Date:
Patient:
Reason for Visit:
Postoperative follow-up for reduction mammoplasty
Assessment of incision site healing, drainage, and pain control
Evaluation for early complications (e.g., bleeding, infection, hematoma)
Removal of dressings (if applicable)
History:
Preoperative Assessment:
Date of surgery
Type of reduction mammoplasty performed (e.g., vertical, T-anchor, inverted T)
Amount of tissue and nipple repositioning planned
Past medical and surgical history
Risk factors for complications (e.g., smoking, obesity)
Operative Details:
Briefly summarize the surgical procedure performed, including any unexpected findings or deviations from the plan.
Physical Exam:
General: Assess for vital signs, signs of infection (fever, redness), and overall well-being.
Wounds: Evaluate incision sites for redness, drainage (amount, color), swelling, and approximation (proper closure).
Dressings: Assess the dressing for saturation or bleeding.
Breasts: Evaluate symmetry, nipple position and sensation, presence of seroma (fluid collection) or hematoma (blood collection).
Range of Motion: Assess arm movement for limitations due to pain or swelling.
Diagnostic Tests (may be ordered if complications are suspected):
Complete Blood Count (CBC): May be used to assess for infection if fever or elevated white blood cell count is present.
Wound Culture: If signs of infection are present (redness, purulence) to identify the causative organism and guide antibiotic therapy.
Assessment:
Wound healing progress: Stage of healing (early inflammation, granulation tissue formation, epithelialization).
Pain control: Assess pain level and effectiveness of pain medication.
Presence of early complications: Bleeding, infection, hematoma, seroma, skin necrosis.
Patient satisfaction (may be addressed later in follow-up): Preliminary assessment of aesthetic outcome and patient’s emotional well-being.
Plan:
Wound care instructions: Reinforce proper wound care techniques (cleaning, dressing changes).
Pain management: Adjust pain medication regimen as needed.
Bra fitting: Recommend appropriate supportive bra for optimal healing and comfort.
Activity restrictions: Advise on limitations to activity and lifting restrictions.
Follow-up schedule: Schedule follow-up appointments for wound monitoring and suture removal (if non-dissolvable sutures used).
Patient education: Provide instructions on wound care, activity restrictions, pain management, signs and symptoms of infection to watch for, and importance of contacting the healthcare provider if any concerns arise.
Discuss the gradual nature of swelling and bruising resolution and the expected timeline for improvement.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified plastic surgeon for diagnosis and treatment specific to reduction mammoplasty.