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.

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.

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.

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, implant lot documentation, OR readiness.

Antibiotic timing S6: cefazolin 2 g (3 g if ≥120 kg) within 60 min before incision S6. Vancomycin 15 mg/kg is started within 120 min before incision S6. Clindamycin 900 mg is given within 60 min S6. Cefazolin is redosed every 4 h, and clindamycin every 6 h, if surgery is prolonged 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, S5. Shared budget: any surgeon infiltration uses the same local-anesthetic budget. IV lidocaine is not run concurrently S1.

3. OR entry and safety time-out

Patient identity and laterality confirmed
Antibiotic given within its window 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

Monitoring: ASA basic monitoring. Blood pressure and heart rate at least every 5 min, plus ECG, pulse oximetry, capnography and temperature 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

Enter the capsule.
Remove the implant and inspect for rupture.
Explantation may be simple, or include partial or total capsulectomy.
Send fluid, capsule or implant for culture if infection is suspected.
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. 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. Sugammadex is preferred for deep to shallow block S10; neostigmine only at minimal depth S10, S12.
Give PONV prophylaxis per plan S7, S8.

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

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

Discharge readiness

Same-day discharge follows institutional criteria, such as a modified Aldrete score ≥9 for PACU phase I 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.

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