AI Scribe for Plastic Surgeons

OPERATIVE REPORT
Date of Surgery: 2026-04-22
Surgeon: M. Hayashi, MD
Assistant: D. Okafor, MD (PGY-6, Plastic Surgery)
Anesthesia: General endotracheal (Dr. Lin)

PRE-OPERATIVE DIAGNOSIS:
1. Right breast invasive ductal carcinoma, status post nipple-sparing mastectomy by surgical oncology (C50.911)
2. Acquired absence of right breast post-mastectomy (Z90.11)

POST-OPERATIVE DIAGNOSIS:
Same

PROCEDURE PERFORMED:
1. Immediate right prepectoral breast reconstruction with smooth round silicone implant 470 cc (CPT 19340)
2. Acellular dermal matrix (ADM) sling — AlloDerm RTM 16 × 8 cm, lot 4521-A (CPT 15777)
3. Closed-suction drain placement, JP × 1 to right reconstruction pocket

ASA CLASS: II (well-controlled HTN, BMI 26)
NPO STATUS: NPO since midnight, 14 hours pre-op
ANTIBIOTICS: Cefazolin 2 g IV at 07:42, 18 minutes before incision; redosed at 4 hours
TXA: 1 g IV at induction
DVT PROPHYLAXIS: Sequential compression devices, enoxaparin 40 mg planned at 24 h post-op

INDICATION:
46-year-old female, BMI 26, BRCA-negative, Stage IIA right breast invasive ductal carcinoma. Underwent nipple-sparing mastectomy by Dr. Reilly (surgical oncology) immediately preceding this case. Reconstruction options were reviewed in detail at consultation 2026-03-15 — implant vs autologous (DIEP, latissimus), one-stage vs two-stage, prepectoral vs subpectoral plane. Patient elected immediate prepectoral implant reconstruction given thin native tissue, oncologic timeline, and preference to avoid abdominal donor site. Risks of bleeding, infection (1–2%), capsular contracture (1-year ~10%, lifetime ~15–20%), implant malposition, rippling, mastectomy flap necrosis, and need for revision were discussed in detail with the patient and her husband. Patient consented in clinic and again in pre-op holding. Women's Health and Cancer Rights Act counseling documented.

PRE-OPERATIVE MEASUREMENTS (right breast, prior to mastectomy):
- Sternal notch to nipple: 22 cm
- Nipple to IMF: 7 cm
- Base width: 13 cm
- Cup approximation: 36C

FINDINGS:
- Mastectomy flaps well-vascularized, capillary refill brisk on SPY-Elite ICG angiography (no perfusion < 30% of baseline)
- IMF intact and well-defined
- Pectoralis fascia intact; pectoralis muscle preserved (prepectoral plane)
- Pocket dimensions: 14.5 × 12 cm after dissection

PROCEDURE NARRATIVE:
After successful nipple-sparing mastectomy by Dr. Reilly, the breast pocket was inspected. Mastectomy flap perfusion was assessed with SPY-Elite ICG angiography — flaps well-perfused throughout, including the inferior pole. Hemostasis confirmed. The pocket was irrigated with triple-antibiotic solution (50,000 U bacitracin + 1 g cefazolin + 80 mg gentamicin in 500 mL saline) per ASPS prophylactic guidelines.

A 16 × 8 cm sheet of AlloDerm RTM (acellular dermal matrix), lot 4521-A, was rehydrated per package insert, inset along the IMF and lateral pocket as a sling, and secured to the pectoralis fascia and IMF with interrupted 3-0 PDS.

The pocket was sized with a 470 cc Allergan smooth round Natrelle 410 sizer; the patient was sat up to 45° on the table for a final symmetry check against the contralateral breast. A 470 cc smooth round silicone implant (Allergan Natrelle Inspira SRX-470, lot 8765-B) was placed in the prepectoral pocket using a Keller funnel "no-touch" technique. Implant orientation confirmed.

A 15 Fr Blake drain was placed in the dependent pocket, exiting through a separate stab incision laterally. Pocket was closed in three layers: ADM/dermis with 3-0 Vicryl, deep dermis with 4-0 Monocryl interrupted, and skin with 4-0 Monocryl subcuticular and Dermabond. Sterile dressing and a soft surgical bra applied.

ESTIMATED BLOOD LOSS: 50 mL
URINE OUTPUT: 250 mL
IV FLUIDS: 1.4 L lactated Ringer's
COMPLICATIONS: None

DISPOSITION:
Patient extubated in OR, transferred to PACU in stable condition. Plan: 23-hour observation, advance diet as tolerated, IV ketorolac 15 mg q6h × 24 h then oral oxycodone 5 mg q6h PRN with bowel regimen, gabapentin 300 mg TID × 7 days, continue cefazolin 2 g q8h × 24 h then transition to PO cephalexin 500 mg QID × 7 days. Drain to bulb suction, output check at 0700 and 1900; remove when output < 30 mL/24 h × 2 days. Soft surgical bra continuously × 6 weeks; no underwire or push-up garments. F/U in clinic POD 7 for drain check and POD 14 for full assessment. Implant card and ADM lot recorded in chart and given to patient.