Reduction Mammaplasty Operative Note

Patient: [Patient name and identifiers]

Date of Procedure: [Date]

Facility: [Facility name]

Surgeon: [Primary surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)] (Include only if applicable; omit if none.)

Anesthesia: [general / regional / local with sedation]

Preoperative Diagnosis: [Diagnosis with symptomatic indication if applicable]

Postoperative Diagnosis: [Diagnosis reflecting intraoperative findings]

Procedure(s) Performed:

• Right reduction mammaplasty [technique qualifiers: pedicle type, skin pattern, adjuncts]
• Left reduction mammaplasty [technique qualifiers: pedicle type, skin pattern, adjuncts]

(Use explicit laterality throughout; do not use "bilateral" alone when documenting pedicles, weights, or specimens.)

Indications

[Medical necessity summary including primary indication, symptoms attributable to macromastia, functional impact, conservative measures tried with duration and outcomes, and confirmation of informed consent]

Preoperative Planning

• Markings: [Markings performed, patient position, incision pattern planned]
• Pedicle Selection:
  • Right: [inferior / superomedial / superior / medial / lateral / central mound / free nipple graft] (Include rationale if nonstandard.)
  • Left: [inferior / superomedial / superior / medial / lateral / central mound / free nipple graft] (Include rationale if nonstandard or differs from right.)
• NAC Positioning: [Planned position and areolar sizing method] (Include if explicitly planned.)
• Asymmetry Plan: [Differential resection plan] (Include only if applicable.)
• Free Nipple Graft: [Indication and grafting plan] (Include only if indicated.)

Findings

[Macromastia severity, ptosis grade if relevant, asymmetry observed, unexpected findings, absence of suspicious masses if specifically assessed]

Description of Procedure

(Describe only steps actually performed. Use explicit Right/Left laterality. Omit elements that do not apply.)

• Positioning and Preparation: [Patient positioning, skin preparation, draping, time-out confirmation]
• Incisions and De-epithelialization: [Incision pattern executed, de-epithelialization approach, tumescent infiltration if used]
• Pedicle Creation:
  • Right: [Pedicle orientation, dimensions, NAC vascular supply preservation]
  • Left: [Pedicle orientation, dimensions, NAC vascular supply preservation]
• Parenchymal Resection: [Regions resected, technique, contouring] (Do not estimate weights here.)
• Hemostasis: [Techniques used, topical agents left in situ if any]
• Liposuction: [Areas treated and technique] (Include only if performed.)
• Symmetry Assessment: [Sitting position assessment, adjustments made] (Include only if performed.)
• NAC Final Positioning: [Viability confirmation, final position, areolar sizing method]
• Closure: [Layered closure with suture materials]
• Drains: [Type, size, number per side, exit sites, securement method] (Include only if placed.)
• Dressings: [Dressings applied, postoperative garment]

Specimens

• Right Breast: [Description], [weight in grams / pending], [orientation marking if used], sent to pathology
• Left Breast: [Description], [weight in grams / pending], [orientation marking if used], sent to pathology

(If weights pending, state plan to file addendum when available. Do not estimate.)

Estimated Blood Loss

[EBL in mL]; hemostasis confirmed prior to closure

Complications

[None / Complication description and management]

Postoperative Plan

• Disposition: [PACU then discharge / Admission with level of care]
• Activity: [Lifting limits, arm ROM guidance, sleeping position]
• Wound Care: [Dressing care, showering instructions]
• Drain Care: [Output recording, removal criteria] (Include only if drains placed.)
• Medications: [Pain regimen, antibiotics with duration if prescribed, stool softener]
• VTE Prophylaxis: [Early ambulation, mechanical devices, pharmacologic if ordered]
• Follow-up: [Timing, provider, pathology review plan]
• Return Precautions: [Signs of hematoma, infection, NAC color changes, DVT/PE symptoms]