INFORMED CONSENT FOR GYNECOMASTIA
(MALE BREAST REDUCTION) SURGERY
This document contains information about gynecomastia (male breast reduction) surgery, its risks, and alternative treatment(s). Please read each paragraph completely. If you have questions or there are words you don’t know, ask Dr. Laverson. Your signature at the bottom confirms your understanding and your desire to proceed with male breast reduction surgery.
Gynecomastia surgery is a procedure to remove excess fat, glandular tissue and/or skin from overdeveloped or enlarged male breasts. There is a broad spectrum of gynecomastia. The problem may be as little as a temperature sensitive, occasional increase in areolar size and projection, or as much as breasts which are large and sagging with enlarged areolae (dark skin around the nipple), and feminine in appearance. In these cases, the position and size of the areola can be surgically improved and excess skin may need to be reduced. Gynecomastia may result from hormonal changes, heredity, disease, or the use of certain medications, and can present unilaterally (one breast) or bilaterally (both breasts).
Different techniques are described for gynecomastia treatment. The techniques used for your procedure depend on your anatomy, your preferences, Dr. Laverson’s recommendaton, and other factors. Gynecomastia surgery can be combined with other forms of body contouring surgery, including liposuction, or performed at the same time as other elective surgeries.
Alternative treatments include not having any surgical procedure, and living with the gynecomastia. Garments which hide the large breasts can be used. Liposuction alone has been used to reduce the size of large breasts. Risks and possible complications are associated with each of these alternatives.
RISKS OF GYNECOMASTIA SURGERY
Every surgical procedure involves risk, limitations, and a chance of unanticipated problems and/or complications. Surgery is not an exact science, and always carries with it an element of unpredictability. It is important to understand the risks and possible complications associated with gynecomastia surgery if you are considering the procedure. Your choice to have the operation should be based on a comparison of risk to expected benefit. Although most patients do not experience complications, discuss each of them with Dr. Laverson to be sure you understand possible consequences of gynecomastia surgery.
Bleeding- It is rare, but possible to experience a bleeding episode during or after surgery. Intraoperative blood transfusion may be required. Should bleeding occur after surgery, it may require an emergency treatment to drain the accumulated blood or blood transfusion. Do not take any aspirin or anti-inflammatory medications for ten days before surgery, because this increases the chance of bleeding. Non-prescription “herbs” and dietary supplements may increase the risk of bleeding. Hematoma (a blood clot) can occur at any time. If blood transfusions are needed to treat blood loss, there is a risk of blood-related infections such as hepatitis or HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets. You have a right to refuse transfusion of blood and blood products.
Infection- Infection is unusual after surgery. Should infection occur, additional treatment including antibiotics, hospitalization, or additional surgery to drain the infection may be necessary.
Change in Nipple and Skin Sensation– You may lose sensitivity of the nipple(s) and/or the skin of your breast(s). Permanent loss of nipple sensation can occur after gynecomastia in one or both nipples. Changes in sensation may affect sexual response. In rare circumstances the nipple may be lost entirely.
Skin Contour Irregularities- Surface contour and shape irregularities may develop after gynecomastia surgery. Visible and palpable rippling or wrinkling of the skin may result. One breast may be smaller than the other. Nipple position and shape may not be identical on both sides. Residual skin irregularities at the ends of the incisions or “dog ears” are a possibility when there is excess skin. Revision surgery may be required to improve these problems. Nipple retraction may occur after gynecomastia surgery.
Sutures– Most surgical techniques use deep sutures (stitches). You may notice these after your surgery. Sutures may spontaneously erode through the skin, become visible, and/or cause irritation. The deep sutures may need to be removed.
Skin Discoloration / Swelling- Bruising and swelling normally occur following gynecomastia surgery. Skin at or near the surgical site can appear lighter or darker than surrounding skin. Rarely, swelling and skin discoloration may persist for long periods of time or be permanent.
Scarring– All surgery leaves scars, some more visible than others. Although good wound healing after surgery is expected, abnormal scars may occur. Scars may be wider or longer than anticipated, and may be unattractive. Scars may be different in color and/or texture than the surrounding skin. Appearance may vary within the same scar. Scars may be asymmetric (appear different on the right and left side of the body). There is a possibility ofvisible marks in the skin from sutures. Scars may require surgical revision or treatment.
Damage to Deeper Structures- There is potential for injury to deeper structures including, but not limited to, nerves, blood vessels, muscles, lungs (pneumothorax) during any surgical procedure. The potential for injury depends on the type of procedure being performed. Injury may be temporary or permanent.
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 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- In rare cases, local allergies to tape, suture materials and glues, blood products, topical preparations or injected agents have been reported. Serious reactions including shock (anaphylaxis) may occur in response to drugs used during surgery and to prescription medications. Allergic reactions may require treatment.
Asymmetry– Breast asymmetry naturally occurs in most men. Factors such as skin elasticity, fat distribution, skeletal prominence, and muscle development may contribute to asymmetry of body features. A difference between right and left sides with respect to breast and/or nipple size and/or shape may become evident after surgery. Additional surgery may be indicated to improve asymmetry.
Surgical Wetting Solutions– It is possible (rare) that large volumes of fluid containing dilute local anesthetic drugs and/or epinephrine injected into fat during surgery may cause fluid overload or an adverse reaction. Additional treatment including hospitalization may be necessary.
Fat Necrosis– Fat found deep in the skin might die. This may result in firmness beneath the skin. Additional surgery to remove lumps of fat necrosis may be necessary. There is a possibility of contour irregularities of skin from fat necrosis and/or its treatment.
Seroma– Fluid may accumulate beneath the skin after surgery. This is called a Seroma. Additional procedure(s) may be indicated to drain the fluid and/or remove the seroma.
Shock– In rare circumstances, your procedure can cause severe trauma and shock, 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.
Skin Sensitivity-Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery. Usually this resolves during healing, but in rare situations it may be chronic.
Surgical Anesthesia– Both local and general anesthesia involve risk. There is the possibility of complications, injury, and (extremely rarely) death from anesthesia or sedation.
Pain- You will have pain after surgery. Pain of varying intensity and duration may occur and persist after this procedure. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue.
Unsatisfactory Result- Although good results are expected, there is no guarantee or warranty expressed or implied, with respect to the final results. You may be disappointed with the results of gynecomastia surgery. Asymmetry in nipple location or unanticipated breast shape and size may occur after surgery. Unsatisfactory scar location, visible deformities at the ends of the incisions (dog ears), loss of function, wound disruption, poor healing, and loss of sensation may occur. It may be necessary to perform additional surgery to improve your results.
Cardiac and Pulmonary Complications- Surgery, especially longer procedures, may be associated with the formation of, or increase in, blood clots within veins. Lung complications may result from blood clots (pulmonary emboli), fat moieties (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary and fat emboli can be life-threatening or fatal in some circumstances. Inactivity and other conditions may increase the chance of blood clots traveling to the lungs causing occlusion of a large vessel, resulting in death. Discuss with your physician any past history of blood clots or swollen legs that may contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require hospitalization and additional treatment.
Long-Term Results- Subsequent alterations in the breast shape may occur as the result of aging, sun exposure, weight loss, weight gain or other circumstances notrelated to your surgery. Breast sagging may normally occur.
Breast Disease in Male Patients– Breast disease and breast cancer can occur independently of gynecomastia surgery. If a mass, nodule, or lump is detected, seek professional care immediately.
Breast and Nipple Piercing Procedures– Self adornment with jewelry secured in piercings are advised that an infection may result at and around the site of piercing.
Interference with Sentinel Lymph Node Mapping Procedures-Breast surgery procedures that involve cutting through breast tissue can interfere with future diagnostic procedures to determine lymph node drainage of breast tissue to stage breast cancer and/or melanoma. If this is a concern, surgery to treat gynecomastia should be avoided.
Sexual Activity After Surgery– Surgery involves coagulating blood vessels. Increased physical and/or sexual activity may increase blood pressure and open these vessels leading to bleeding or a hematoma. Activity that increases your pulse or heart rate may cause additional bruising, swelling, and the need for return to surgery to control bleeding. Avoid strenuous physical and sexual activity until Dr. Laverson states it is safe (usually three to four weeks following the procedure).
Mental Health Disorders and Elective Surgery- All patients planning elective surgery should have realistic expectations that focus on improvement rather than perfection. Although Dr. Laverson strives to achieve perfection every time, complications and imperfect results can be unpredictable and unavoidable. Additional surgery and expense may be needed. This is often are stressful. Please openly discuss with Dr. Laverson any history that you have of significant emotional depression or mental health disorders. Although many individuals benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted.
Medications– Over-the-counter, herbal, and/or prescription medications. Be sure to check with your physician about any drug interactions that may exist with medications which you are already taking. If you have an adverse reaction, stop the drugs immediately and call your plastic surgeon 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, do not operate complex equipment, do not make any important decisions, and do not drink any alcohol while taking these medications. Be sure to take your prescribed medication only as directed.
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 potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have a significant 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 significantly lower risk of this type of complication.
Do not smoke any tobacco containing products for at least 6 weeks consecutively and continuously before surgery and until Dr. Laverson states it is safe to resume, if desired.
ADDITIONAL SURGERY NECESSARY
There are many variable conditions that may influence the long-term result of gynecomastia. 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 gynecomastia. Other complications and risks can occur but are even more uncommon. 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. 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 the success of your outcome. It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing. Personal and vocational activity needs to be restricted. Protective dressings and drains should not be removed unless instructed by your plastic surgeon. Successful post-operative function depends on both surgery and subsequent care. Physical activity that increases your pulse or heart rate may cause bruising, swelling, fluid accumulation and the need for return to surgery. It is wise to refrain from intimate physical activities after surgery until your physician states it is safe. It is important that you participate in follow-up care, return for aftercare, and promote your recovery after surgery.
Most health insurance companies exclude coverage for cosmetic surgical operations such as a gynecomastia or any complications that might occur from surgery. Please carefully review your health insurance subscriber-information pamphlet. Most 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 surgeon, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient 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. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome Additional costs may occur should complications develop from the surgery. Secondary surgery or hospital day-surgery charges involved with revision surgery will also be your responsibility. In signing the consent for this surgery/procedure, you acknowledge that your have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.
Informed-consent documents are used to communicate information about planned surgery for a disease or condition along with disclosure of risks and alternative forms of treatment(s), 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, informed-consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Dr. Laverson may provide additional or different information 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.
Read all of the above information and have all of your questions answered before signing the consent for surgery below.
CONSENT FOR MALE BREAST REDUCTION (GYNECOMASTIA) SURGERY
1. My signature below indicates my request for and my agreement with Dr. Steve Laverson and selected assistants performing GYNECOMASTIA SURGERY (MALE BREAST REDUCTION) upon me. I have read and understand the above information, including alternatives to treatment and risks of gynecomastia (male breast reduction) surgery.
2. Rarely, during the course of plastic surgery and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize Dr. Laverson to perform only such other procedures that are in his professional judgment necessary, desirable, and in my own best interest. The authority granted under this paragraph includes all conditions that require treatment and are not known at the time the procedure is begun.
3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death.
4. The results of gynecomastia (male breast reduction) surgery are not guaranteed.
5. I consent to photography before and after the operation, 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 disposal of any tissue, medical devices or body parts which are removed.
7. I consent to transfusion of blood products (highly unexpected) if they are considered necessary by my surgeon, and I am aware that there are risks to my health with their utilization.
8. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required.
9. I realize that not having the operation is an option.
10. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. MALE BREAST REDUCTION (GYNECOMASTIA) SURGERY
b. ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT (INCLUDING NO TREATMENT)
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO GYNECOMASTIA SURGERY AND THE ABOVE LISTED ITEMS (1-10). I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient
Date __________________________ Witness ____________________________________