CONSENT FOR COSMETIC REDUCTION and/or RESHAPING of the VULVA / LABIA MINORA / NYMPHAE
1. Dr. Steve Laverson and assistant(s) are hereby requested and authorized to perform upon me a surgical procedure to reduce the size of the enlarged folds of skin and mucous membrane (labia minora, or nymphae) of my vulva (genitalia). The operation, entitled “labiaplasty,” is expected to reduce the size of the labia, and to maintain normal appearance and function. If and only if requested by me, the operation will also include modifications to skin covering my clitoris and to skin and soft tissue of the labia majora.
2. A good result from the procedure is expected, but cannot be guaranteed. Surgery is an inexact science. Dr. Laverson has told me to expect a good result, but has not made any promise of a specific outcome, or guaranteed whether expressed or implied, a specific result.
3. Healing for days to weeks after the surgery is part of the process toward the expected good result. For seven to ten days after labiaplasty, swelling is excessive, and the labia appear deformed. This is normal. Bruising, and intermittent spotting may be noted and may last several weeks. Application of an external pad is recommended. Minimal areas of numbness may occur lasting for a few weeks. If I experience bleeding, wound problems, excessive pain, or any unexpected problem, I will return to Dr. Laverson for examination.
4. Absorbable sutures used to secure a smaller labia may be felt by me for several weeks. These can be removed at a follow up visit if necessary or desired.
5. There are risks associated with this procedure, and with all surgical procedures. Some common complications during labiaplasty and recovery include, but are not limited to: hematoma (localized collection of blood or blood clot), infections, itching, poor wound healing, need for re-operation or revision, change in sensation, and others. To minimize the chance of these complications, careful hygiene, protection from trauma, and abstinence from sexual intercourse for several (three to five) weeks is recommended. Any problems I have during the post-surgical healing period will be brought to Dr. Laverson’s attention.
6. Limited permission is hereby granted for photography before the procedure to document my condition and after the procedure to document my result. As part of my medical record, my photographs are protected health information, and as such are subject to federal privacy laws specified in the Health Insurace Portability and Accountability Act (HIPAA). A separate photographic consent permits distribution of photographs for education of others about the labiaplasty procedure. Never at any time or in any place will my name or any other identifying information accompany photographs of me (with the possible exception of jewelry or body art).
7. Dr. Laverson will be notified immediately of any problems or concerns, and I will attend all recommended post-surgical follow up appointments.
8. Although the decision to proceed with labiaplasty is mine, my sexual partner or significant other is aware that I am having the procedure, and we are both aware that there will be a period of sexual abstinence afterward. Dr. Laverson is hereby released from any and all liability associated with emotional and other consequences of this hiatus, as well as any unanticipated complications of this procedure. I have no known significant emotional disorder presently.
9. Genital hygiene is important to minimize the chance of infection. Application of antibiotic ointment and daily gentle showers and/or baths may be recommended.
10. Smoking cigarettes may interfere with healing, and increase the chance of complications.
11. Recovery from this procedure includes rest for several (2-4) days after surgery, and no immediate return to exercise or intense physical exertion. Riding a bicycle, horseback, and exercises that potentially impact my vulva and perineum will be delayed until healing has progressed sufficiently that such activities are not painful, usually four to six weeks. I agree to abstain from sexual intercourse for five weeks following surgery, or until it is not painful.
12. Alternatives to labiaplasty include no surgery. There are no known non-surgical treatments recommended as safe and effective. Radiofrequency and other skin tightening devices may change labial texture, but do not reduce labial size significantly.
I have read this document completely, I understand it, and my questions have been answered to my satisfaction. This request for labiaplasty surgery is signed without duress in the presence of a witness whose signature appears below.
Patient Signature Date
I have personally witnessed that the above patient has read this document, or agreed to sign without reading. Questions have been answered to her satisfaction.
Witness Signature Date