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.

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. The tag links to the source in 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.

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) — record drug, dose and daily MME; plan to continue the baseline regimen 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. One point each:

• Female sex
• Non-smoker
• History of PONV or motion sickness
• Postoperative opioids expected

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.

5.3 OSA screen (STOP-Bang)

Source: S32, S33.

Snoring · Tiredness · Observed apnea · high blood Pressure · BMI >35 kg/m² · Age >50 years · Neck circumference >40 cm · male Gender S32

Score: ___ / 8 → 0–2 low risk; 3–4 intermediate risk; 5–8 high risk of moderate-to-severe OSA S33

5.4 Hemodynamic notes

• Chronic beta-blocker (bradycardia risk with dexmedetomidine S14)
• Baseline bradycardia or conduction disease
• Poorly controlled hypertension (ketamine caution 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.
• 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.

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. 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)

See 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. Contraindicated in severe hepatic impairment 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.
• Gabapentinoid — not routine. A 2020 meta-analysis found no clinically meaningful analgesic benefit and more dizziness and visual disturbance (Verret 2020; see 06). 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.

• Cefazolin 2 g IV, or 3 g if weight ≥120 kg, within 60 min before incision; redose every 4 h in prolonged surgery 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, or vancomycin 15 mg/kg IV started within 120 min before incision 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).
• Site marked and laterality confirmed
• Antibiotic timing planned: cefazolin or clindamycin within 60 min; vancomycin within 120 min before incision S6
• Premedications given as ordered
• Regional block performed if planned; local-anesthetic dose recorded for the cumulative total S4, 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, S5. No concurrent IV lidocaine S1.)
• Analgesic approach and PONV prophylaxis plan S7, 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. Author: Collin B. George, pre-medical student.