BREAST REDUCTION CONSULT Patient Initial: ______mild (augmentation), moderate/severe (mastopexy) AC height Sternal (19-21cm): notch to nipple Nipple to IMF during stretch (7-8cm): Base width (11-14cm): Areolar diameter (35-45mm): Nipple to midline (9-11cm): Superior: Lower pole: Psyche: embarrassment or anxiety Family History of Breast Cancer Previous Breast Surgery Breast disease Height, weight, body frame (S, M, L): Diabetes Bleeding Daithesis Scarring Upper Thoracic Backache Bra Strap Grooving Breast Pain nt Name:
Intertrigo Mastodyina Mammogram Masses Biopsies N
Patie Street ______Address: State: City, Daytime ______Phone: Cell: ______Email: ______q q q q q Parenchymal coverage (pinch test) q q q q Oncologic History q q ______q q q q q q Ptosis: ______Measurements: q q q q Symptoms q q ______BMI: ______planned: __ desired: (by 35yo if surgery; q2y at 40; qly at 50) ______
: ______
______: ______: ______Wt
______chest wall, scoliosis and breast ______
______tone, elasticity, striae tone, elasticity,
______Breast volume IMF height Smoker Collagen Vascular Collagen Vascular ______
BREAST REDUCTION CONSULT BREAST REDUCTION q q Symmetry: ______Skin: ______Cancer screening: masses, dimpling, discharge and lymph nodes PHYSICAL Ht: q Weight Loss: recent Weight q ______Breast size: current Plans for more children: Mammogram: screening Breastfeeding, size before/during/after: ______Pregnancy history: Personal or Family h/o Br. CA or Dz: Personal or Family h/o Br. ______HISTORY Age: Attending: Attending: of consult: Date Resident: PHYSICAL (cont.)
Asymmetries
Constriction: Left: ______Right: ______
Tubular: Left: ______Right: ______
Baker Ptosis I - Normal I - NAC at IMF II - Palpable, min firm, II - NAC below IMF/ not visible above lower breast III - Visible, mod firm, III - NAC below IMF and breast easily palpable Pseudo - NAC above IMF/ IV - Painful, hard, distorted breast below
COUNSELING COMPLICATIONS
Expectations: ______q Lactation: (50%)
______q Sensation: (90% but can take up to a year to return) Breast Shape Changes Desires to Achieve: ______q q Mammography: Preop and 9-12 months postop ______
Desires to Avoid: ______
______
OTHER NOTES