# 04 — Surgical Workflow & Timeline

> **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 — November 2026

## Purpose
This is an illustrative **sequence** showing how the surgeon, anesthesia, scrub and circulating roles interlock during implant revision. Implant revision is not one standardized operation. Indication, reconstruction type, prior radiation, tissue quality and infection change the plan, and technique is surgeon-dependent. Medication numbers are tagged to [DOSING_SOURCES.md](DOSING_SOURCES.md).

*v2.0's clock times and typical OR duration were removed. No acceptable source supports them, and this repository does not prescribe a procedural timeline. 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).*

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## Phase sequence

| Order | Phase | Key actions |
|---:|---|---|
| 1 | Preoperative holding | Marking, consent and implant checklist, antibiotic timing, premedication, analgesic plan |
| 2 | Regional block (approach 1 only) | PECS I+II or serratus plane block; local-anesthetic dose recorded |
| 3 | OR entry, induction, time-out | Safety checklist, positioning, monitoring |
| 4 | Incision | Re-open prior incision (mastectomy scar or inframammary fold) |
| 5 | Explantation and pocket irrigation | Implant removal, inspection, cultures if indicated, irrigation per surgeon and pharmacy |
| 6 | Pocket revision | Capsulotomy/capsulectomy and pocket adjustments as indicated |
| 7 | Sizer → final implant | Upright symmetry check; low-contact insertion |
| 8 | Closure and dressing | Layered closure, drains if indicated, support garment |
| 9 | Emergence and PACU handoff | Reversal confirmed by quantitative monitoring, structured handoff |

---

## Detailed workflow

### 1. Preoperative holding
**Surgeon:** marks the inframammary fold, midline and pocket limits; confirms implant inventory.
**Anesthesia:** IV access (not on a lymphedema/ALND-side arm), premedication, antibiotic timing.
**Nursing:** consent, FDA Patient Decision Checklist [S39](DOSING_SOURCES.md#s39), implant lot documentation, OR readiness.

**Antibiotic timing [S6](DOSING_SOURCES.md#s6):** cefazolin 2 g (3 g if ≥120 kg) within 60 min before incision [S6](DOSING_SOURCES.md#s6). Vancomycin 15 mg/kg is started within 120 min before incision [S6](DOSING_SOURCES.md#s6). Clindamycin 900 mg is given within 60 min [S6](DOSING_SOURCES.md#s6). Cefazolin is redosed every 4 h, and clindamycin every 6 h, if surgery is prolonged [S6](DOSING_SOURCES.md#s6).

### 2. Optional regional block (approach 1)
**Anesthesia:** PECS I+II or serratus plane block under ultrasound. The total local-anesthetic dose is calculated before draw-up against the label maximum for the agent [S4](DOSING_SOURCES.md#s4), [S5](DOSING_SOURCES.md#s5).
**Shared budget:** any surgeon infiltration uses the same local-anesthetic budget. IV lidocaine is not run concurrently [S1](DOSING_SOURCES.md#s1).

### 3. OR entry and safety time-out
- [ ] Patient identity and laterality confirmed
- [ ] Antibiotic given within its window [S6](DOSING_SOURCES.md#s6)
- [ ] Backup implant sizes/profiles in room
- [ ] Insertion funnel (if used) on the sterile field
- [ ] Irrigation solutions labeled per institutional pharmacy
- [ ] Electrosurgical return pad placed
- [ ] Difficult dissection discussed (radiation, fibrosis, infection)
- [ ] 20% lipid emulsion location known if a block or infiltration is planned [S3](DOSING_SOURCES.md#s3)

**Monitoring:** ASA basic monitoring. Blood pressure and heart rate at least every 5 min, plus ECG, pulse oximetry, capnography and temperature [S35](DOSING_SOURCES.md#s35).

**Positioning:** supine; arms on padded boards, avoiding hyperabduction (brachial plexus); forced-air warming; BP cuff and IV away from any lymphedema/ALND-side arm.

### 4. Incision
- Re-open the prior incision (mastectomy scar or inframammary fold scar)
- Extend if exposure is inadequate (surgeon judgment)
- Dissect to the capsule

### 5. Explantation and pocket irrigation
1. Enter the capsule.
2. Remove the implant and inspect for rupture.
3. Explantation may be simple, or include partial or total capsulectomy.
4. Send fluid, capsule or implant for culture if infection is suspected.
5. Irrigate the pocket per the surgeon and institutional pharmacy.
   - The regimen is not prescribed here.
   - Injectable bacitracin, a component of the classic "triple-antibiotic" irrigation, has been off the U.S. market since FDA's January 2020 withdrawal request [S38](DOSING_SOURCES.md#s38). Centers now use bacitracin-free or povidone-iodine–containing solutions.
   - *v2.0's irrigation recipe was removed. Its only sources are primary studies, not an acceptable dose source, and one component is withdrawn.*

### 6. Pocket revision
- Capsulotomy or capsulectomy as indicated (for example, Baker III–IV contracture)
- Medial or lateral release, plication or inferior-pole reinforcement as needed
- Acellular dermal matrix (ADM) used selectively (surgeon preference)

### 7. Sizer → final implant
- Sizer with sterile technique; upright assessment of symmetry and projection
- Final pocket adjustments
- Definitive implant placed with a low-contact technique (for example, an insertion funnel)

### Drain decision (surgeon judgment; expert-opinion level)
Common considerations: suspected or confirmed infection, extensive capsulectomy or raw surface, prior seroma, dissection in radiated tissue. *These are heuristics, not sourced criteria.*

### 8. Closure and dressing
- Layered closure per surgeon; dressing; support garment fitted before transfer

### 9. Emergence and PACU transfer
**Anesthesia:**
- Stop infusions.
- Antagonize neuromuscular blockade guided by quantitative monitoring, and confirm TOFR ≥0.9 before extubation [S10](DOSING_SOURCES.md#s10). Sugammadex is preferred for deep to shallow block [S10](DOSING_SOURCES.md#s10); neostigmine only at minimal depth [S10](DOSING_SOURCES.md#s10), [S12](DOSING_SOURCES.md#s12).
- Give PONV prophylaxis per plan [S7](DOSING_SOURCES.md#s7), [S8](DOSING_SOURCES.md#s8).

**Handoff:** analgesic approach, block and infiltration details (agent and total mg), opioid totals, PONV agents given, drains, special concerns.

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## Intraoperative complication quick reference (surgeon-directed)

| Complication | Immediate management |
|---|---|
| Significant bleeding | Hemostasis; topical hemostatic agents per surgeon |
| Gross implant rupture | Culture if indicated; thorough washout |
| Capsular defect | Repair per surgeon |
| Pocket too loose / too tight | Capsulorrhaphy or targeted release |
| Unexpected purulence | Cultures; treatment antibiotics beyond prophylaxis; drain consideration |
| Signs of LAST (after block or infiltration) | Stop local anesthetic, call for help, airway, benzodiazepine for seizures, 20% lipid emulsion per ASRA checklist [S3](DOSING_SOURCES.md#s3) |

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## Discharge readiness
Same-day discharge follows institutional criteria, such as a modified Aldrete score ≥9 for PACU phase I [S34](DOSING_SOURCES.md#s34), plus surgeon and anesthesia clearance. This document gives no fixed pain-score, vital-sign-duration or drain targets. *v2.0 numeric criteria were removed; see [RELEASE_NOTES.md](RELEASE_NOTES.md).*

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*Educational resource only. Doses are illustrative and must be individualized; see [DOSING_SOURCES.md](DOSING_SOURCES.md). Author: Collin B. George, pre-medical student.*