Informed Consent
Free Myocutaneous Flap Surgery ©2020 American Society of Plastic Surgeons®.
Purchasers of the Informed Consent Resource are given a limited license to modify documents contained herein and reproduce the modified version for use in the Purchaser's own practice only.
The American Society of Plastic Surgeons® does not authorize the use of these documents for purposes of any research or study. All other rights are reserved by the American Society of Plastic Surgeons . Purchasers may not sell or allow any other party to use any version of the Informed Consent Resource, any of the documents contained herein or any modified version of such documents. Informed Consent –
Free Musculocutaneous Flap Surgery
____________________________________________________________________________________ Page 1 of 4 ______ Patient Initials ©2020 American Society of Plastic Surgeons® This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed consent for this procedure in the jurisdiction of your practice.
INSTRUCTIONS This document is about informed consent. It will tell you about the free musculocutaneous flap surgery. It will outline the risks and other treatment options. It is important that you read the whole document carefully. Please initial each page. Doing so means you have read the page. Signing the consent agreement means that you agree to the surgery that you have talked about with your plastic surgeon.
GENERAL INFORMATION In a free musculocutaneous flap surgery, muscle, fat, or skin from one part of your body is moved to another. This rebuilds or heals the part of your body that gets the new tissue. After the surgeon moves the muscle, fat, or skin, a microscope is used to reconnect the artery(s) and vein(s) between the muscle and the blood vessels where it has been moved. This will restart blood flow.
ALTERNATIVE TREATMENTS Depending on what you need, you may have other options. You may not need surgery. If you want a part of your body to be rebuilt, you may need surgery. Ask your surgeon about your options. You may want to go in for traditional wound management. You can also go in for negative pressure therapy, getting a local tissue flap, a skin graft, or amputation. All surgeries have their risks and possible problems.
RISKS OF FREE MUSCULOCUTANEOUS FLAP SURGERY Every surgery has risks. It is important that you understand the risks and the possible problems that can result from them. All procedures have limits. Choosing to have surgery means comparing the risks and benefits. Most patients do not face problems, but you should talk about them with your plastic surgeon. Make sure you understand all possible outcomes of the myocutaneous flap surgery.
SPECIFIC RISKS OF FREE MYOCUTANEOUS FLAP SURGERY
Loss or Failure of Flap: There is a possible risk in such a surgery. An artery or vein may get blocked where the surgeon connects the flap. In such a case, you may need another surgery. You can also go in for other types of medical therapies, like medicinal leeches. The surgeon may need to remove the flap that didn’t work and use another flap to fix the block. Donor Site Issues: Problems can occur in the body part where the surgeon takes the flap from. This can cause problems after the surgery. Your abdomen may feel weak. You may get a hernia(s) or a swelling. You can also lose feeling or feel stiff. Your limbs may not work the same, or you may lose a limb. You may not like the way your skin looks after surgery. You may have wound issues or infections. The healing may take longer than normal. You may feel pain or bleed. Fluid may collect between your skin and tissue. These are some of the problems, and they may need more surgeries to fix them. Slow Healing: Wound healing can be delayed or slow. Some areas of the abdomen, like your belly, waist, back, or buttocks may not heal normally. They may take a long time to heal. Parts of the skin may die or come off. You may need to change the cloth over the wound. You may also need to go in for more surgeries to remove the problem tissue. If you have less blood supply to the tissue from past surgeries or radiation therapies, you may be at high risk for slow healing and poor results. Smokers are at high risk of skin loss and healing problems.
Informed Consent – Free
Musculocutaneous Flap Surgery
____________________________________________________________________________________ Page 2 of 4 ______ Patient Initials ©2020 American Society of Plastic Surgeons® This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed consent for this procedure in the jurisdiction of your practice.
Change in Sensation: Many people have less or no feeling in the skin after surgery. This reduced feeling may go away as you start healing, but in some cases may remain. It is unlikely, but you can get a motor nerve injury. This can damage how a part of your body works or moves. Scars: All surgeries leave scars. Some scars are seen more clearly than others. Wounds are likely to heal after surgery, but can leave long, visible scars that will not go away. Unusual scars may occur in the skin and in the tissues below. Scars may look bad and be a different color than your other skin. The same scar may look different on the right and left side of your body. The stitches may leave a mark on your skin. These scars may be raised and red in the first few weeks or months. They usually fade over time. However, some patients can have “hypertrophic” or “keloid” scars, which means you can clearly see and feel them. They may be red, and they do not go away. You may need more treatments, like medication and/or surgery to fix this.
Seromas (Fluid Collection): It is rare, but fluid can build up between your skin and tissue after surgery, trauma, or heavy exercise. If this occurs, it may need to be drained. To solve this problem, doctors usually put in a drain.
Drains: During your surgery, your doctor may need to put in a drain(s). A drain is a small tube that removes fluid from the surgery site. You will be told how to use the drain. Putting the drain in may require a separate small cut. The drain will be taken out when your doctor feels you no longer need it. When the drain is taken out, your doctor may close the area of the drain. Closing the drain site may need surgical tape or stitches. Your doctor may also leave the site open to drain any leftover fluid under the wound.
Pain: You will have pain after your surgery. The pain you feel after surgery may vary in how strong it is and how long it lasts. Continued pain happens in rare cases when nerves are stuck in the scar (called neuromas).
Fat Necrosis: Fat tissue in the flap may die. If the flap tissue dies, then it can get too firm. You may need another surgery to remove the tissue that died. As a result, the shape of the flap may be uneven.
Systemic Complications: Flap surgery is major surgery. It can cause problems for how other parts of the body work. These problems can come from stress, blood loss, fluid build-up, blood thinners, and blood flow issues. They can also come from the surgery taking a long time or if problems come up during the surgery. Problems may arise in the lungs, heart, brain, liver, and kidneys.
You can get blood clots in your legs, arms, and torso. These complications can result in losing the flap or even the limbs. Your organs could stop working, and you could even die. The flap must be fixed to fix these problems. You may need more surgeries, medical treatments, and time in the hospital. Informed Consent – Free
Musculocutaneous Flap Surgery
____________________________________________________________________________________ Page 3 of 4 ______ Patient Initials ©2020 American Society of Plastic Surgeons® This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed consent for this procedure in the jurisdiction of your practice.
DISCLAIMER Informed consent documents give you information about a surgery you are considering. These documents explain the risks of that surgery. They also discuss other treatment options, including not having surgery. However, informed consent documents can’t cover everything. Your plastic surgeon may give you more or different information. This may be based on the facts of your case. Informed consent documents are not meant to define or serve as the standard of medical care. Standards of medical care are determined based on the facts involved in an individual case. They may change with advances in science and technology. They can also change with the way doctors practice medicine. It is important that you read the above information carefully and get all your questions answered before signing the consent agreement on the next page. Informed Consent – Free Musculocutaneous Flap Surgery Page 4 of 4 ______ Patient Initials ©2020 American Society of Plastic Surgeons®
CONSENT FOR PROCEDURE OR TREATMENT
I permit Dr. Thanapoom Boonipat and the doctor’s assistants to do the Free Musculocutaneous Flap Surgery.
I got the information sheet on Free Musculocutaneous Flap Surgery.
I understand that, during the surgery, an unexpected situation may require a different medical procedure than the surgery listed above. I permit the doctor listed above, the assistants and/or designees to provide any treatment that my doctor thinks is needed or helpful. My permission includes all treatments that my doctor does not plan to do at the start of the surgery.
I understand what my surgeon can and cannot do. I understand that no warranties or guarantees have been hinted at or stated outright about the outcome of the surgery. I have explained my goals. I understand which outcomes are realistic and which are not. All my questions have been answered. I understand the surgery’s risks. I am aware of other risks and possible issues, benefits, and options. I understand and choose to have the surgery.
I agree to the anesthetics that are needed or helpful. I understand that all types of anesthesia have risks and may result in complications, injury, and even death.
I am aware of the serious risks to my health when blood products are used. I agree to my doctor using them if my doctor, assistants, and/or designees think they are needed or helpful.
I agree to the disposal of any tissue, medical devices, or body parts taken out during or after surgery. I
also agree to any additional surgeries or treatment that is needed or helpful.
I agree to have parts of my body photographed or televised appropriately before, during, and after the surgery for medical, scientific, or educational reasons, if the pictures do not reveal my identity.
For medical education, I agree that onlookers can be in the operating room.
I permit my Social Security Number to be given to the right agencies for legal reasons and medical device registration, when necessary.
I agree to the charges for this surgery. I understand that the doctor’s charges are separate from the charges for the hospital and the anesthesia. I understand that there may be more charges if more procedures or treatments are needed or helpful. I agree to those charges, if any.
I understand that not having the surgery is an option and that I can opt-out of having the surgery.
IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: a. THE ABOVE SURGERY TO BE
PERFORMED b. THERE MAY BE OTHER SURGERIES OR TREATMENT OPTIONS c. THERE ARE RISKS TO THE SURGERY