CONSENT FOR SUCTION LIPOLYSIS
WITH AUTOLOGOUS FAT TRANSFER

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 a surgical procedure known as suction lipolysis and injection of autologous fat.
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. There can be necrosis with tissue loss or scarring tissues. This is a relatively new procedure and the long-term results are unknown. These risks have been explained to me and I accept them.
3. The healing of any wound is with scar tissue, and I understand that scars require a year’s time to look their best but, in fact, are permanent.
4. 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, and for any materials required. I agree to be responsible for these charges.
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 understand that I will be in a surgical dressing for approximately one week. Upon my return visit, I will wear a support girdle or support dressing for one month if necessary.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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. I am aware that after suction lipolysis there will be bruising and swelling which may take weeks or months to resolve. Occasionally, the skin becomes wrinkled or pitted and cellulite may look worse. The skin could have a corrugated look.
13. I realise after fat injection that the product may not last a long time and could dissolve leaving the original defect. Part of the product may dissolve and a repeat injection may be necessary. The fat could appear calcified in a later X-ray of the area of fat injection.

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____________________________________________________________________________

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