Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Checklist of Requirements on Equipment/Instruments for

Plastic and Reconstructive Ambulatory Surgery

The following equipment/instruments shall be required for the specified procedure. Place a check (/) if
the ASC is compliant and x mark (X) if not compliant.

AVAILABILITY ADDITIONAL COMPLIANCE REMARKS

(/ if available) EQUIPMENT/INSTRUMENTS
1.Cheiloplasty, Adson forceps (2)
Blepharoplasty, Blade handle
Augmentation Caliper or ruler
Rhinoplasty
Cautery machine
Cord handle with tip
Mosquito forceps, curved (2)
Kidney basin/bowl
Needle holder (small)
Marking instrument/gentian violet
Skin hooks (2)
Fine scissors
Suture scissors
Fine suction tip
Towel clips (4)
2. Flap/Skin Graft Blade handle
Caliper or ruler
Cord handle with tip
Dermatome of choice
Fine forceps (2)
Kidney basin/bowl
Mosquito forceps curved (2)
Marking instrument/ gentian violet
Needle holder (small)
Skin hook (2)
Fine scissors
Suture scissors
Fine suction tip
Towel clips (4)
3.Liposuction (<2.5 Adson forceps (2)
liters) Blade handle
Marking instrument/ gentian violet
Needle holder (small)
Fine scissors
Suture scissors
Set of liposuction cannulae
Liposuction syringes
Towel clips (4)

DOH-ASC-LTO-AT Checklist PR
Revision:01
01/26/2015
Page 1 of 3
 AVAILABILITY ADDITIONAL COMPLIANCE REMARKS
(/ if available) EQUIPMENT/INSTRUMENTS
4. Mini Blade handle
Abdominoplasty Caliper or ruler
Cord handle with tip
Dermatome of choice
Fine-tipped forceps (2)
Mosquito forceps curved (4)
Kidney basin/bowl
Marking instrument/gentian violet
Needle holder (small)
Needle holder (medium)
Army-Navy retractors (2)
Richardson retractors (2)
Fine scissors
Suture scissors
Skin hooks (2)
Suction tip
Towel clips (4)
5. Augmentation Blade handle
Mammoplasty Caliper or ruler
Cord handle with tip
Fine-tipped forceps (2)
Mosquito forceps curved(4)
Kidney basin/bowl
Marking instrument/ gentian violet
Needle holder (small)
Army-Navy retractor
Beaver retractor
Fine scissors
Suture scissors
Suction tip
Towel clips (4)
6. Otoplasty Adson forceps (2)
Blade handle
Caliper or ruler
Cord handle with tip
Mosquito forceps curved (2)
Kidney basin/bowl
Marking instrument/gentian violet
Needle holder (small)
Fine scissors
Suture scissors
Fine suction tip
Towel clips (4)

DOH-ASC-LTO-AT Checklist PR
Revision:01
01/26/2015
Page 2 of 3
 PROCEDURE AVAILABILITY ADDITIONAL COMPLIANCE REMARKS
(/ if available) EQUIPMENT/INSTRUMENTS
7. APTOS Surgery Thumb forceps, toothless
Kidney basin/bowl
Marking instrument/gentian violet
Scissors (Mayo/Metzenbaum)
Towel clips (4)

Dermabrasion Fine forceps (2)

Dermabrasion machine
Kidney basin/bowl
Marking instrument/gentian violet
Towel clips (4)

DOH-ASC-LTO-AT Checklist PR
Revision:01
01/26/2015
Page 3 of 3