# 01 — Preoperative Assessment & Checklist > **Educational work by a pre-medical student — not medical advice.** Not a clinical protocol, prescription, or patient handout, and not for patient care. See [DISCLAIMER](DISCLAIMER.md). ### Post-mastectomy breast implant revision — educational dosing reference, November 2026 **How to read the numbers.** This is an educational template showing the parts of a perioperative assessment. Every dose, threshold or timing carries a tag such as [S6](DOSING_SOURCES.md#s6). The tag links to the source in [DOSING_SOURCES.md](DOSING_SOURCES.md). The values show what that guideline, label or score paper states. They are illustrative only. A treating clinician individualizes them under institutional policy. This is not an order set, and it has not been validated for this procedure. *Values changed from v2.0, and v2.0 values removed for lack of an acceptable source, are listed in [RELEASE_NOTES.md](RELEASE_NOTES.md).* --- ## 1. Patient identification and background ### 1.1 Demographics - **Age:** ______ years - **Height / weight / BMI:** ______ (record weight; some drugs are dosed on ideal or lean body weight) ### 1.2 Primary surgical indication *(select all that apply)* - [ ] Prior bilateral or unilateral mastectomy - [ ] Implant malposition - [ ] Capsular contracture (Baker grade III–IV) - [ ] Suspected or confirmed infection - [ ] Implant rupture - [ ] Chronic or recurrent seroma - [ ] Size or style change - [ ] Pocket revision for symmetry - [ ] Concern for breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) — needs specialist evaluation, not extrapolation from a cosmetic revision workflow ### 1.3 Relevant comorbidities - [ ] Hypertension - [ ] Diabetes mellitus - [ ] GERD / reflux - [ ] Coronary artery disease / heart failure - [ ] Asthma / COPD - [ ] Chronic kidney disease (affects NSAID, ketorolac and opioid choices) - [ ] Obesity - [ ] Obstructive sleep apnea — screen with STOP-Bang (§5.3) - [ ] Coagulopathy or antithrombotic therapy - [ ] Anxiety / psychiatric illness - [ ] Long-term opioid therapy (use on most days for >3 months [S21](DOSING_SOURCES.md#s21)) — record drug, dose and daily MME; plan to continue the baseline regimen [S21](DOSING_SOURCES.md#s21) - [ ] Opioid use disorder on medication treatment (buprenorphine, methadone or naltrexone) — coordinate with the prescriber; do not withhold indicated analgesia **ASA physical status:** [ ] I [ ] II [ ] III [ ] IV --- ## 2. Oncologic and prior reconstruction history ### 2.1 Cancer treatment - Year of mastectomy: ______ - Prior radiation therapy: [ ] Yes [ ] No - Prior chemotherapy: [ ] Yes [ ] No ### 2.2 Previous reconstruction - Type: [ ] Direct-to-implant [ ] Tissue expander → implant [ ] Autologous - Implant: [ ] Silicone [ ] Saline [ ] Unknown - Pocket plane: [ ] Prepectoral [ ] Partial subpectoral (± ADM) [ ] Total submuscular - Axillary surgery: [ ] SLNB [ ] ALND — side: [ ] L [ ] R [ ] Bilateral - Lymphedema: [ ] Yes (side: ____) [ ] No → note for the team: avoid BP cuff, IV and venipuncture on the affected or at-risk arm where possible; plan alternative sites if bilateral ### 2.3 Prior complications - [ ] Infection [ ] Seroma [ ] Hematoma [ ] Capsular contracture - [ ] Wound dehiscence [ ] ADM exposure/failure [ ] Implant extrusion --- ## 3. Infection risk **Current signs or symptoms** - [ ] Fever [ ] Erythema [ ] Purulent drainage [ ] Warmth - [ ] Pain out of proportion [ ] Recent antibiotics [ ] Elevated WBC → If infection is suspected, the surgical team plans intraoperative cultures and antibiotic therapy beyond prophylaxis. --- ## 4. Laboratory and imaging review **Commonly reviewed (as indicated by history and institutional policy)** - [ ] CBC [ ] Metabolic panel [ ] Coagulation studies if indicated - [ ] Pregnancy test per institutional policy [ ] HbA1c if diabetic **As indicated** - [ ] Breast MRI/ultrasound (rupture evaluation) - [ ] Prior operative reports - [ ] Previous culture data --- ## 5. Airway and anesthesia-specific evaluation ### 5.1 Airway examination - Mallampati class: [ ] I [ ] II [ ] III [ ] IV - Thyromental distance: ______ cm - Inter-incisor distance: ______ cm - Limited neck extension: [ ] Yes [ ] No - History of difficult airway: [ ] Yes [ ] No ### 5.2 PONV risk — Apfel simplified score Source: [S9](DOSING_SOURCES.md#s9). One point each: - [ ] Female sex - [ ] Non-smoker - [ ] History of PONV or motion sickness - [ ] Postoperative opioids expected | Risk factors | Estimated PONV risk [S9](DOSING_SOURCES.md#s9) | Prophylaxis intensity (adults) | |---:|---:|---| | 0 | ~10% | Consider risk reduction; prophylaxis individualized [S7](DOSING_SOURCES.md#s7) | | 1 | ~21% | Two interventions [S7](DOSING_SOURCES.md#s7), [S8](DOSING_SOURCES.md#s8) | | 2 | ~39% | Two interventions [S7](DOSING_SOURCES.md#s7), [S8](DOSING_SOURCES.md#s8) | | 3 | ~61% | Three to four interventions [S7](DOSING_SOURCES.md#s7) | | 4 | ~79% | Three to four interventions [S7](DOSING_SOURCES.md#s7) | The Apfel score estimates risk. It does not choose the anesthetic. The fifth consensus also lists other risk factors, such as younger age, volatile anesthetic, nitrous oxide and longer anesthesia [S8](DOSING_SOURCES.md#s8). ### 5.3 OSA screen (STOP-Bang) Source: [S32](DOSING_SOURCES.md#s32), [S33](DOSING_SOURCES.md#s33). Snoring · Tiredness · Observed apnea · high blood Pressure · BMI >35 kg/m² · Age >50 years · Neck circumference >40 cm · male Gender [S32](DOSING_SOURCES.md#s32) Score: ___ / 8 → 0–2 low risk; 3–4 intermediate risk; 5–8 high risk of moderate-to-severe OSA [S33](DOSING_SOURCES.md#s33) ### 5.4 Hemodynamic notes - [ ] Chronic beta-blocker (bradycardia risk with dexmedetomidine [S14](DOSING_SOURCES.md#s14)) - [ ] Baseline bradycardia or conduction disease - [ ] Poorly controlled hypertension (ketamine caution [S15](DOSING_SOURCES.md#s15)) --- ## 6. Regional anesthesia considerations (PECS I/II or serratus plane block) ### 6.1 Contraindications and cautions - [ ] Infection at the block site - [ ] Patient refusal - [ ] Allergy to amide local anesthetics - [ ] Antithrombotic therapy or coagulopathy. This is a *relative* concern for superficial, compressible plane blocks. Apply the ASRA guideline by agent, dose, timing and block depth [S36](DOSING_SOURCES.md#s36). - [ ] Planned IV lidocaine infusion. IV lidocaine is **not** given concurrently with a block or infiltration. The consensus separates the two by about 4 h [S1](DOSING_SOURCES.md#s1). ### 6.2 Planned regional technique - [ ] PECS I + II - [ ] Serratus anterior plane block - [ ] No block (patient preference or contraindication) The 2026 ASA guideline addresses fascial plane blocks for mastectomy, not implant revision specifically [S37](DOSING_SOURCES.md#s37). Evidence from one breast-surgery population should not be read as proof of benefit in every revision. --- ## 7. Analgesic approach discussed (numbering does not imply preference) | Approach | Selected | |---|---| | **1** — Regional block + multimodal general anesthesia (opioid-sparing) | [ ] | | **2** — Systemic multimodal general anesthesia, no block (opioid-sparing) | [ ] | | **3** — Opioid-inclusive balanced general anesthesia | [ ] | See [03_Anesthesia_Protocols/README.md](03_Anesthesia_Protocols/README.md). No approach is universally superior. Opioid-free general anesthesia has its own risk profile: the POFA trial reported more hypoxemia and bradycardia with dexmedetomidine-based opioid-free anesthesia. --- ## 8. Perioperative medication plan (illustrative label and guideline values) ### 8.1 Oral premedication / multimodal analgesia - [ ] **Acetaminophen** 1000 mg (adults ≥50 kg). Maximum 4000 mg/day from all routes and products [S24](DOSING_SOURCES.md#s24). Contraindicated in severe hepatic impairment [S24](DOSING_SOURCES.md#s24). - [ ] **Celecoxib**, if no renal, GI or cardiovascular contraindication. Label acute-pain regimen: 400 mg initially, then 200 mg if needed on day 1 [S25](DOSING_SOURCES.md#s25). - [ ] **Gabapentinoid — not routine.** A 2020 meta-analysis found no clinically meaningful analgesic benefit and more dizziness and visual disturbance (Verret 2020; see [06](06_References_Evidence_Breast_Augmentation.md)). Perioperative analgesic use is off-label, and no acceptable dose source is cited, so **no dose is given here**. ### 8.2 Antibiotic prophylaxis Source: [S6](DOSING_SOURCES.md#s6). - [ ] **Cefazolin** 2 g IV, or 3 g if weight ≥120 kg, within 60 min before incision; redose every 4 h in prolonged surgery [S6](DOSING_SOURCES.md#s6) - [ ] Reported penicillin allergy: follow the institutional allergy pathway. Cefazolin is usually considered unless there is a severe β-lactam reaction history. - [ ] Severe β-lactam allergy: **clindamycin** 900 mg IV (redose every 6 h) [S6](DOSING_SOURCES.md#s6), or **vancomycin** 15 mg/kg IV started within 120 min before incision [S6](DOSING_SOURCES.md#s6) --- ## 9. Day-of-surgery checklist - [ ] Identity confirmed with two identifiers - [ ] Surgical and anesthesia consent documented. FDA-required breast implant Patient Decision Checklist reviewed (labeling approved in 2021 [S39](DOSING_SOURCES.md#s39)). - [ ] Site marked and laterality confirmed - [ ] Antibiotic timing planned: cefazolin or clindamycin within 60 min; vancomycin within 120 min before incision [S6](DOSING_SOURCES.md#s6) - [ ] Premedications given as ordered - [ ] Regional block performed if planned; local-anesthetic dose recorded for the cumulative total [S4](DOSING_SOURCES.md#s4), [S5](DOSING_SOURCES.md#s5) - [ ] Implants and sizers available - [ ] Airway equipment and difficult-airway cart confirmed --- ## 10. Team brief — topics - Laterality and planned procedure - Drains and postoperative garment - Regional block performed? Planned surgeon infiltration? (Shared local-anesthetic budget [S4](DOSING_SOURCES.md#s4), [S5](DOSING_SOURCES.md#s5). No concurrent IV lidocaine [S1](DOSING_SOURCES.md#s1).) - Analgesic approach and PONV prophylaxis plan [S7](DOSING_SOURCES.md#s7), [S8](DOSING_SOURCES.md#s8) - Anticipated difficulty (scarring, radiation fibrosis, infection) - Communication plan for hemodynamics and pain --- *Educational resource only. Doses are illustrative and must be individualized; see [DOSING_SOURCES.md](DOSING_SOURCES.md). Author: Collin B. George, pre-medical student.*