LIPOSUCTION Informed Surgical Consent Booklet

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1 LIPOSUCTION Informed Surgical Consent Booklet INSTRUCTIONS This Informed Surgical Consent Booklet has been prepared by Dr. Mulholland to help inform you about the potential benefits, associated risks and alternatives of SmartLipo, Ultrasound-assisted and Microcannula Tumescent Liposuction surgery. During your consultation and medical assessment, Dr. Mulholland and your SpaMedica Consultation and Pre-Operative Professional will have reviewed with you the potential benefits, associated risks and alternatives of liposuction that are outlined in this booklet. They will have also provided you with answers to any and all questions you may have had about the procedure. It is important that you read the information contained in this booklet again carefully and completely. Only when all of your questions and concerns about the procedures have been addressed should you then initial each page, indicating that you have read and fully understood all the items this booklet discusses. When you reach the end of the booklet, please sign the consent for the procedure as proposed by Dr. Mulholland. If you have any remaining questions or concerns about the potential benefits, associated risks or alternatives of liposuction, do not initial any pages or sign the consent without speaking with Dr. Mulholland and/or a SpaMedica Consultation and Pre-Operative Professional. INTRODUCTION Liposuction is a surgical technique to remove unwanted deposits of fat from specific areas of the body, including the face and neck, upper arms, trunk, abdomen, buttocks, hips, thighs, knees, calves, and ankles. This is not a substitute for weight reduction, but a method for removing localized deposits of fatty tissue that do not respond to diet or exercise. Dr. Mulholland may recommend that your liposuction be performed as a primary procedure for body contouring or be combined with other surgical techniques such as facelift, abdominoplasty, or thighlift procedures to tighten loose skin and supporting structures. The best candidates for liposuction are individuals of relatively normal weight who have excess fat in particular body areas. Having firm, elastic skin will result in a better final contour after the procedure. Hanging, loose or cellulitic skin will not reshape itself to the new contours and may require additional surgical procedures to remove and tighten excess skin. Body contour irregularities due to structures other than fat cannot be improved by this technique. Liposuction will not likely improve, nor significantly worsen areas of dimpled skin known as cellulite. Liposuction surgery is performed by inserting a hollow metal surgical instrument known as a cannula through small skin incisions and passing it gently and slowly back and forth through the area of fatty deposit. The cannula is attached to a vacuum source, which provides very low-pressure suction needed to remove the fatty tissue. Dr. Mulholland performs three types of liposuction, microcannula (small cannula), ultrasonic assisted and the SmartLipo. Microcannula Liposuction: A saline solution containing xylocaine and epinephrine is first injected into the fat cells to swell them and constrict the surrounding blood vessels, a process called tumescent liposuction. The tiny (2-3mm) size of the cannula, physical force and suction are then used in conjunction to break down the fat cells. Ultrasonic-Assisted Liposuction: A saline solution containing xylocaine and epinephrine is first injected into the fat cells to swell them and constrict the surrounding blood vessels, a process called tumescent liposuction. Ultrasonic sound waves are then used to breakdown the fat cells, resulting in a less traumatic removal of the broken-down fat cells. In general, ultrasonic liposuction works best in areas of the body with decreased skin tone and elasticity and/or fibrous type fat. Smartlipo : The Smartlipo is a gentle way to liquefy, through the use of a small fiber-optic laser beam, and remove fat, as well as tighten skin in small contour zones. Generally, Smartlipo can be performed on single zone contour concerns, under local anesthesia, without general of IV sedation risks and patients can go home after the procedure. The tumescent liposuction technique involves the infiltration of fluid containing dilute local anesthetic and epinephrine into areas of fatty deposits. This technique can reduce discomfort at the time of surgery, as well as reduce post-operative bruising. The tumescent fluid also improves delivery of the ultrasound to your fat deposits. There are advantages and disadvantages to each technique and Dr. Mulholland will recommend the technique that is best suited to your skin and fat characteristics in a given anatomical location. It is not uncommon for Dr. Mulholland to use several different techniques in different areas on the same patient depending upon the type of fat and skin quality. Liposuction Informed Surgical Consent Booklet Page 1 of 6

2 Liposuction surgery is generally performed as an outpatient under local sedation or, as a general anesthetic case. In multiple zone liposuction Dr. Mulholland will usually recommend staying overnight in the facility. Post-operatively, support garments, compressive foam and dressings will be provided by our clinic and are to be worn to control swelling and promote healing. POTENTIAL BENEFITS OF LIPOSUCTION SURGERY Benefits include improved figure, contour and shape. There is less risk of bruising, pain or swelling than with traditional liposuction, with better skin retraction, a more rapid healing and return to normal activities. Dr. Mulholland is able to offer patients the best technique of liposuction (Microcannula, Ultrasonic-assisted or SmartLipo ) dependant upon the needs of the individual patient. When discussing the potential benefits of liposuction with you, Dr. Mulholland and/or your SpaMedica Consultation and Pre-Operative Professional may have shown you a variety of before and after images. It is important to remind you that these images were used as an educational tool to allow you to visualize the general range of body shape improvements that may be achieved with your proposed surgery; the before and after images are not meant to be guarantees of actual or exact outcome. RISKS ASSOCIATED WITH LIPOSUCTION SURGERY SpaMedica is one of Canada s most sophisticated, full service cosmetic surgery and laser skin care centers. We have treated thousands of skin care, laser hair removal, laser leg vein and cosmetic surgery patients, and our large experience has proven our treatments to be very safe. However, every cosmetic procedure involves a very small degree of risk and, although exceedingly uncommon, it is important that you understand and accept the rare risks involved with liposuction. An individual s informed decision to undergo any cosmetic procedure is based upon a comparison of the risks against the potential benefits, alternatives and costs. Although the vast majority of liposuction patients never experience any of these complications, you should discuss each of them with a SpaMedica Consultation and Pre-Operative Professional to ensure you fully understand the alternatives, risks, potential complications and average outcomes of liposuction. Patient Selection: Individuals with poor skin tone, medical problems, obesity, or unrealistic expectations may not be candidates for liposuction. Bleeding: It is possible, though unusual, to have a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or require a blood transfusion. Do not take any aspirin or anti-inflammatory medications or the specified naturopathic medications for 21 days before surgery and 10 days after, as they may increase the risk of bleeding. Infection: An infection is quite unusual after this type of surgery. Usually the infection is not severe, however, there have been rare cases of flesh-eating infections after elective surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary. Smokers have a greater risk of skin loss and wound healing complications. Skin Scarring: Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. In rare cases, abnormal scars may result. Scars may be large, unattractive and of a different colour than surrounding skin. Additional treatments, including surgery, may be necessary. Change in Skin Sensation: A temporary decrease in skin sensation over the operative area may occur after liposuction. This usually resolves over a period of time. Diminished (or complete loss of skin sensation) infrequently occurs and may not totally resolve. Rarely, the skin of the areas treated may be hypersensitive temporarily or permanently. Skin Discoloration/Swelling: Skin discoloration (bruising) and swelling normally occurs and lasts for 8-21 days following liposuction. In rare situations, swelling and skin discoloration may persist for long periods of time. Permanent skin discoloration is rare. Skin Contour Irregularities: Contour irregularities and depressions in the skin may occur after liposuction. Visible and palpable wrinkling of skin can occur. Additional treatments, including surgery, may be necessary to treat contour irregularities, wrinkling, or loose skin following liposuction. Most areas of modest cellulite show some improvement. Asymmetries: It will not be possible to achieve a completely symmetrical body appearance following liposuction surgery. Factors such as skin tone, bony prominences, muscle tone, and residual fat may contribute to normal asymmetries in body features. Liposuction Informed Surgical Consent Booklet Page 2 of 6

3 Seroma: Trapped fluid accumulations infrequently occur in areas where liposuction has been performed. Additional treatments or surgery to drain accumulations of fluid may be necessary. There is a risk that a seroma may become infected. Wearing your compression garment as directed will help decrease this risk. Long-term Effects: Subsequent alterations in body contour may occur as the result of aging, weight loss or gain, pregnancy, or other circumstances not related to the improvements you may have witnessed from liposuction. Tumescent Liposculpture: There is the possibility that the 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. Dissatisfaction with your Results: You may be disappointed with the results of your liposuction surgery. Infrequently, it is necessary to perform additional surgery to improve your results. Before and After Photos: Dr. Mulholland may have reviewed and discussed computer images. It is important to remind you once again that these images are used as an educational tool designed to allow you to visualize the general range of body shape improvements that may be achieved with your proposed surgery. The computer images are not meant to be guarantees of actual or exact outcomes. It is very rare for a patient not to achieve the general range of body contour improvements that have been demonstrated in the computer-simulated surgery. Surgical Anaesthesia: Both local and general anesthesia involves risk. There is the possibility of complication, injury, and even death from all forms of surgical anesthesia or sedation. This surgical anesthesia will be necessary to provide you with a painless procedure. One of the advantages of laser lipolysis (SmartLipo ) for single zone treatments is that the procedure may be performed under local anesthesia with no general aesthetic risks. Allergic Reaction: In rare cases, local allergies to medications, tape, suture materials, or topical preparations have been reported. Systemic reactions, which are more serious, may occur due to drugs used during surgery and may require treatment or supportive measures. Surgical Shock: In rare circumstances, Liposuction has been reported to cause severe trauma, particularly when multiple or extensive areas are suctioned at one time or major organs are damaged. Dr. Mulholland does not perform megaliposuction sessions and removes only that amount recommended by the guidelines of the Canadian Society of Plastic Surgery. Although serious complications are infrequent, infections or excessive fluid loss can lead to severe illness and even death. Should surgical shock occur after liposuction, hospitalization and additional treatment would be necessary. Skin Loss: Skin loss is very rare after Liposuction. Additional treatments including surgery may be necessary. More common than patches of dead skin are areas of loose skin where elastic recoil has been insufficient to snap the skin back to the new contour. Chronic Pain: Chronic pain and discomfort following Liposuction is very rare. If present, these areas of chronic pain may require subsequent treatment. Burns: Ultrasonic devices have been reported to produce burns and tissue damage, either at the location where the cannula is inserted into the skin or in other areas if the cannula touches the undersurface of the skin for prolonged periods of time. If burns occur, additional treatment and surgery may be necessary. With the low energy ultrasound device used by Dr. Mulholland, there have been no cases of skin burns. Cannula Fragmentation: Ultrasonic energy produced within the cannula may cause stress fatigue and disintegration (fragmentation) of the surgical instrument, which may become lodged deep within your fat. The occurrence and effect of this is unpredictable. Should this occur, additional treatment, including surgery, may be necessary. Ultrasonic Energy: Although ultrasound is considered safe and has been used in medicine for several decades, the long-term effect on tissue and organs to exposure to short-duration, high-density ultrasonic energy is unknown. There is the possibility that additional risks and effects of Liposuction may be discovered. This will not occur with microcannula liposuction. Heart, Lung and Medical Complications: Any surgical procedure may result in injury to your heart, lungs or internal organs which may be fatal. Heart attacks, angina and strokes, although rare, can occur from the stress of surgery. Fat embolism syndrome occurs when fat droplets are trapped in the lungs. This is a rare and possibly fatal complication of surgery. Should fat embolism or other pulmonary complications occur, additional treatment including hospitalization may be necessary. Blood clots (called DVT s) may also form in your leg veins, which may then travel to your lungs (pulmonary embolism), which may stop your breathing and lead to death. The incidence of deep vein thrombosis or pulmonary embolism increases when you are on birth control pills and Dr. Mulholland recommends stopping the birth control medication 6 weeks prior to your surgery and to use other birth control means and start up again one cycle after the surgery. If you have a pre-existing Liposuction Informed Surgical Consent Booklet Page 3 of 6

4 medical condition Dr. Mulholland may insist you see a medical internist prior to surgery. The cost of this medical consultation is an additional expense. Computer Imaging: When discussing the potential benefits of liposuction with you, Dr. Mulholland and/or your SpaMedica Treatment Professional may have shown you a variety of before and after images. It is important to remind you that these images were used as an educational tool to allow you to visualize the general range of body shape improvements that may be achieved with your proposed surgery; the before and after images are not meant to be guarantees of actual or exact outcome. There are many variable conditions in addition to risks and potential complications listed above that may influence the long-term result from a liposuction. Even though risks and complications can occur infrequently, the risks cited in this booklet are particular for liposuction. Other complications and risks can occur but are even less common. Should complications occur, additional surgery or treatment may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is not a guarantee or warranty expressed or implied as to the results that may be obtained. Infrequently, it is necessary to perform additional treatment to improve your results. ALTERNATIVES TO LIPOSUCTION SURGERY Alternative forms of management consist of not treating the areas of fatty deposits and wearing loose-fitting clothing. Diet and exercise regimens may be of benefit in the overall reduction of excess body fat. Other surgical alternatives, including traditional liposuction or surgical lipectomies (directly cutting out the fat), will be discussed with you. Direct removal of excess skin and fatty tissue may be necessary in addition to liposuction in some patients. Risks and potential complications are associated with alternative forms of treatment that involve surgery. DRIVING AFTER LIPOSUCTION SURGERY Surgery, sedation and post-operative discomfort often limit full mobility of the body and/or face and may compromise the ability to safely drive a car. Post-operative patients are not to drive or take public transportation home on the day of surgery. It is recommended that all surgical patients do not drive for at least 7 days following surgery or longer if pain, drowsiness and immobility limit the full capacity to drive a car. Patients that do not have someone to accompany them are advised to arrange for a limousine to drive them home; the SpaMedica staff can make these arrangements for you. Patients are advised not to take a taxi home unaccompanied HOME NURSING REQUESTS Dr. Mulholland strongly recommends that all surgical patients have a responsible person stay with them for at least 3 days following surgery. This requirement may vary depending on the surgery performed and individual healing. If you would like a nurse to care for you after your discharge from SpaMedica, it will be your responsibility to make arrangements directly with any nursing service of your choice. If you prefer, SpaMedica may be able to provide you with names of nurses who are familiar with the post-operative care of cosmetic surgery procedures. You are under no obligation to use these nurses for your post-operative care. These nurses have limited time available and should you request their services, your surgery may need to be scheduled according to their availability. It is your responsibility to ensure that appropriate arrangements are made for proper care to be available. Some of the recommended nurses work at SpaMedica in the Recovery Room. Please be advised that in performing home care post-operative nursing services, these nurses are not functioning as employees of SpaMedica. They are contracting directly with you and SpaMedica assumes no liability in respect of post-discharge nursing care, whether provided by nurses who also work at SpaMedica, or by others. Arrangements and payment for all post discharge nursing care is to be negotiated directly between the patient and nurse. HEALTH INSURANCE Most health insurance companies, including OHIP, exclude coverage for cosmetic surgical procedures, such as liposuction, and any complication that might occur from surgery. Please carefully review your health insurance subscriber-information pamphlet, if you have a private insurance carrier. Liposuction Informed Surgical Consent Booklet Page 4 of 6

5 FINANCIAL RESPONSIBILITES The cost of surgery involves several charges for the services provided. The total includes fees charged by your surgeon, the cost of surgical supplies, anesthesia, nursing staff, and possible outpatient facility 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 facility day-surgery charges involved with revisionary surgery would also be your responsibility. Enhancement/Revision Surgery Financial Policy: There may be a desire for revision or enhancement surgery. All enhancement surgery will have a minimum cost of $ associated with the procedure. Depending upon the procedure, type of anesthesia, overnight stay and any additional requirements, costs may be substantially higher. Changes in body weight of more than 5 pounds heavier or lighter from the time of your original surgery may also significantly increase the costs of enhancement surgery. DISCLAIMER Informed Surgical Consent Booklets are used to communicate information about the proposed treatment of a condition along with disclosure of risk and alternative 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. What Dr Mulholland and your SpaMedica Consultation and Pre-Operative Professional have discussed with you and has been included in this booklet are the material risks both common and uncommon that Dr. Mulholland feels a reasonable person would want to know, understand and consider in deciding if the proposed treatment of a condition is something they would like to proceed with. However, Informed Surgical Consent Booklets should not be considered all-inclusive in defining other methods of care and risk encountered. Dr Mulholland and your SpaMedica Consultation and Pre-Operative Professional may provide you with additional or different information that 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 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 contained on this and all preceding pages carefully and have all of your questions answered by Dr Mulholland and/or a SpaMedica Consultation and Pre-Operative Professional before signing the consent on the last page. Liposuction Informed Surgical Consent Booklet Page 5 of 6

6 I have received the following information/informed Surgical Consent Booklet for: Consent for Surgical Procedure and/or Treatment LIPOSUCTION (Microcannula, Ultrasonic-assisted, and/or SmartLipo ) 1. I hereby authorize Dr. Mulholland and/or such assistants as may be selected to perform the following surgical procedure and/or treatment: Liposuction (Microcannula, Ultrasonic-assisted and/or SmartLipo ). 2. I recognize that during the course of the operation, medical procedure/treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and/or 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, by the anesthetist or under the direction of my surgeon, of such anesthesia considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury and sometimes death. 4. As part of the requirements of the Canadian Association for Accreditation of Ambulatory Surgical Facilities, my chart may be subject to a peer review for quality control. 5. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. 6. I consent to the photographing or televising of the procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided they do not reveal my identity. These photographs and videos may be used for medical meetings, advertising, or any promotional or public relations purposes. 7. For purposes of advancing medical education, I consent to the admittance of observers to the treatment room. 8. I consent to the disposal of any tissue, medical devices or body parts, which may be removed during the course of the procedures(s) and/or treatment(s). 9. I authorize the release of my Social Insurance Number (S.I.N.) to appropriate agencies for legal reporting and medical-device registration, if applicable. 10. I have been advised not to bring any valuable items on the day of my procedure(s) and/or treatment(s) including but not limited to: valuable clothing, watches, jewelry, glasses & dentures. I understand that SpaMedica is not responsible for any items lost or stolen during my stay. 11. I understand that the signature of the witness (if a non-physician) on this document indicates only that the signing of my name has been observed and not that the witness has necessarily provided information regarding the procedure. 12. IT HAS BEEN EXPLAINED TO ME BY MY PHYSICIAN AND/OR ASSISTANTS IN A WAY THAT I UNDERSTAND: i. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN ii. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT iii. THERE ARE RISKS TO THE PROCEDURE/TREATMENT PROPOSED iv. ANY QUESTIONS I MAY HAVE ASKED HAVE BEEN ANSWERED TO MY SATISFACTION I CONSENT TO THE PROCEDURE AND/OR TREATMENT AND THE ABOVE LISTED ITEMS (1-12). I AM SATISFIED WITH THE EXPLANATION. Patient or Person Authorized to Sign for Patient Please Print Name Here DATE WITNESS Liposuction Informed Surgical Consent Booklet Page 6 of 6

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