Informed Consent 

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Fat Transfer Procedures, Fat Grafts and Injections- Breast 

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INSTRUCTIONS 

This is an informed-consent document that has been prepared to help inform you about fat transfer (fat grafts or fat injection) procedures, its risks, as well as alternative treatment(s). 

It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your plastic surgeon and agreed upon by you. 

GENERAL INFORMATION 

A person’s own fat may be used to improve the appearance of the body by moving it from an area where it is less needed (usually the thighs or abdomen) to an area that has lost tissue volume due to aging, trauma, surgery, birth defects, or other causes. Typically, the transferred fat results in an increase in volume of the breast. Before the procedure, the areas from where the fat is being removed may be injected with a fluid to minimized bruising and discomfort. The fat may be removed from the body by a narrow surgical instrument (cannula) through a small incision or may be excised (cut out) directly through a larger incision. In some cases, the fat may be prepared in a specific way before being replaced back in the body. This preparation may include washing, filtering, and centrifugation (spinning) of the fat. The fat is then placed into the desired area using either a smaller cannula or needle, or it may be placed directly through an incision or puncture wholes. Since some of the fat that is transferred does not maintain its volume over time, your surgeon may inject more than is needed at the time to achieve the desired end result. Over a few weeks, the amount of transferred fat will decrease. At times, more fat may need to be transferred to maintain the desired results. Fat transfer procedures may be done using a local anesthetic, sedation, or general anesthesia depending on the extent of the procedure. 

Fat Transfer to the Breasts: 

Fat transfer has been used to improve the appearance of breasts reconstructed after cancer treatment, to improve the appearance of breast deformities, and to enlarge breasts for cosmetic purposes. While there is limited information regarding the long-term implications of such procedures, there are some potential concerns especially with regards to breast cancer detection. Since the transferred fat may become firm and cause lumps, it may be necessary to have radiological studies (mammogram, ultrasound, or MRI) performed to be sure these lumps are not due to cancer. It is also possible that the firmness may make it more difficult for you or your doctor to examine the breasts. It is also possible that a biopsy may be needed if there is concern about any abnormal findings in your breasts. However, there is no reason currently to believe that fat transfer procedures may cause breast cancer. 

Fat Transfer to the breast for cosmetic augmentation may require additional surgical procedures to obtain your desired breast size. A limited amount of fat can be injected during each surgical procedure to maintain viability. Sometimes adjuvant devices (Brava) are recommended to assist in this process. 

ALTERNATIVE TREATMENTS 

Alternative forms of nonsurgical and surgical management consist of injections of man-made substances to improve tissue volume (such as hyaluronic acid, polylactic acid, etc.), use of man-made implants, or other surgical procedures that transfer fat from the body (flaps). Risks and potential complications are associated with alternative forms of treatment. 

INHERENT RISKS OF FAT TRANSFER PROCEDURES 

Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand all possible consequences of fat transfer procedures. 

SPECIFIC RISKS OF FAT TRANSFER TO THE BREASTS PROCEDURES 

Change in Appearance: 

Typically, the transferred fat loses some of its volume over time and then becomes stable. It is possible that more treatments may be needed to maintain the desired volume of the transferred fat and resulting appearance. Less commonly, if you experience significant weight gain, the transferred fat may increase in volume and cause an undesirable appearance. It is important to understand that more than one treatment may be needed and therefore to discuss with your surgeon the costs associated with repeat treatments. 

Firmness and Lumpiness: 

While most transferred fat results in a natural feel, it is possible that some or all of the fat may become firm, hard, or lumpy. If some of the fat does not survive the transfer, it may result in fat necrosis (death of transferred fat tissue), causing firmness and discomfort or pain. Cysts may also form at the site of the transferred fat. Surgery may be required to improve such conditions. 

Under / Over Correction: 

The transfer of fat may not achieve the desired outcome. The amount of correction may be inadequate or excessive. It may not be possible to control the process of fat transfer due to factors attributable to each patient’s situation. If under correction occurs, you may be advised to consider additional fat transfer procedure. If over correction occurs other surgical procedures such as liposuction or excision of the fat could be required. 

Asymmetry: 

Symmetrical body appearance may not result from a fat transfer procedure. Factors such as skin tone, fatty deposits, bony prominence, and muscle tone may contribute to normal asymmetry in body features. It may not be possible to achieve or maintain exact symmetry following fat transfer. 

Long-Term Effects: 

Subsequent changes in the shape or appearance of the area where the fat was removed or placed may occur as the result of aging, weight loss or gain, or other circumstances not related to the fat transfer procedure. 

Combined Procedures: 

Fat grafting is safe to be performed with other surgical procedures such as breast augmentation, revisional breast surgery and breast reconstruction. There are many other surgical procedures where fat transfer may be included including facelifts, abdominoplasty, liposuction, the treatment of open wounds, scleroderma, ulcers and scars to name just a few. 

Seroma: 

Fluid may accumulate between the skin and the underlying tissues following surgery, trauma or vigorous exercise which is referred to as a seroma. You may notice an increase in fat graft area, localized swelling or a shape change that should alert you that a seroma may have occurred in your post-operative period. Seroma’s should be addressed to prevent an unfavorable outcome. Should this problem occur, notify your surgeon and additional procedures for drainage of fluid may be required. 

Donor Sites: 

The removal of fat in the process of fat transfer is often advantageous. The common complications from liposuction can occur at your donor site. Folds, wrinkles or creases could occur. Some patients may have inadequate donor sites for fat grafting. These are typically patients who have previously had a liposuction procedure. 

Fat Necrosis: 

Fat that is transferred may not survive. Fatty tissue found deep in the skin might die. Fat necrosis may produce areas of firmness within the skin, hard lumps, localized tenderness/ pain or skin contracture. 

Calcifications and oil cysts may occur. Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour irregularities in the skin that may result from fat necrosis. 

Accidental Intra-Arterial Injection: 

It is extremely rare that during the course of injection, fat could be accidentally injected into arterial structures and produce a blockage of blood flow. The risk and consequences of accidental intravascular injection of fillers is unknown and not predictable. 

Serious Complications: 

Although serious complications have been reported to be associated with fat transfer procedures, these are very rare. Such conditions include, but are not limited to: fat embolism (a piece of fat may find its way into the blood stream and result in a serious or life threatening condition), stroke, meningitis (inflammation of the brain), serious infection, blindness or loss of vision, or death. 

GENERAL RISKS OF SURGERY 

Healing Issues: 

Certain medical conditions, dietary supplements and medications may delay and interfere with healing. Patients with massive weight loss may have a healing delay that could result in the incisions coming apart (partial wound dehiscence), infection, and tissue changes resulting in the need for additional medical care, surgery, and prolonged hospitalizations. Patients with diabetes or those taking medications such as steroids on an extended basis may have prolonged healing issues. Smoking will cause a delay in the healing process, often resulting in the need for additional surgery. There are general risks associated with healing such as swelling, bleeding, possibility of additional surgery, prolonged recovery, color changes, shape changes, infection, not meeting patient goals and expectations, and added expense to the patient. There may also be a longer recovery due to the length of surgery and anesthesia. Patients with significant skin laxity (patients seeking facelifts, breast lifts, abdominoplasty, and body lifts) will continue to have the same lax skin after surgery. The quality or elasticity of skin will not change and recurrence of skin looseness will occur at some time in the future, quicker for some than others. There are nerve endings that may become involved with healing scars from surgery such as suction-assisted lipectomy, abdominoplasty, facelifts, body lifts, and extremity surgery. While there may not be a major nerve injury, the small nerve endings during the healing period may become too active producing a painful or oversensitive area due to the small sensory nerve involved with scar tissue. Often, massage and early non-surgical intervention resolves this. It is important to discuss post-surgical pain with your surgeon. 

Bleeding: 

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 you may require a blood transfusion, though such occurrences are rare. The collection of blood that can occur under your skin following surgery is referred to as a Hematoma. Increased activity too soon after surgery can lead to increased chance of bleeding and additional surgery. It is important to follow postoperative instructions and limit exercise and strenuous activity for the instructed time. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually in the first three weeks following injury to the operative area. You could require a blood transfusion. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). It can be common for your surgeon to provide medications after your fat transfer to the buttock to prevent blood clots. Medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets. 

Infection: 

Although infection following injection of fat transfer is unusual, bacterial, fungal, and viral infections can occur. 

Herpes simplex virus infections around the mouth can occur following fat transfer around the mouth. This applies to both individuals with a past history of herpes simplex virus infections and 

individuals with no known history of herpes simplex virus infections in the mouth area. Specific medications must be prescribed and taken both prior to and following the treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. 

Infection, although uncommon, can occur after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. It is important to tell your surgeon of any other infections, such as a history of MRSA infections, an open wound, recent upper respiratory infection/ pneumonia, or urinary tract infection. Infections in other parts of the body, may lead to an infection in the operated area. Postoperative infections often result in scaring which may require revision surgery at a later date. There can be an expense associated with these revision surgeries. 

Scarring: 

All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of a different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. In some cases, scars may require surgical revision or treatment. 

Firmness: 

Excessive firmness can occur after surgery due to internal scarring. The occurrence of this is not predictable. Additional treatment including surgery may 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. 

Major Wound Separation: 

Wounds may separate after surgery. Should this occur, additional treatment including surgery may be necessary. 

Sutures: 

Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures may spontaneously poke through the skin, become visible or produce irritation that requires suture removal. 

Tissue Loss: 

In rare cases, the transferred fat may cause the skin over the treated area to be injured resulting in loss of the skin and surrounding tissue. This may leave scars and disfigurement and require surgery for treatment. 

Delayed Healing: 

Wound disruption or delayed wound healing is possible. Some areas of the skin may not heal normally and may take a long time to heal. Areas of skin may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to tissue from past surgery or radiation therapy may be at increased risk for wound healing and poor surgical outcome. Smokers have a greater risk of skin loss and wound healing complications. 

Revision Surgery: 

Every effort is made for you to have a favorable outcome but, unforeseen events can occur that may require revsional surgery. Patients with multiple medical problems, massive weight loss patients, smokers, patients that develop infections in the post-operative period and other high risk patients have a greater propensity to require revisional surgery. Issues that could need to be addressed in the post- 

operative period include but are not limited to dog ears, asymmetry, contour irregularities, folds, wrinkles, loose skin, over correction and under correction. 

Damage to Deeper Structures: 

There is the potential for injury to deeper structures including nerves, blood vessels, lymphatics, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent. 

Surgical Anesthesia: 

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

Shock: 

In rare circumstances, your surgical procedure can cause severe trauma, 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. 

Pain: 

You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist after surgery. If you are a chronic pain patient followed by a Pain Therapy Practitioner, you may be asked to see this practitioner pre operatively to assist you in the management of your pain disorder in the post- operative period. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or due to tissue stretching. 

There are nerve endings that may become involved with healing scars from surgery. While there may not be a major nerve injury, the small nerve endings during the healing period may become too active producing a painful or oversensitive area due to the small sensory nerve involved with scar tissue. Often, massage and early non-surgical intervention resolves this. It is important to discuss post-surgical pain with your surgeon. 

Cardiac and Pulmonary Complications: 

Pulmonary complications may occur secondarily to blood clots (pulmonary emboli), fat deposits (fat emboli), pneumonia, or partial collapse of the lungs after general anesthesia. Pulmonary emboli can be life- threatening or fatal in some circumstances. Inactivity and other conditions may increase the incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important to discuss with your physician any past history of swelling in your legs or blood clots 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. 

Venous Thrombosis (Clot) and Sequelae: 

Thrombosed veins, which resemble cords, occasionally develop around IV sites, and usually resolve without medical or surgical treatment. Often a screening process is conducted to determine if you are at increased risk for DVT/ PE. Measures can be taken at the time of your Fat Transfer to prevent such events from occurring. It is important to discuss with your surgeon if you or your family have a history of DVT/ PE. Certain high estrogen pills, obesity, history of cancer, history of inflammatory bowel disease, etc. may increase your risk of thrombosed veins and the development of DVT/ PE. 

Allergic Reactions: 

In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur in response to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment. It is important to notify your physician of any previous allergic reactions. 

Drug Reactions: 

Unexpected drug allergies, lack of proper response to medication, or illness caused by the prescribed drug are possibilities. It is important for you to inform your physician of any problems you have had with any medication or allergies to medication, prescribed or over the counter, as well as medications you now regularly take. Provide your surgeon with a list of medications and supplements you are currently taking. 

Surgical Wetting Solutions: 

There is the possibility that large volumes of fluid containing dilute local anesthetic drugs and epinephrine that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to these medications. Additional treatment including hospitalization may be necessary. 

Fat/Air Embolism: 

In rare cases, during or after liposuction and/or fat grafting, fat particles or air can enter the vascular system and can travel to the heart, lungs or brain. This can result in significant complications including death. 

Persistent Swelling (Lymphedema): 

Persistent swelling can occur following surgery. 

Unsatisfactory Result: 

Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. The body is not symmetric and almost everyone has some degree of unevenness which may not be recognized in advance. One side of the face may be slightly larger, one side of the face droopier. The breast and trunk area exhibits the same possibilities. Many of such issues cannot be fully corrected with surgery. The more realistic your expectations as to results, the better your results will appear to you. Some patients never achieve their desired goals or results, at no fault of the surgeon or surgery. You may be disappointed with the results of surgery. Asymmetry, unanticipated shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur after surgery. Size may be incorrect. Unsatisfactory surgical scar location or appearance may occur. It may be necessary to perform additional surgery to improve your results. Unsatisfactory results may NOT improve with each additional treatment. 

ADDITIONAL ADVISORIES 

Medications and Herbal Dietary Supplements: 

There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or prescription medications. Aspirin and medications that contain aspirin interfere with forming blood clots, and therefore may contribute to more bleeding issues. If you have a medical condition (such as heart arrhythmia, heart stent, blood vessels with blockages, or blood clots) and are taking medications to thin your blood and prevent clotting such as Plavix, Warfarin, Coumadin, Xarelto, Effient or Pradaxa, discuss management of these medications around the time of surgery with your plastic surgeon. Your plastic surgeon may sometimes coordinate a plan for these medications with the doctor that prescribed them for your medical condition. If you have been prescribed drugs for a medical condition, do not stop them without discussing it first with your plastic surgeon. Stopping these medications 

abruptly may result in a heart attack, stroke, or death. 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. 

Sun Exposure – Direct or Tanning Salon: 

The effects of the sun are damaging to the skin. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their surgeon and either delay treatment, or avoid tanning until the surgeon says it is safe to resume. The damaging effect of sun exposure occurs even with the use sun block or clothing coverage. 

Travel Plans: 

Any surgery holds the risk of complications that may delay healing and your return to normal life. Please let the surgeon know of any travel plans, important commitments already scheduled or planned, or time demands that are important to you, so that appropriate timing of surgery can occur. There are no guarantees that you will be able to resume all activities in the desired time frame. Allow at least 10-14 days to travel via airplane. Medications may be required should you have a long flight/ trip to prevent DVT/ PE in the immediate post-operative period. 

Long-Term Results: 

Subsequent alterations in the appearance of your body may occur as the result of aging, sun exposure, weight loss, weight gain, pregnancy, menopause or other circumstances not related to your surgery. 

Interference with Sentinel Lymph Node Mapping Procedures: 

Breast surgery procedures that involve cutting through or grafting breast tissue, similar to a breast biopsy, can potentially interfere with diagnostic procedures to determine lymph node drainage of breast tissue to stage breast cancer. 

Body-Piercing: 

Individuals who currently wear body-piercing jewelry in the surgical region are advised that an infection could develop from this activity. Body-piercing jewelry should be removed prior to your surgical procedure. 

Nails: 

To determine your vitals status during surgery your anesthesia provider may require access to your finger nails for monitoring. Make sure to have at least two finger nails free of nail polish or acrylic nails on the date of your surgery. 

Jewelry: 

Jewelry should not be brought with you at the time of your surgical procedure. Items such as earrings, wedding rings, necklaces, etc. should be removed and placed in a safe place. Do not bring your jewelry with you for your surgery. 

Future Pregnancy and Breast Feeding: 

This surgery is not known to interfere with pregnancy. If you are planning a pregnancy, your breast skin may stretch and offset the results of surgery. You may have more difficulty breast feeding after this operation. 

Female Patient Information: 

It is important to inform your plastic surgeon if you use birth control pills, estrogen replacement, or if you suspect you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy. 

Intimate Relations After Surgery: 

Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional bruising, swelling, and the need for return to surgery to control bleeding. It is wise to refrain from intimate physical activities until your physician states it is safe. 

Mental Health Disorders and Elective Surgery: 

It is important that all patients seeking to undergo elective surgery have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional surgery and often are stressful. Please openly discuss with your surgeon, prior to surgery, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted. 

ADDITIONAL SURGERY NECESSARY (Re-Operations) 

There are many variable conditions that may influence the long-term result of surgery. It is unknown how your tissue may respond or how wound healing will occur after surgery. Secondary surgery may be necessary to perform additional tightening or repositioning of body structures. Should complications occur, additional surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are associated with this surgery. Other complications and risks can occur but are less common. 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. You and your surgeon will discuss the options available should additional surgery be advised. There may be additional costs and expenses for such additional procedures, including surgical fees, facility and anesthesia fees, pathology and lab testing. 

PATIENT COMPLIANCE 

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 important that you participate in follow-up care, return for aftercare, and promote your recovery after surgery. 

DVT/PE Risks and Advisory: 

There is a risk of blood clots, Deep Vein Thrombosis (DVT) and Pulmonary Embolus (PE) with every surgical procedure. It varies with the risk factors below. The higher the risk factors, the greater the risk and the more involved you must be in both understanding these risks and, when permitted by your physician, walking and moving your legs. There may also be leg stockings, squeezing active leg devices, and possibly medicines to help lower your risk. 

There are many conditions that may increase or affect risks of clotting. Inform your doctor about any past or present history of any of the following: 

Past History of Blood Clots Family History of Blood Clots Birth Control Pills Hormone Stimulating Drugs Swollen Legs 

History of Cancer Large Dose Vitamins 

Varicose Veins 

Past Illnesses of the Heart, Liver, Lung, or Gastrointestinal Tract. History of Multiple Spontaneous Abortions or 

Miscarriages 

I understand the risks relating to DVT/PE and how important it is to comply with therapy as discussed with my surgeon. The methods of preventative therapy include: Early ambulation when allowed 

Compression devices (SCD/ICD) Anticoagulation Protocols when Allowed 

For high risk patients, the risks of VTE are still high, even in the setting of appropriate chemoprophylaxis. If your surgery is elective and you’re a high risk patient, it’s best to consider with not proceeding with such elective surgery. 

DISCLAIMER 

Informed-consent documents are used to communicate information about the proposed surgical treatment of 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. Your plastic surgeon may provide you with additional or different information which is 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. 

It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page. 

CONSENT FOR SURGERY / PROCEDURE or TREATMENT 

1. I hereby authorize Thanapoom Boonipat and such assistants as may be selected to perform Fat Transfer/ Fat 

Grafting- Breast. 

I have received the following information sheet: Fat Transfer/ Fat Grafting- Breast. 



I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun. 





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. 





I understand what my surgeon can and cannot do, and understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed. 





I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures. 





For purposes of advancing medical education, I consent to the admittance of observers to the operating room. 





I consent to the disposal of any tissue, medical devices or body parts that may be removed. 





I am aware that there are potential significant risks to my health with the utilization of blood products, and I consent to their utilization should they be deemed necessary by my surgeon and/or his/her appointees. 





I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable. 



1. 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. 



I realize that not having the operation is an option. I opt out of having this procedure  





IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: 





THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN 





THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT 





THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED 



I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-12). I AM SATISFIED WITH THE EXPLANATION. 

Patient or Person Authorized to Sign for Patient