B ody L o g i C ® S y s t e m P r eope r at i v e W o r k shee t
Patient Name:
Age:
Height:
Weight:
PreOp Bra Size:
Desired Outcome:
2.
3.
4.
-N
SN
C-N
1.
{
Breast Break Point
BH
BBW
Skin Envelope:
Right: IMD
Tight
Moderate
Loose
with Ptosis
N-IMF
BH
Left: Tight
Moderate
Loose
(Stretched)
with Ptosis
Patient Dimensions:
N-IMF
Desired IMF
Right
Left
Right
Sternal Notch to Nipple (SN-N):
Clavicle to Nipple (C-N):
Breast Base Width (BBW):
Breast Height (BH):
Medial Pinch:
Lateral Pinch:
Left
Nipple to IMF (N-IMF):
Nipple* to IMF (stretched):
*Compare with Lower Pole Arc measurement when using MemoryShape® Breast Implants
Upper Pole Pinch:
Areolar Diameter:
X
vert.
X
horiz.
vert.
horiz.
Intermammary Distance:
Observations:
R
Breast Shape:
L
R
Tubular
L
R
Round
L
Conical
R
L
R
Wide
L
Narrow
R
L
Other
Breast Exam:
Estimated Breast Volume: Right:
Left:
Difference:
Asymmetry:
Chest Wall:
Breast:
Nipple Level Discrepancy:
IMF Level Discrepancy:
Surgery Planning:
Surgery Date:
Preferred External Sizer:
Incision Approach:
Implant Placement:
Surgery Type:
Augmentation
Location:
Subpectoral
Reconstruction
Inframammary Fold:
Volume:
Inframammary
Revision
Subglandular
Axillary
Keep
Lower
Breast Base Width:
Profile:
Periareolar
Raise
Other
Dual Plane
caliper measurement
Implant Base Diameter:
Breast Base Width – 1/2 medial pinch – 1/2 lateral pinch
1cm 2cm 3cm 4cm 5cm 6cm 7cm 8cm 9cm 10cm11cm12cm13cm14cm15cm16cm17cm18cm19cm20cm21cm22 cm
B ody L o g i C ® S y s t e m P r eope r at i v e W o r k shee t
Product Selection:
Patient Name:
MemoryGel® Breast Implants
Mentor® Implant Type:
Saline
Spectrum® Adjustable Saline Breast Implant
Tissue Expander
Implant Specs
MemoryShape® Breast Implants
Right
LowMediumTall
Tissue Expander Specs
Left
Catalog #
Catalog #
Base Width
Base Width
Height
Height
Profile
Volume
Gel Volume
Saline Nominal Fill Volume
Saline Final Fill Volume
Right
Left
Final Fill Volume
Notes:
Right
Left
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Important Safety Information:
MENTOR® MemoryGel® Breast Implants, MENTOR® MemoryShape® Breast Implants, and MENTOR® Saline-filled Breast Implants are indicated for breast augmentation in women at least 22 years old for MemoryGel® Implants and MemoryShape® Implants, and
18 years old for Saline Implants. Breast implant surgery should not be performed in women with active infection anywhere in their body, with existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions, or who are
currently pregnant or nursing.
Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. The most common complications for breast augmentation and reconstruction with MemoryGel® Implants include any reoperation, capsular contracture, and implant
removal with or without replacement. The most common complications with MENTOR® MemoryShape® Implants for breast augmentation include reoperation for any reason, implant removal with or without replacement, and ptosis. A lower risk of complication is
rupture. The health consequences of a ruptured silicone gel breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture.
The most common complications with MENTOR® Saline-filled Implants include reoperation, implant removal, capsular contracture, breast pain, and implant deflation.
For MemoryGel® Implants, patients should receive a copy of Important Information for Augmentation Patients about MENTOR® MemoryGel® Breast Implants or Important Information for Reconstruction Patients about MENTOR® MemoryGel® Breast Implants. For
MemoryShape® Implants, patients should receive a copy of Patient Educational Brochure – Breast Augmentation with MENTOR® MemoryShape® Breast Implants or Patient Educational Brochure – Breast Reconstruction with MENTOR® MemoryShape® Breast
Implants, and a copy of Quick Facts about Breast Augmentation & Reconstruction with MENTOR® MemoryShape® Breast Implants. For MENTOR® Saline-filled Implants, patients should receive a copy of Saline-Filled Breast Implants: Making an Informed Decision.
Your patient needs to read and understand the information regarding the risks and benefits of breast implants, with an opportunity to consult with you prior to deciding on surgery.
For detailed indications, contraindications, warnings, and precautions associated with the use of all MENTOR® Implantable Devices, which include MENTOR® Saline-filled Implants, MemoryGel® Implants, and MemoryShape® Implants, please refer to the Product
Insert Data Sheet provided with each product or visit www.mentorwwllc.com.
MENTOR® CONTOUR PROFILE® Tissue Expanders can be utilized for breast reconstruction after mastectomy, correction of an underdeveloped breast, scar revision and tissue defect procedures. This expander is intended for temporary subcutaneous or submuscular implantation and is not intended for use beyond six months. Do not use the CONTOUR PROFILE® Expander in patients where an MRI may be needed. The device could be moved by the MRI causing pain or displacement, potentially resulting in a revision surgery.
The incidence of extrusion of the expander has been shown to increase when the expander has been placed in injured areas.
For detailed indications, contraindications, warnings, and precautions associated with the use of all MENTOR® implantable devices, which include MENTOR® Saline Filled Breast Implants, MemoryGel® Implants, MemoryShape® Implants, and CONTOUR PROFILE®
Expanders, please refer to the Product Insert Data Sheet provided with each product or visit www.mentorwwllc.com.
These tools are meant to assist you in selecting the right implant to achieve the patient’s desired results. How you use these tools will depend upon your personal preferences and experience. The BodyLogic® System does not dictate a specific implant, but provides
guidance in selecting a range of devices that will increase the likelihood of patient satisfaction. The BodyLogic® System is not intended to replace your independent professional judgment.
© Mentor Worldwide LLC 2015 027489-150109