CONSENT FOR REMOVAL OF SKIN LESIONS (SKIN CANCER) WITH FLAP RECONSTRUCTION

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

1. I hereby request the above-named surgeon and/or his or her associates to perform a surgical operation known as Removal of skin lesions with flap reconstruction. 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 risks and possibilities of complications such as bleeding, infection, poor healing, etc, and that these and other complications may follow even when the surgeon(s) uses the utmost care, judgement and skill. These risks have been explained to me and I accept them. The following points have been explained in detail:

a. Removal will result in a permanent scar, which will be placed and made as inconspicuous as reasonably possible.

b. Scars which are permanent require an indefinite period of time to soften, fade, and look their best, usually six months to one year. All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within both the skin and deeper tissues. Scars may be unattractive and of darker colour than surrounding skin tone. There is the possibility of visible marks from sutures used to close the wound after the removal of skin cancer. There is the possibility that scars may limit motion and function. Additional treatments including surgery may be needed to treat scarring.

c. 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.

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

e. Removal may result in redness of the skin which may require an indefinite period of time to fade and return to normal skin pigment.

f. Deeper structures such as nerves, blood vessels and muscles may be damaged during the course of surgery. The potential for this to occur varies with where in the body, surgery is being performed. Injury to deeper structures may be temporary or permanent.

g. Certain varieties of skin cancer can spread to other areas of the body. Depending on the cell type and degree of invasion of the skin cancer, additional surgery or cancer treatment may be necessary.

h. Skin cancers in rare situations can recur after surgical excision. Additional treatment or secondary surgery may be necessary.

i. There is the possibility of a poor result from the removal of skin cancer. Surgery may result in unacceptable visible deformities, loss of function, wound disruption, skin death and loss of sensation. Even if the skin cancer is removed successfully, you may be disappointed with the results of reconstructive surgery.

j. 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.

k. Both local and general anaesthesia involve risk. There is the possibility of complications, injury and even death from all forms of surgical anaesthesia or sedation.

3. I have an understanding of the operation which includes but is not limited to the above items. I understand that secondary 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 judgement, necessary and desirable. The authority granted under this Paragraph 4 shall extend to remedying conditions that are not known to or could not be reasonably anticipated by the above doctor(s) at the time the operation commenced.

5. I consent to the administration of local or general anaesthesia 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 treatment; that these photographs shall be the property of the above-named doctor(s) 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 the doctor’s 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 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 operation, understand it, accept these facts and hereby authorise the above 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