INFORMED CONSENT FOR BODY LIFT PROCEDURE
It is required by law that you be fully informed about risks and alternatives of surgery before proceeding with any operation. It is Dr. Laverson’s responsibility to provide this information for you. It is your responsibility to become familiar with this information and consider it when deciding whether or not to proceed with body lift surgery. Read this document carefully and completely. If there is anything you do not understand, call Dr. Laverson and ask him to explain further. Surgery is not an exact science. Because it is impossible to predict your outcome precisely in advance of the procedure, you must understand some of the possible complications of body lift surgery. Your signature at the end of this document confirms your understanding of this information, and your agreement to the proposed body lift procedure.
A body lift is a surgical procedure to remove excess skin and fat from the hips, outer thighs, back, and buttocks. A body lift is not a good treatment for being overweight. Obese individuals who intend to lose weight should postpone body contouring surgery until they have reached a stable healthy weight. There are several techniques used by plastic surgeons for a body lift. A body lift can be combined with other body contouring procedures such as liposuction or performed at the same time as other elective surgeries.
Alternative treatments include no surgery (not removing the excess loose skin and fat), or liposuction if there is good skin tone and localized fat bulges in an individual of normal weight. Diet and exercise programs may be of benefit in the overall reduction of excess body fat and contour improvement. Risks and potential complications are associated with alternative surgical treatments.
RISKS and LIMITATIONS of BODY LIFT SURGERY
Every surgical procedure involves a risk of problems, complications, and/or unanticipated adverse events. Your decision for this (or any) operation should be based on a comparison of risk to expected benefit. There are also limitations of what the body lift procedure can achieve even when the operation and recovery proceed well. Although most patients do not experience complications, you should understand the following possible problems most often associated with body lift surgery. The development of complications is often unpredictable in advance. After reading about these risks, please address any and all questions to Dr. Laverson.
Bleeding- It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require an emergency treatment to drain the accumulated blood or blood transfusion. Intra-operative blood transfusions may be required. Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this may increase the risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the risk of bleeding. Hematoma (an accumulation of blood in the tissues) can occur at any time following surgery. If blood transfusions are needed to treat blood loss, there is a risk of blood related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.
Infection- Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary.
Change in Skin Sensation- It is common to experience diminished (or loss) of skin sensation (numbness) in areas that have had surgery. Diminished (or complete loss of skin sensation) may not totally resolve after a body lift.
Skin Contour Irregularities- Contour and shape irregularities and depressions may occur after a body lift. Visible and palpable wrinkling or dimpling of skin can occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility as is skin pleating or rippling when there is excessive redundant skin. This may improve with time, or it can be surgically corrected.
Major Wound Separation- Repaired (sutured) skin edges may separate creating open wounds. Should this occur, additional treatment including surgery may be necessary.
Skin Discoloration / Swelling- Bruising and swelling normally develop following a body lift. The skin at or near the surgical site can appear lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time or, rarely, may be permanent.
Skin Sensitivity-Skin itching, tenderness, or exaggerated response to hot or cold temperatures may develop after surgery. Usually this resolves during healing, but in rare situations it may be persist.
Sutures- Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures may poke through the skin, become visible or produce irritation that requires removal.
Fat Necrosis- Fat found deep in the skin might die. This may produce areas of firmness or lumps beneath the skin. Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour irregularities in the skin that may result from fat necrosis.
Damage to Deeper Structures- There is the potential for injury to deeper structures including, nerves, blood vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.
Scarring- All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be wide, thick, raised, discolored, unattractive, and asymmetric between right and left sides of the body. Scars my be difficult to conceal beneath the clothing you prefer. Scar appearance may vary within the same scar, exhibit texture variations or “bunching” due to the amount of excess skin. There is a possibility ofvisible marks in the skin from sutures. Scars may be objectionable enough to require surgical revision or treatment to improve their location or appearance, which may or may not be possible.
Surgical Anesthesia– Both local and general anesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation.
Asymmetry- Symmetrical body appearance may not result from a body lift. Factors such as skin tone, fat distribution, skeletal prominence, and muscle tone may contribute to normal asymmetry in body features. Most patients have differences between the right and left side of their body before surgery is performed. Additional surgery may be necessary to attempt to improve asymmetry.
Delayed Healing– Wound disruption or delayed wound healing is possible. Some areas of the abdomen, flank, back, or buttocks may not heal normally and may take a long time to heal. Some areas of skin may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Smokers have a greater risk of skin loss and wound healing complications.
Allergic Reactions- During or after plastic surgery, local allergies to tape, suture material and glues, blood products, topical preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur to drugs used during surgery and prescription medications. Allergic reactions may require additional treatment.
Seroma– After plastic surgery, fluid accumulations frequently occur in between the skin and the abdominal wall, legs, flank, back, or buttocks. This may require additional procedures for drainage of fluid.
Shock- In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or extensive procedures are performed. Although serious complications are infrequent, infections or excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization and additional treatment would be necessary.
Surgical Wetting Solutions– There is the possibility that large volumes of fluid containing dilute local anesthetic drugs and epinephrine that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to these medications. Additional treatment including hospitalization may be necessary.
Persistent Swelling (Lymphedema)- Persistent swelling in the legs can occur following body lift surgery.
Pain- You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist after body lift surgery. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue after a body lift.
Unsatisfactory Result– Although good results are expected and usually achieved, there is no guarantee or warranty, expressed or implied, that you will be pleased with the outcome of Body Lift Surgery. You may be disappointed and/or dissatisfied with the results. This would include the possibility of asymmetry, abnormal surface contour, unsatisfactory or highly visible surgical scar location, unacceptable visible deformities, bunching and rippling in the skin near the suture lines or at the ends of the incisions (dog ears), poor healing, wound disruption, and loss of sensation. It may not be possible to correct or improve the resulting scars. In some situations, it may not be possible to achieve optimal results with a single operation. Additional surgery may be required to improve results.
Deep Venous Thrombosis (Blood Clots in the Veins), Heart and Lung Complications- Surgery, especially longer procedures, may be associated with the formation of, or increase in, blood clots in your veins. Pulmonary (lung) complications may occur from blood clots (pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary and fat emboli can be life-threatening or fatal. Air travel, inactivity and other conditions may increase the chance of blood clots traveling to the lungs (embolizing) causing a catastrophe resulting in death. It is important to discuss with Dr. Laverson any past history of blood clots, swollen legs or the use of estrogen or birth control pills that may contribute to this condition. Cardiac (heart) complications are a risk with any surgery and anesthesia, even in patients without symptoms. Should any of these complications occur, you may require hospitalization and additional treatment. If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately.
Metabolic Status of Massive Weight Loss Patients– Your blood chemistry and protein levels may be abnormal following bariatric surgery and massive weight loss. Individuals with metabolic abnormalities may be at risk for serious medical and surgical complications, including delayed wound healing, infection or even in rare cases, death.
Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray)-
Patients who are currently smoking, use tobacco products, or nicotine products (patch, gum, or nasal spray) are at a greater risk for significant surgical complications of skin dying, delayed healing, and additional scarring. Individuals exposed to second-hand smoke are also at risk for similar complications attributable to nicotine exposure. Smoking may have a negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine-containing products have a lower risk of this type of complication.
Absolutely NO SMOKING for at least 6 weeks before surgery and until Dr. Laverson states it is safe to resume, if desired.
Post-bariatric patients- It is highly recommended that you quit smoking before undergoing this procedure as it will adversely affect your outcome. Only under certain circumstances, clearly specified by Dr. Laverson, should this procedure be done on an individual who smokes.
Long-Term Results- Subsequent alterations in the appearance of your body may occur as the result of aging, sun exposure, weight loss, weight gain, pregnancy, menopause or other circumstances notrelated to your surgery.
Female Patient Information- It is important to inform Dr. Laverson if you use birth control pills, estrogen replacement, or if you believe you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy.
Physical Activity After Surgery– Surgery involves cauterization and ligation of blood vessels. Physical activity following surgery may open these vessels causing them to bleed. Activity that increases your pulse and/or heart rate may cause additional pain, bruising, swelling, wound separation, and the need for return to surgery. Delay sexual activity and strenuous physical activity for at least four weeks after the procedure, and then proceed with gradual increases in activity only as you are able to do so without significant pain. Pain is your body’s signal that you should rest.
Medications- Adverse reactions may result from over-the-counter, herbal, and/or prescription medications. Check with your physician about drug interactions that may exist with medications that you are already taking. If you have an adverse reaction, stop the drugs immediately and call Dr. Laverson for further instructions. If the reaction is severe, go immediately to the nearest emergency room. When taking the prescribed pain medications after surgery, realize that they can affect your thought process and coordination. Do not drive or operate complex equipment or make any important decisions or drink any alcohol while taking these medications. Take prescribed medication only as directed, and call Dr. Laverson if the medication is not relieving your pain or if you are not tolerating the medication well.
Mental Health Disorders and Elective Surgery- All patients considering cosmetic surgery should have realistic expectations that focus on improvement rather than perfection. Complications or unsatisfactory results are sometimes unavoidable, may require additional surgery, and are often stressful. Before your procedure, openly discuss with Dr. Laverson any history that you have of emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted.
ADDITIONAL SURGERY NECESSARY (Re-operations)
Many conditions influence the outcome after surgery. If complications occur, additional surgery or other treatments may be necessary. Secondary surgery may be necessary to improve the result. Even though complications occur infrequently, those mentioned above are particularly associated with abdominoplasty. Other complications can occur but are even less common. The practice of medicine and surgery is not an exact science. Although good results are expected, your satisfaction cannot be guaranteed. In some situations, it may not be possible to achieve optimal results with a single surgical procedure.
Follow all physician instructions carefully; This is essential for a good outcome. Healing is a gradual process (weeks to months). Surgical incisions should not be subjected to excessive force, swelling, abrasion, or motion during the time of healing. Personal and vocational activity must be restricted. Protective dressings and drains should notbe removed unless instructed by Dr. Laverson. Successful recovery depends on how the surgery is performed, but also on your care and activity during the days and weeks after the procedure when your body is healing and your tissues are repairing. Physical activity that increases your pulse or heart rate may cause bruising, swelling, fluid accumulation, and the need to return to surgery. It is wise to refrain from sexual and strenuous physical activities after surgery until Dr. Laverson states it is safe (Usually several weeks). Participate in follow-up care, return for aftercare, and promote your recovery by resting and allowing your body to heal after surgery.
The cost of surgery involves several charges for the services provided. The total includes fees charged by Dr. Laverson, anesthesia, post-operative garment(s), and outpatient surgery center charges. If surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. The fees charged for this procedure do not include future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional expenses may be incurred if complications develop from the surgery. Secondary surgery or revision surgery will also be your responsibility. In signing the consent for this surgery/procedure, you acknowledge that you have been informed about the most common associated risks and adverse consequences. When you sign, you are also accepting responsibility for the clinical decisions that were made along with the financial costs of all future treatments.
Health insurance companies exclude coverage for cosmetic surgical operations such as body lift surgery and complications that result from surgery. Please carefully review your health insurance contract or ask your insurance company for a detailed explanation of their policies. Most insurance plans exclude coverage for secondary or revisionary surgery.
Informed consent documents are used to communicate information about proposed surgical treatment and to disclose risks and alternatives for treatment, including no surgery. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, this documents should not be considered all inclusive in defining other methods of care and risks encountered. Dr. Laverson may provide you with additional or different information that is based on all the facts in your particular case and the current state of medical knowledge.
Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
Understand the above information before signing the consent below.
CONSENT FOR BODY LIFT SURGERY
1. Dr. Steve Laverson and assistant(s) is requested and authorized to perform BODY LIFT (Flank-thigh-buttock lift) surgery upon me. I have reviewed the above five pages of information, and understand risks of the procedure, possible complications, and alternatives.
2. Rarely, during the course of plastic surgery, unforeseen conditions may necessitate changes in the surgical plan. Dr. Laverson is authorized to perform such procedures that are in the exercise of his best professional judgment necessary, desirable, and in my own best interest. The authority granted under this paragraph shall include conditions that require treatment and are not known at the commencement of surgery.
3. I consent to the administration of such anesthetics considered necessary or advisable. All forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death.
4. Nobody has guaranteed or indicated to me that I will be satisfied with the results of this procedure.
5. I consent to be photographed before and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.
6. I consent to the disposal of any tissue, medical devices or body parts that may be removed.
7. Although the possibility is extremely unlikely, I consent to the utilization of blood products should they be deemed necessary by Dr. Laverson, and I am aware that there are potential significant risks to my health with their utilization.
9. I understand that the surgeons’ fees are separate from the anesthesia and surgery center charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure may be required.
10. I realize that not having the operation is an option.
11. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE BODY LIFT PROCEDURE
b. ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. RISKS OF BODY LIFT SURGERY
I REQUEST AND CONSENT TO BODY LIFT SURGERY AND THE ABOVE LISTED ITEMS (1-11). I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient
Date __________________________ Witness ____________________________________