INFORMED CONSENT for REDUCTION MAMMAPLASTY (BREAST REDUCTION)
This document contains information about reduction mammaplasty (breast reduction) surgery, its risks, and alternative treatments. Please read each paragraph carefully and completely. If you have questions or there are words you don’t know, ask Dr. Laverson. Your signature indicates that you have read and understand this information, and that you agree to have the breast reduction procedure.
Women who have large breasts may experience a variety of problems from the weight and size of their breasts, such as back, neck, and shoulder pain, and skin irritation. Breast reduction is usually performed for relief of these symptoms rather than to enhance the appearance of the breasts. The best candidates are those who are mature enough to understand the procedure and have realistic expectations about the results. There are a variety of different surgical techniques used to reduce and reshape the female breast. There are both risks and complications associated with reduction mammaplasty surgery.
Reduction mammaplasty is an elective surgical operation. Alternative treatment would consist of not undergoing the surgical procedure, physical therapy to treat pain complaints, or wearing undergarments to support large breasts. In selected patients, liposuction has been used to reduce the size of large breasts. Risks and potential complications are associated with alternative surgical forms of treatment.
RISKS of REDUCTION MAMMAPLASTY SURGERY
Every surgical procedure involves a certain amount of risk. It is important that you understand the risks involved with reduction mammaplasty. Your choice to have this surgical procedure should be based on the comparison of risk to expected benefit. Although most women do not experience the following complications, these are the most likely problems associated with breast reduction surgery.
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 quite unusual after this type of surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary.
Change in nipple and skin sensation– You may experience a change in the sensitivity of the nipples and the skin of your breast. Permanent loss of nipple sensation can occur after a reduction mammaplasty in one or both nipples. Nipple sensation may be lost if nipple graft techniques are used for breast reduction.
Skin scarring– All surgical incisions produce scarring. The quality of these scars is unpredictable. Abnormal scars may occur within the skin and deeper tissue. In some cases, scars may require surgical revision or other treatments.
Unsatisfactory result– There is the possibility of a poor result from the reduction mammaplasty surgery. You may be disappointed with the size and shape of your breasts. Asymmetry in nipple location, unanticipated breast shape and size may occur after surgery. Breast size may be incorrect. Unsatisfactory surgical scar location may occur. It may be necessary to perform additional surgery to improve your results or remove implants.
Pain– A breast reduction may not improve complaints of musculoskeletal pain in the neck, back and shoulders. Abnormal scarring in skin and the deeper tissues of the breast may produce pain.
Firmness– Excessive firmness of the breast can occur after surgery due to internal scarring or fat necrosis. The occurrence of this is not predictable. If an area of fat necrosis or scarring appears, this may require biopsy or additional surgical treatment.
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. It is even possible to have loss of skin or nipple tissue. 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 breast and nipple shape, size, or symmetry may also occur after surgery. Additional surgery may be necessary to revise asymmetry after a reduction mammaplasty.
Breast disease– Breast disease and breast cancer can occur independently of breast reduction 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.
Breast feeding– Although some women have been able to breast feed after breast reduction, in general this is not predictable. If you are planning to breast feed following breast reduction, it is important that you discuss this with your plastic surgeon prior to undergoing reduction mammaplasty.
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.
ADDITIONAL SURGERY NECESSARY
Many conditions influence the long term result of reduction mammaplasty. 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 particularly associated with breast reduction surgery. Other complications and risks 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 expressed or implied, on the results that may be obtained.
Depending on your particular health insurance plan, breast reduction surgery may be considered a covered benefit. There may be additional requirements in terms of the amount of breast tissue to be removed and duration of physical problems caused by large breasts. Breast reductions involving removal of small amounts of tissue may not be covered by your insurance. Please review your health insurance subscriber-information pamphlet, call your insurance company, and discuss this further with Dr. Laverson. Many insurance plans exclude coverage for secondary or revisionary surgery.
The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, laboratory tests, blood bank, anesthesia, and hospital charges, depending on where the surgery is performed. 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 from the surgery. Costs of surgical revision may also be your responsibility. In the rare event that revision becomes necessary, Dr. Laverson tries to minimize added expenses.
Informed consent documents are used to communicate information about the proposed surgical treatment of a disease or condition 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.
However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your plastic surgeon 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.
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.
Please understand the above information before signing the consent below.
CONSENT FOR BREAST REDUCTION / REDUCTION MAMMAPLASTY
1. Dr. Steve Laverson and assistant(s) is requested and authorized to perform BILATERAL (RIGHT AND LEFT BREAST) REDUCTION MAMMAPLASTY (BREAST REDUCTION) surgery upon me. I have read and understand the above information, including risks of the procedure and alternative treatments.
2. Rarely, during the course of plastic surgery, unforeseen conditions necessitate different procedures than those above. Dr. Laverson is authorized to perform such other 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 to Dr. Laverson at the commencement of the procedure.
3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve some risk and the possibility of complications, injury, and extremely rarely, death.
4. No guarantee has been given by anyone regarding the final results of the procedure.
5. I consent to photography before and after breast reduction surgery, 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 which may be removed.
7. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. BREAST REDUCTION (REDUCTION MAMMAPLASTY) SURGERY
b. ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. RISKS OF BREAST REDUCTION, AND POSSIBLE COMPLICATIONS
| I CONSENT TO BREAST REDUCTION SURGERY AND THE ABOVE LISTED ITEMS (1-7).I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient