This is an informed-consent document
that has been prepared to help your plastic surgeon inform
you about gynaecomastia surgery, its risks, and alternative
treatments.
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.
GENERAL INFORMATION
Gynaecomastia is the development of breast tissue in a male;
it may be due to hormonal influences or due to the use of
steroids. This can also occur with out any know factors.
Gynaecomastia is usually performed for relief of these
symptoms of breasts and return to the normal chest
configuration.
ALTERNATIVE TREATMENT
Gynaecomastia reduction is an elective surgical operation.
Alternative treatment is not undergoing surgical procedure.
In selected patients, liposuction has been used to reduce
the size of large breasts.
RISKS of GYNAECOMASTIA SURGERY
Every surgical procedure involves a certain amount of risk.
It is important that you understand the risks involved with
Gynaecomastia excision. An individual’s choice to undergo a
surgical procedure is based on the comparison of the risk to
potential benefit. Although the majority of men do not
experience the following complications, you should discuss
each of them with your plastic surgeon to make sure you
understand the risks, potential complications and
consequences of Gynaecomastia excision.
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 blood transfusion.
Excision of gynaecomastia does often cause excessive
bruising and this is reduced by use of a compression garment
post-operatively. Do not take any aspirin or
anti-inflammatory medications for ten days before surgery,
as this may increase the risk of bleeding. Non-prescription
"herbs" and dietary supplements can increase the risk of
surgical bleeding.
Infection- An infection is quite unusual after this type of
surgery. Should an infection occur, treatment including
antibiotics or additional surgery may be necessary.
Change in nipple and skin sensation- You may experience a
change in the sensitivity of the nipples and the skin of
your chest. Permanent loss of nipple sensation can occur
after a reduction. This is however unusual.
Skin scarring- All surgical incisions produce scarring. The
quality of these scars is unpredictable. Abnormal scars may
occur within the skin and deeper tissue. In some cases,
scars may require surgical revision or other treatments.
Unsatisfactory result- There is the possibility of a poor
result from the Gynaecomastia excision. You may be
disappointed with the size and shape of your chest.
Asymmetry in nipple location or rippling may occur. It may
be necessary to perform additional surgery to improve your
results or to correct the scars.
Pain- Gynaecomastia excision can occasionally cause pain in
the deeper structures, but this is unusual.
Delayed healing- Wound disruption or delayed wound healing
is possible. Some areas of the chest skin or nipple region
may not heal normally and may take a long time to heal. It
is even possible to have loss of skin or nipple tissue. This
may require frequent dressing changes or further surgery to
remove the non-healed tissue.
Smokers have a greater risk of skin loss and wound healing
complications.
Allergic reactions- 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.
Surgical anesthesia- Both local and general anesthesia
involve risk. There is the possibility of complications,
injury, and even death from all forms of surgical anesthesia
or sedation.
ADDITIONAL SURGERY NECESSARY
Should complications occur, additional surgery or other
treatments may be necessary. Even though risks and
complications occur infrequently, the risks cited are
particularly associated with Gynaecomastia surgery. Other
complications and risks can occur but are even more
uncommon. 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.
HEALTH INSURANCE
Depending on your particular health insurance plan,
Gynaecomastia surgery may be considered a covered benefit.
There may be additional requirements in terms of the amount
of breast tissue to be removed and duration of physical
problems caused by breasts. Gynaecomastias involving removal
of small amounts of tissue may not be covered by your
insurance. Please review your health insurance
subscriber-information pamphlet, call your insurance
company, and discuss this further with your plastic surgeon.
Many insurance plans exclude coverage for secondary or
revisionary surgery.
FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the
services provided. The total includes fees charged by your
doctor, the cost of surgical supplies, laboratory tests,
blood bank, anesthesia, and hospital charges, depending on
where the surgery is performed. Depending on whether the
cost of surgery is covered by an insurance plan, you will be
responsible for necessary co-payments, deductibles, and
charges not covered. Additional costs may occur should
complications develop from the surgery. Secondary surgery or
hospital day-surgery charges involved with revisionary
surgery would also be your responsibility.
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). 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 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.
GoSculptura reminds you that all cosmetic surgery carries a
risk, has limitations which could include disappointment
with the results.
You should agree about the anticipated outcome of your
surgery and concur about your expectations of the results.
You should discuss alternative treatments and thoroughly
understand the risk of the procedures
If any dispute may arise the surgeon is only liable if
litigation takes place in Argentina, under Argentinean Law.
It is important that you read the above information
carefully and have all of your questions answered before
signing the consent.
CONSENT FOR SURGERY/ PROCEDURE or TREATMENT
1. hereby authorize Dr. ____________________________________
and such assistants as may be selected to perform the
following procedure or treatment:
________________________________________________________________________
I have received the following information sheet:
INFORMED-CONSENT-GYNAECOMASTIA
________________________________________________________________________
2. 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.
3. I consent to the administration of such anesthetics
considered necessary or advisable. I understand that all
forms of anesthesia involves risk and the possibility of
complications, injury, and sometimes death.
4. I acknowledge that no guarantee has been given by anyone
including GoSculptura or any of the staff employed by
GoSculptura as to the results that may be obtained.
If any litigation may arise a s result of the surgery it can
only be done in Argentina under Argentinean Law and that
GoSculptura , its management or staff can not be held liable
in any way what so ever.
5. I consent to the disposal of any tissue, medical devices
or body parts which may be removed.
6. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF
TREATMENT
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED
ITEMS (1-6).
I AM SATISFIED WITH THE EXPLANATION.
______________________________________________________________________
Patient or Person Authorized to Sign for Patient
Date____________________
____________________________________Witness
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