Dear Dr. Smith,
I am writing to provide an update on our mutual patient, Jane Doe, who was seen in my clinic on 1 November 2024.
Jane Doe presented with concerns regarding a previous breast augmentation. She reported dissatisfaction with the aesthetic outcome and asymmetry. The patient also reported a history of capsular contracture in the left breast. Discussion topics included revision options, risks, and benefits of further surgery, and expectations.
During the consultation, we discussed her past medical history, including the previous breast augmentation and subsequent revision. She has had no previous surgeries other than the breast augmentation and revision.
Jane Doe is currently taking no medications or herbal supplements.
Jane Doe has reported no known allergies.
The physical examination revealed asymmetry of the breasts, with the left breast appearing firmer and more contracted than the right. There was also some malposition of the implants.
My assessment is that Jane Doe is experiencing capsular contracture in the left breast and asymmetry requiring revision.
The plan moving forward includes a revision breast augmentation with capsulectomy and implant exchange on the left side. I have advised Jane Doe to avoid smoking and to follow post-operative instructions carefully. Follow-up appointments will be scheduled to monitor healing and aesthetic outcome.
Please do not hesitate to contact me if you require any further information or if you have any questions regarding Jane Doe's care.
Sincerely,
Dr. Thomas Kelly
Plastic & Reconstructive Surgeon
123 Harley Street, London, UK, 020 7123 4567