INFORMED CONSENT for BREAST LIFT (MASTOPEXY)
This document contains information about mastopexy (breast lift) surgery, its risks, and alternative treatment. Please read and understand each paragraph completely. If you have questions, need more explanation, or see words you don’t know, ask Dr. Laverson. Your signature at the bottom confirms your understanding and indicates your desire to proceed with breast lift surgery.
Breast lift, or mastopexy is a surgical procedure to raise and reshape sagging breasts. Pregnancy, nursing, weight gain or loss, aging, and gravity change the appearance of a woman’s breasts. As skin loses its elasticity, breasts may lose their shape and sag. Breast lift, or mastopexy is a surgical procedure to raise and reshape sagging breasts. This operation can also reduce the size of the areola, the darker skin around the nipple. If your breasts are small or have lost volume after pregnancy, breast implants inserted in conjunction with mastopexy can increase both firmness and size. The best candidates for mastopexy are healthy, emotionally stable women who have realistic expectations about what this type of surgery can accomplish. Breasts of any size can be lifted, but the results may not last as long in women with heavy, large breasts. Mastopexy does leave permanent, noticeable scars on the breasts. There are several surgical techniques used for the reshaping and lifting of the female breast.
A separate consent form for the use of breast implants with mastopexy is necessary.
Mastopexy is an elective surgical operation. Alternative treatment is to not have mastopexy. Supportive bras can lift sagging breasts, and inserts used to create an appearance of breast fullness. If breasts are large and sagging, a reduction mammaplasty may be considered. Risks and potential complications are associated with alternative treatments.
RISKS of MASTOPEXY SURGERY
Every surgical procedure involves risk, and you should understand risks of mastopexy if you plan to have the operation. Your choice to have surgery is based on a comparison of the risk to expected benefit. While most women do not experience listed complications, they occasionally occur. Ask Dr. Laverson if you want further explanation. Try your best to understand the risks, potential complications, and consequences of mastopexy (breast lift).
Bleeding– It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or blood transfusion. 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 surgical bleeding.
Infection– An infection is unusual after mastopexy. If infection occurs, treatment including antibiotics or additional surgery may be necessary.
Change in nipple and skin sensation– You may experience a change in sensitivity of one or both nipples or on your breast skin. Permanent loss of nipple sensation is unusual, but possible after breast lift surgery.
Breast implants– Risks associated with breast implants are explained in a separate document.
Breast and/or Skin scarring– All surgery leaves scars, some more visible than others. Although good wound healing after mastopexy is expected, abnormal scars may occur on the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin tone. There is a possibility of visible marks on the skin from sutures. Scars may require surgical revision or treatment.
Firmness– Excessive firmness of the breast can occur after surgery due to internal scarring or scarring around a breast implant if one is used. The occurrence of this is not predictable. Additional treatment including surgery may be necessary.
Unsatisfactory result– There is the possibility of a poor result from the mastopexy surgery. You may be disappointed with the results of surgery. Cosmetic risks would include unacceptable visible deformities, poor healing, and unacceptable breast shape. You may be dissatisfied with the size of your breasts after mastopexy.
Delayed healing– Wound disruption or delayed wound healing is possible. Some areas of the breast skin or nipple region may not heal normally and may take a long time to heal. Areas of skin or nipple tissue 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.
Asymmetry– Some breast asymmetry naturally occurs in most women. Differences in terms of breast and nipple shape, size, or symmetry may also occur after surgery. Additional surgery may be necessary to revise asymmetry after a mastopexy.
Recurrent sagging of breasts – Depending on skin elasticity, your activity level, and multiple other factors, breasts may sag or become “ptotic” (pendulous) after breast lift surgery, causing you to become dissatisfied with the long term result of your procedure. A secondary surgery may be indicated to improve on this recurrent sagging, and even a secondary surgery may not completely correct the sagging.
Allergic reactions– In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions which are more serious may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.
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.
Breast disease– Breast disease and breast cancer can occur independently of breast lift surgery. It is recommended that all women perform periodic self-examination of their breasts, have mammography according to American Cancer Society guidelines, and to seek professional care should a breast lump be detected.
Future pregnancy and breast feeding– Mastopexy is not known to interfere with pregnancy or breast feeding. If you are planning a pregnancy, your breast skin may stretch and offset the results of mastopexy.
ADDITIONAL SURGERY NECESSARY
Many conditions may influence the long term result of mastopexy surgery. Secondary surgery may be necessary to perform additional tightening or repositioning of the breasts. Should complications occur, additional surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are the ones particularly associated with mastopexy. Other complications can occur but are even less likely. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty regarding the final result.
Most health insurance companies exclude coverage for cosmetic surgical operations such as mastopexy and complications that might occur from surgery. Some carriers have excluded breast diseases in patients who have breast implants. Please carefully review your health insurance contract. Most insurance plans exclude coverage for surgical revision.
The cost of surgery involves several charges for services provided. The total includes fees charged by Dr. Laverson, the cost of surgical supplies, anesthesia, and the surgery center. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional expenses may be incurred if complications develop after surgery. If secondary surgery is indicated, this also is your financial responsibility. Dr. Laverson tries to minimize these costs in the unusual event that this becomes necessary .
Informed consent documents are used to communicate information about the proposed surgical treatment along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. This informed consent document 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 which is based on all the facts in your particular case and the state of medical knowledge. This document is 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 completely before signing the consent below.
CONSENT FOR BREAST LIFT (MASTOPEXY) SURGERY
1. I hereby request that Dr. Steve Laverson and assistant(s) perform RIGHT AND LEFT BREAST LIFT/MASTOPEXY upon me. I have read and understand the above information about risks of and alternatives to breast lift surgery.
2. During the course of the operation, (although highly unlikely), unforeseen conditions may necessitate different procedures than those above. Dr. Laverson is authorized to perform such other procedures that are in his professional judgment necessary, desirable, and in my own best interest. The authority granted under this paragraph shall include all conditions that require treatment and are not known to Dr. Laverson at the commencement of the procedure.
3. I consent to the administration of anesthetics considered necessary or advisable. Anesthesia involves a small risk and the possibility of complications, injury, and very rarely death.
4. No guarantee or warranty has been offered by anyone regarding the final results.
5. I consent to disposal of my tissue, medical devices or body parts which may be removed.
6. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. DETAILS OF BREAST LIFT (MASTOPEXY) SURGERY
b. ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. RISKS AND COMPLICATIONS OF BREAST LIFT SURGERY
I CONSENT TO BREAST LIFT (MASTOPEXY) SURGERY AND THE ABOVE LISTED ITEMS (1-6).
I AM SATISFIED WITH THE EXPLANATION.