Informed Consent for Cosmetic Surgery The following is a copy of the general operative permit given to patients having surgery at our Center. It is provided here for general information, and the exact form given may differ in some minor respects. By including the form in this booklet, patients will have a better understanding of the general risks that they will be asked to acknowledge prior to their operation. Please don’t hesitate to ask any questions you might have about the form when you come in for your consultation.


TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I voluntarily request Dr. Howard A. Tobin as my physician, the staff of the Facial Plastic & Cosmetic Surgical Center, and such associates, technical assistants, and other health care providers as they deem necessary, to carry out the following surgery: __________________________________________________________

I understand that no warranty or guarantee has been made to me as to result or cure. I realize that, as in all medical treatment, complications or delay in recovery may occur which could lead to the need for additional treatment or surgery, and could also result in economic loss to me because of my inability to return to normal activity as soon as anticipated. I understand that Dr. Tobin may discover other or different conditions which require additional or different procedures than those planned. I authorize him, and such associates, technical assistants, and other health care providers to perform such other procedures which are advisable in their professional judgment.

I consent to the use of blood and blood products as deemed necessary.

I understand that external incisions may leave scars that are visible. The locations of these incisions have been described to me. I realize that occasionally, scars may have to be revised because of unsatisfactory appearance.

Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical procedures planned for me. I realize that common to surgical procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also realize that the following risks and hazards may occur in connection with this procedure: unsatisfactory appearance, poor healing, skin loss, nerve damage or prolonged pain or discomfort, painful or unattractive scarring, and impairment of organs such as eye or lip function, when surgery is performed in those areas. Hair loss can occur when incisions are made in the scalp, and although usually temporary, can be permanent.

I also realize that the following additional risks and hazards may occur in connection with the following procedures:

Laser resurfacing Chemical Peel or Dermabrasion: Pigment changes which can possibly be permanent. Scarring which can be thick or hypertrophic. Prolonged redness. Activation of herpetic lesions. ___________ (pt’s initials)

Breast Augmentation: Leakage from the implant may occur as a result of trauma or a defect in the wall of the implant. This will require replacement of the implant. Bleeding or infection may require removal of the implant. With infection, the implant must be left out for several months before attempting replacement. Although every attempt will be made to make both breasts exactly the same following surgery, their appearance usually will not be identical in size or shape. The size of the breasts may not be exactly the same as anticipated. Breast implants may wrinkle, and the wrinkles could be palpable or even visible in cases where there is a limited amount of breast tissue to cover the implant. Prolonged discomfort or numbness of parts of the breasts and nipples can occur, and although usually temporary, it can be long lasting or permanent. Fibrous tissue may cause unnatural firmness around the implants and this could require further surgery or removal of the implants. Breast-feeding may not be possible after surgery.

Certain studies have suggested that women with breast implants may not recognize breast cancer until in has progressed to a more advanced stage. In this regard, it is important that women undergoing this operation carry out diligent self-examination post operatively with periodic high quality mammography interpreted by a qualified radiologist with experience in this area. Appropriate attention must be paid to any abnormalities that develop. ___________ (pt’s initials)

Breast Elevation or Reduction: The breasts may be of different size or shape. Significant time is required before the final shape is achieved. There may be discomfort or numbness of the breast or nipple which could be permanent. There may be loss of tissue including of all or part of the nipple which could require further reconstructive surgery. Breast-feeding may not be possible after surgery. Unsatisfactory scars may require revision, and breast shape may change with time requiring revision surgery.___________ (pt’s initials)

Liposuction Surgery: Although experience is proving this operation to be as safe as other similar elective operations, there still exists the potential for complications as described above under general risks and hazards as well as the possibility of indentation, waviness, numbness or pain, skin discoloration or unsatisfactory contouring. With extractions of larger volumes, patients can anticipate weakness and easy fatigue until depleted blood volume is restored, as well as stiffness and soreness for several weeks. Significant scarring, skin loss and perforation of underlying organs are complications that have occurred following liposuction.___________ (pt’s initials)

Fat transfer The long term effectiveness of this treatment is undetermined. Some absorption occurs and the results are not known to be permanent.___________ (pt’s initials)

Blepharoplasty (eyelid surgery): Loss of vision, though rare, is possible. Lowering or irregularity of the lower eyelid can occur. Dryness of the eyes and difficulty closing the eye can occur, and although usually temporary can be long lasting or permanent.___________ (pt’s initials)

Nasal Surgery: The nose may not achieve the desired improvement in shape that was anticipated. Deformity of skin, bone or cartilage, perforation of the nasal septum, breathing obstruction, recurrence or worsening of the condition may occur. Additional surgery may be required for correction. Nostril asymmetry can occur after surgery. When secondary, or revision surgery is carried out, there is a higher risk of complications.___________ (pt’s initials)

Facial Rejuvenation Surgery (Facelift, Coronal Lift, Extended Subperiosteal Coronal Lift): Scars will result from surgery and I understand their location. There can be loss of hair or a shift in the normal hair pattern. Additional scarring can result from poor or decreased wound healing ability. Excessive or postoperative bleeding can delay normal healing and recovery as well as leading to additional scarring. Surgery can result in loss of nerve function. On rare occasions, this could result in permanent weakness of muscles of facial expression.___________ (pt’s initials)

Abdominoplasty: Scars after abdominoplasty are significant, take many months to mature and can widen or thicken requiring revision. There can be loss of skin, which could require further treatment or grafting. Blood or fluid can accumulate beneath the skin requiring further treatment or additional surgery. Delayed healing can prolong recovery. There can be deformity or malposition of the umbilicus. Pulmonary embolus can complicate the development of deep vein thrombosis.___________ (pt’s initials)

Other risks include: _______________________________________________pt’s initials)

THIS PARAGRAPH PERTAINS TO SMOKERS – Smokers are recognized to have a significantly higher risk of postoperative wound healing problems as well as operative and postoperative bleeding. Smokers understand and must agree to discontinue smoking for two weeks before and after surgery. Although it helps to stop smoking for several weeks before and after surgery, this does not eliminate the increased risk resulting from long-term smoking. ___________ (Pt’s initials)

ANESTHESIA: I understand that the anesthetists that administer my anesthetic are independent providers who are not under the employment of the Facial Plastic & Cosmetic Surgical Center. I acknowledge that they have reviewed the proposed anesthetic with me and answered my questions in this regard. I understand that anesthesia involves additional risks and hazards but I request the use of anesthetics for the relief and protection from pain during the planned and additional procedures. I realize the anesthesia may have to be changed possibly without explanation to me. I understand that certain complications may result from the use of any anesthetic including respiratory problems, drug reaction, paralysis, brain damage, or even death. Other risks and hazards that may result from the use of general anesthetics range from minor discomfort to injury to vocal cords, teeth, or eyes.


Anesthetic agents can be harmful to the fetus of a pregnant woman. General anesthesia should be avoided during pregnancy whenever possible. I hereby state that I am not pregnant and accept the responsibility of making this determination. ___________ (pt’s initials)

I hereby give permission to Dr. Tobin or any assistant he may designate to take photographs for diagnostic purposes and to enhance the medical record. I agree that these photographs will remain his property and he may use them for medical, scientific or other presentations and publications.

{ } If initialed, I have been told that a medical grade synthetic implant may be used in the above mentioned operation and have been advised of the risks as well as alternative methods of treatment. I understand that on occasion, the body rejects implants. { } If initialed Medicare Patients – I understand that my surgery is considered by Medicare to be “medically unnecessary.” Medicare will not pay for this surgery and I hereby state that I am voluntarily paying for these services.

I certify that I have read and filled out the patient registration and medical history form fully and correctly to the best of my knowledge, and that the information that I have supplied is complete and correct. I understand that withholding medical information could lead to complications or problems that may have been prevented if that information were known prior to my surgery.

I certify that Dr. Tobin has discussed the operation with me to my satisfaction, this form has been fully explained to me, that I have read it or have had it read to me, that the blank spaces have been filled in, and that I understand its contents. I have been given an opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of non treatment, the procedures to be used, and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent.

I agree to follow the instructions given to me by Dr. Tobin to the best of my ability before, during and after the above mentioned surgical procedure, and will notify Dr. Tobin of any problems following my surgery.

Pre-operative marking reviewed prior to surgery: Patient initials:____




DATE: _____________________________

TIME: ____________________A.M./P.M.