striae]
• [Diastasis assessment; hernia suspicion]
• [Clinical interpretation and implications for abdominoplasty/body contouring]

Extremities

• [Skin laxity patterns; fat distribution; skin quality]
• [Clinical interpretation and implications for arm/thigh contouring]

Photography

Consent: [Clinical documentation consent obtained / Separate authorization for non-clinical use obtained / declined]

Views obtained: [Standard views by region; deviations from standard series with reason]

Image handling: [Uploaded to medical record; deleted from capture device per policy]

3D imaging/simulation: [If performed, note simulation is illustrative and not a guarantee; patient response] (Omit if not performed.)

(Omit entire Photography section if no photos taken and no photo plan discussed.)

Assessment

1. [Problem 1 - Aesthetic concern/diagnosis]: [Candidacy modifiers: nicotine status, BMI, comorbidities, prior surgery, BDD result if concerning, anticoagulation] — [Candidate / Needs optimization / Deferred / Declined]
2. [Problem 2 - Aesthetic concern/diagnosis]: [Candidacy modifiers] — [Candidacy determination]

(Add additional problems as needed in patient priority order.)

Plan

(Organize by problem number to mirror Assessment.)

Problem 1: [Name]

• Options discussed: [Surgical options, non-surgical alternatives, observation]
• Recommendation and rationale: [Recommendation linked to goals and anatomy; why certain options not recommended if applicable]
• Risks discussed: [Common risks: scarring, infection, bleeding, hematoma, seroma, asymmetry, prolonged swelling. Serious risks: VTE, anesthetic complications, nerve injury, skin necrosis, procedure-specific risks. Aesthetic risks: dissatisfaction, revision possibility, no guarantee. Patient-specific risk factors.]
• Patient decision: [Stated preferences/values; chosen option or deferral; questions asked and answered; confirmation of understanding] (Note teach-back if performed.)
• Preoperative requirements: [Nicotine cessation and verification method, medication holds, labs/clearances, weight stability, other optimization] (Omit if not proceeding.)
• Referrals: [Mental health if BDD concern or expectation mismatch; specialty clearances if indicated] (Omit if none.)

Problem 2: [Name]

• Options discussed: [Surgical options, non-surgical alternatives, observation]
• Recommendation and rationale: [Recommendation linked to goals and anatomy]
• Risks discussed: [Material risks discussed with patient-specific factors]
• Patient decision: [Decision and confirmation of understanding]
• Preoperative requirements: [If proceeding]
• Referrals: [If indicated]

(Repeat for additional problems as applicable.)

Orders

• [Labs with indication]
• [Imaging with indication]
• [Referrals with indication]
• [Prescriptions with name, dose, frequency, indication]

(Omit entire section if no orders placed.)

Follow-Up

Next appointment: [Timing and purpose—preoperative visit, return after optimization, PRN]

Prerequisites for surgical scheduling: [Nicotine test, clearances, labs, photo completion, etc.]

Return precautions: [Symptoms/findings warranting earlier contact] (Omit if none.)