CONSENT FOR A NIPPLE REPAIR

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

1. I hereby request the above named surgeon(s) and/or their associates to perform the surgical operation known as nipple reconstruction. This procedure has been explained to me 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. From every incision of the skin in whatever part of the human body, there will be a scar. Every reasonable effort will be made to make a scar look as inconspicuous as possible.

b. The eventual appearance of the scar will be variable and dependent on the healing of the scar.

c. The scar will require a healing period of up to one year before any further revision surgery would be undertaken to improve the appearance of the scar.

d. Stitches or sutures will be used to sew the cut skin and deepest structure together. Occasionally, a stitch will work to the surface and have to be removed.

e. Delayed healing at times occurs along the margins of the incisions; and occasionally there is some loss of skin edges or entire flap requiring prolonged dressings or additional surgery for correction. Additional surgical procedures will involve additional charges or fees.

f. The reconstructed nipple may not be exactly the same size as the other side.

g. Firmness in the area and redness of the scar are to be expected for an indefinite period of time after repair of the nipple. Swelling and bruising will probably last for up to two or three weeks after repair of the nipple.

h. If my nipple reconstruction is for the repair of an inverted nipple, if full reversal has not occurred, then a second or third procedure may be required as it is common for the nipple to retract slightly after removal of the dressings.

i. I understand that there may be some loss of sensation which is usually only temporary.

3. I understand that the above-named surgeon and his associates are plastic surgeons and their fees reflect the high degree of skill, surgical judgment and training that they have. 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 office 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), anaesthetist, or nurse 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 an unfavourable result.

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 emergency room charges and that they are my responsibility completely. 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 will 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 the surgical procedure of repair of a nipple.

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