Plastic & Reconstructive Surgeon's Note

Plastic & Reconstructive Surgeon's Note Subjective: - Reason(s) for consultation, including specific surgical concerns or symptoms related to previous surgery. Patient presents with persistent discomfort and unsatisfactory aesthetic outcome following a previous breast augmentation surgery performed 2 years ago. Specifically, she reports capsular contracture in the right breast, causing firmness, distortion, and mild pain, and a desire for revision surgery. - Detailed history of the presenting complaint(s), including duration, severity, aggravating/alleviating factors, associated symptoms, nature, any previous treatments and responses. The patient notes the firmness in the right breast began approximately 6 months post-op, gradually worsening. Pain is intermittent, rated 4/10 at its peak, aggravated by physical activity and relieved by rest. She denies any redness, fever, or discharge. She has attempted massage and a course of Vitamin E without significant improvement. - Past medical and surgical history, highlighting previous surgeries, hospitalizations, outcomes. Past medical history is unremarkable. Surgical history includes a bilateral breast augmentation in 2022 with subpectoral silicone implants (350cc right, 350cc left). No complications were noted during the initial recovery period, aside from expected post-operative soreness. - Current medications, including any anticoagulants, pain management, or antibiotics. Currently taking oral contraceptives (combined pill) and occasional paracetamol for headaches. No anticoagulants or antibiotics. - Social history, focusing on tobacco, alcohol use, and occupation, given their relevance to surgical risks and recovery. Non-smoker, drinks alcohol socially (2-3 units per week). Works as an office administrator, which is largely sedentary. - Allergies, including allergies to medications, latex, or materials used in surgical procedures. No known drug allergies. No latex allergy. Reports no adverse reactions to implant materials previously. Objective: - Vital signs including Blood Pressure, Heart Rate, Temperature, Oxygen Saturation, etc. BP 120/78 mmHg, HR 72 bpm, Temp 36.8°C, SpO2 99% on room air. - Physical examination findings, with emphasis on areas relevant to surgical assessment, including inspection, palpation, percussion, and auscultation findings. General inspection reveals a well-nourished female. Breast examination: Left breast appears soft, symmetrical, and without palpable masses or skin changes. Right breast exhibits Grade III capsular contracture per Baker classification; firm to palpation, noticeably distorted superiorly, and the implant is palpable. Skin over the right breast is intact, no erythema or signs of infection. Nipple sensation intact bilaterally. No axillary lymphadenopathy. - System-specific examination relevant to the surgical concern. Cardiovascular and respiratory examinations are normal. No signs of systemic illness. - Investigation results, including imaging and laboratory tests pertinent to surgical assessment with dates where possible. - Mammogram (10 October 2024): Confirms presence of bilateral implants. Right breast shows dense fibrous capsule formation consistent with capsular contracture. No suspicious breast lesions identified. - Ultrasound (15 October 2024): Confirms thick, echogenic capsule surrounding the right breast implant. No signs of implant rupture. Assessment & Plan: 1. Right Breast Capsular Contracture (Baker Grade III) - Assessment, including the likely diagnosis and rationale based on subjective and objective findings. The patient presents with classic symptoms and signs of capsular contracture, specifically firmness, distortion, and pain in the right breast following augmentation. Physical examination findings and imaging (mammogram, ultrasound) confirm the diagnosis of Baker Grade III capsular contracture. - Differential diagnosis, considering other potential surgical or medical conditions. Implant rupture, infection, seroma, breast mass (ruled out by imaging). - Investigations planned, specifying any additional imaging or tests needed for a definitive diagnosis or pre-operative planning. Routine pre-operative blood tests (FBC, U&E, Coagulation screen, Group and Save). - Surgical treatment planned, detailing the type of procedure, expected outcomes, and potential risks. - Procedure: Right breast capsulectomy (en bloc where possible) and implant exchange. Discussion regarding potentially changing implant type/size for optimal aesthetic outcome and reducing recurrence risk. Consideration of acellular dermal matrix (ADM) if capsule is particularly thin or damaged. - Expected Outcomes: Resolution of pain, improved aesthetic contour, softer breast tissue. - Potential Risks: Bleeding, infection, scarring, asymmetry, recurrent capsular contracture, implant rupture, delayed wound healing, anaesthetic risks. - Pre-operative preparation, including any necessary lifestyle modifications, pre-medication, and fasting instructions. Patient advised to cease oral contraceptives 4 weeks prior to surgery to reduce VTE risk. Strict nil by mouth from midnight the day before surgery. Advised to avoid NSAIDs for 1 week prior. - Post-operative care plan, covering expected hospital stay, pain management, wound care, and follow-up appointments. Expected overnight hospital stay. Oral analgesia (paracetamol and ibuprofen, with tramadol for breakthrough pain). Compression bra to be worn for 6 weeks. Wound care instructions for incision sites. First follow-up appointment scheduled for 2 weeks post-op for wound check and drain removal (if applicable), then 6 weeks and 3 months post-op. - Relevant referrals for multidisciplinary care or further evaluation if needed. No immediate referrals required. Additional Notes: - Patient education and informed consent, including discussion of procedure, risks, benefits, and alternatives. Thorough discussion held regarding the proposed capsulectomy and implant exchange. All risks (bleeding, infection, scarring, recurrence, asymmetry) and benefits (pain relief, improved aesthetics) were explained. Alternatives, including watchful waiting or implant removal without replacement, were also discussed. Patient verbalized understanding and provided informed consent for the planned procedure. - Instructions for emergency care or signs to watch for post-operation. Patient educated on signs of infection (redness, warmth, increased pain, fever) and significant bleeding, with instructions to contact the clinic immediately or attend A&E if severe. - Any specific patient or family concerns addressed during the consultation. Patient expressed concern about the likelihood of recurrence; this was discussed in detail, including strategies to minimise risk.