CONSENT FOR REDUCTION MAMMAPLASTY

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

General Information

Women who have large breasts may experience a variety of problems from the weight and size of their breasts, such as back, neck, shoulder pain and skin irritation. Breast reduction is usually performed for relief of these symptoms as well as 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.

1. I hereby request the above named surgeon(s) and/or their associates to perform a surgical procedure known as reduction mammaplasty, a plastic surgical procedure to alter the size and shape of my breasts. This procedure has been explained to me by the doctor(s) and I completely understand its nature and consequences.

2. I understand that every surgical procedure involves certain risks and possibilities of complications such as bleeding, infection, poor healing, etc and that these and other complications may follow even when the surgeon uses the utmost care, judgment and skill. These risks have been explained to me and I accept them. The following points have been explained in detail.

a. There are always rather long scars following this procedure. Every reasonable effort will be made to make them as inconspicuous as possible.

b. Delayed healing at times occurs along the margins of the incisions; and occasionally there is some loss of the skin edges or of the nipple itself, requiring prolonged dressings or additional surgery for correction. Additional surgical procedures will involve additional charges or fees. * Smokers have a greater risk of skin loss and wound healing complications.

c. No guarantee as to size, shape or brassiere size has been made.

d. The breast will feel irregular (lumpy), firm and uncomfortable for an indefinite period of time. Very rarely, portions or all of the nipple may not survive.

e. 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.

f. An infection is quite unusual after this type of surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary.

g. 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.

h. 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.

i. 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.

3. I have an understanding of the operation which includes but is not limited to the above items. I understand that secondary revisions may be required in some cases. I also understand that charges will be made for the use of the operating room, whether in the day surgery or in the hospital. I agree to be responsible for these charges.

4. I recognise that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those outlined. I, therefore, further authorise and request that the above-named surgeon or his/her assistants perform such procedures as are, in his or her professional judgment, necessary and desirable. The authority granted under this Paragraph 4 shall extend to remedying conditions that are not known to or could not reasonably be anticipated by the above doctor(s) at the time the operation is commenced.

5. I consent to the administration of local or general anaesthetic agents by or under the direction and supervision of the above doctor(s), and anaesthetist working with them.

6. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure; nor are there any guarantees against unfavourable results.

7. I consent to be photographed before, during and after the surgery; that these photographs shall be the property of the above doctors and may be used as they deem proper for scientific and educational purposes.

8. I agree to keep the above doctor(s) informed of any change of address, and I agree to cooperate with them in my care after surgery until completely discharged.

9. I understand that the doctors’ fees are separate from the anaesthesia and hospital charges, and implant costs and the doctors’ fees are agreeable to me. There may be a fee if a secondary procedure is required. Personal expectations vary; please ensure that you have liaised with your doctor and he has understood your expectations of surgery. Some operations require secondary or multiple procedures to obtain a better result.

10. Secondary surgical procedures are much more difficult than primary procedures. The operations for repair are much more complex than the primary operations because of scarring and more bleeding and bruising. The possibility of nerve damage and poor healing is greater and most importantly, the results are unpredictable. It is important for the patient to realise that the results of secondary surgery will never be as predictable as those of primary surgery. If a secondary procedure is necessary, further expenditure ill be required, namely surgeon’s fees, the use of the operating room, anaesthesia and possibly hospitalisation. Before embarking on secondary surgery, you should be aware of your possible future commitments to multiple procedures in order to gain an acceptable result for yourself.

11. I have read a copy of the foregoing consent for the operation, understand it, accept these facts, and hereby authorise the above doctor(s) to perform this surgical procedure on me.

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036