Breast Implant Patient Review Advisory

The following items should be discussed with the patient, and the patient should initial each space, or otherwise mark any items which require further explanation, prior to consenting to the performance of a breast augmentation procedure:

GENERAL INFORMATION

1. Description of alternative operative procedures, preferred technique and why
2. Available methods of anesthesia and discussion of surgeon's preference
3. Post-operative recovery time and limitation of normal activities
4. Long-term limitations on individual lifestyles, if any

ANTICIPATED OUTCOME

1. Anticipated size, shape and aesthetics
2. Constraints of individual's anatomy
3. Complete correction of asymmetry impossible
4. Location and probable nature of scar (3 or more possible incisions)

THE IMPLANTS

1. Types available
2. Advantages/disadvantages
3. Type to be used and why
4. Subglandular vs. submuscular

INHERENT RISKS

1. Inherent risk assumed by patient as part of procedure
2. Nature and unpredictability of capsular contracture and its physical effects
3. Treatment options, including open or closed, and risks
4. High probability of need for future implant replacement

5. Uncertain life span of implants, including probability of rupture, leakage or gel migration

6. Risk of compromised detection of early breast cancer, even with mammography techniques
7. Rare and unsubstantiated, but possible, relationship to connective tissue disorders
8. Possible effects on future pregnancy and nursing
9. Possible exclusion for breast diseases by some health insurance carriers
10. Need for initial mammography prior to breast implantation in patients over 35 years of age

COMPLICATIONS

1. Capsular contractures (possibly requiring further surgery)
2. Infection (requiring implant removal)
3. Bleeding requiring return to the Operating Room (Hematoma)
4. Excess or obvious scar
5. Changes in nipple sensation (which could be permanent)
6. Chronic pain (which could be permanent)
7. Asymmetries significant enough to require reoperation
8. Lowering of the inframammary fold or a “double bubble” requiring reoperation

ECONOMICS

1. Costs of procedure (patient will be responsible for all secondary surgery costs)

Even though the risks and complications cited occur infrequently, these are the ones that are particularly peculiar to the operation; other complications and risks can occur but are even more uncommon.

Patient wants these described_________________ Patient does not want-these described_________________

The practice of medicine and surgery is not an exact science. Although good results are expected, there cannot be any guarantee or warranty, expressed or implied, as to the results that may be obtained.

Additional Comments:___________________________________________
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Pre and post-op photos will be taken of the treatment site for record purposes. I understand that these photos/videos will be the property of the attending physician.  I do____, do not ___ agree to allow these pictures to be used for publication, teaching purposes or the practice web site. If I agree, I understand that my name will be kept confidential and protected.

IF YOU HAVE ANY QUESTIONS, DO NOT HESITATE TO CALL THE OFFICE DURING BUSINESS HOURS (949-888-9700) OR AFTER HOURS, CALL YOUR SURGEON  - DR BUNKIS CELL PHONE NUMBER IS  (949) 500-8856, OR REGISTERED NURSE, TRACEY PRESCOTT’S NUMBER IS (949) 338-6072.     

WITH AN EMERGENCY THAT REQUIRES IMMEDIATE ATTENTION, CALL 911 BUT PLEASE HAVE YOUR FAMILY NOTIFY DR. BUNKIS OF ANY PROBLEMS YOU MAY HAVE!

I, ____________________________________________, certify that I have read and understand the “Breast Augmentation” information sheets dated March 2008, that my surgeon has answered all of my questions to my satisfaction, and that I give my informed consent for this procedure. I certify that all the blank spaces were checked or filled in prior to my signature.

Patient Signature_______________________ Date__________________

Witness_______________________________ Date__________________

I certify that I, or a member of my staff has discussed all of the above with the patient and have offered to answer any questions regarding the procedure. We believe that the patient fully understands the explanation and answers.

Surgeon’s Signature_____________________ Date_________________

Initial if copy requested/given to patient____________________________ Copy placed in chart __________________________________________

Copyright 11/87 Last revised 03/08
Juris Bunkis, M.D., F.A.C.S.