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INFORMED CONSENT-ABDOMINOPLASTY (TUMMY-TUCK) INSTRUCTIONS This is an informed consent document that has been prepared to help your surgeon inform you of abdominoplasty (Tummy-Tuck) surgery, its risks, as well as alternative treatments. It is important that you read this information carefully and completely. Please initial each section, indicating that you have read the section and sign the consent for surgery as proposed by your surgeon. INTRODUCTION Abdominoplasty is a surgical procedure to remove excess skin and fatty tissue from the middle and lower abdomen and to tighten the muscles of the abdominal wall. Abdominoplasty is not a surgical treatment for being overweight. Obese individuals who intend to loose weight should postpone all forms of body contouring surgery until they have been able to maintain their weight loss. There are a variety of different techniques used by surgeons for abdominoplasty. Abdominoplasty can be combined with other forms of body contouring surgery including suction assisted lipectomy (liposuction) or performed at the same time with other elective surgeries. ALTERNATIVE TREATMENTS Alternative forms of management consist of not treating the areas of loose skin and fatty deposits. Suction assisted lipectomy surgery may be a surgical alternative to abdominoplasty if there is good skin tone and localized abdominal fatty deposits in an individual of normal weight. Diet and exercise programs may be of benefit in the overall reduction of excess body fat. Risks and potential complications are associated with alternative forms of treatment that involve surgery. RISKS SPECIFIC TO ABDOMINOPLASTY SURGERY Every surgical procedure involves a certain amount of risk and it is important that you understand the risks involved with abdominoplasty. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your surgeon to make sure you understand all possible consequences of abdominoplasty. Allergic reactions – In rare cases, 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 medication. Allergic reactions may require additional treatment. Please inform your surgeon of any allergies or sensitivities so these may be avoided. Patient Initials ________ 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. Patient Initials ________

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Asymmetry – Symmetrical body appearance may not result from abdominoplasty. Factors such as skin tone, fatty deposits, bony prominence, and muscle tone may contribute to normal asymmetry in body features. Patient Initials ________ Bleeding – It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it might require emergency treatment to drain accumulated blood or blood transfusion? Do not take any aspirin, anti-inflammatory medication or herbal remedies (Ginseng, Garlic, Ginko, etc.) for two weeks before surgery, as this may increase the risk of bleeding. If you are currently taking an anticoagulant medication such as Coumadin, Plavix, Aspirin etc. – please advise your doctor immediately. Patient Initials ________ Change in skin sensation – Diminished (or loss of) skin sensation in the lower abdominal area may not totally resolve after abdominoplasty. Areas of numbness or tingling may persist indefinitely. Patient Initials ________ Delayed healing – Wound disruption or delayed wound healing is possible. Some areas of the abdomen may not heal normally and may take a long time to heal. Some areas of skin may die. 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. Patient Initials ________ Infection – Infection is unusual after this type of surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary. Patient Initials ________ Lung complications – Complications may occur from blood clots, which form in the legs and travel to the lungs (pulmonary emboli) or from partial collapse of the lungs after general anesthesia. Should either of these complications occur, you might require hospitalization and additional treatment. Pulmonary emboli can be life threatening or fatal in some circumstances. Patient Initials ________ Pain – Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue after abdominoplasty. Patient Initials ________ Scarring – Excessive scarring is uncommon. In rare cases, abnormal scars may result. Scars may be unattractive and of different color than surrounding skin. Additional treatments including surgery may be necessary to treat abnormal scarring. Patient Initials ________ Seroma – Fluid accumulations may occur in between the skin and the abdominal wall. Should this problem occur, it might require additional procedures for drainage of fluid. Drains are typically placed to help prevent the formation of seromas. Patient Initials ________

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Skin contour irregularities – Contour irregularities and depressions may occur after abdominoplasty. Visible and palpable wrinkling of skin can occur. This may be due to the underlying tissues such as muscles and bones. Patient Initials ________ Umbilicus (Belly Button) – Malposition, scarring, unacceptable appearance or loss of the umbilicus (naval) may occur. Patient Initials ________ Long-term effects – Subsequent alternations in body contour may occur as the result of aging, weight loss/gain, pregnancy, or other circumstances not related to abdominoplasty. Patient Initials ________ Other – You may be disappointed with the results of surgery. Infrequently, it is necessary to perform additional surgery to improve your results. Patient Initials ________

Risk of Associated Disease According to BMI and Waist Size

BMI

Waist less than or equal to 40 in. (men) or 35 in. (women)

Waist greater than 40 in. (men) or 35 in. (women)

18.5 or less Underweight -- N/A 18.5 - 24.9 Normal -- N/A 25.0 - 29.9 Overweight Increased High 30.0 - 34.9 Obese High Very High 35.0 - 39.9 Obese Very High Very High 40 or greater Extremely Obese Extremely High Extremely High

BMI (kg/m2) 19 20 21 22 23 24 25 26 27 28 29 30 35 40

Height (in.) Weight (lb.)

58 91 96 100 105 110 115 119 124 129 134 138 143 167 191

59 94 99 104 109 114 119 124 128 133 138 143 148 173 198

60 97 102 107 112 118 123 128 133 138 143 148 153 179 204

61 100 106 111 116 122 127 132 137 143 148 153 158 185 211

62 104 109 115 120 126 131 136 142 147 153 158 164 191 218

63 107 113 118 124 130 135 141 146 152 158 163 169 197 225

64 110 116 122 128 134 140 145 151 157 163 169 174 204 232

65 114 120 126 132 138 144 150 156 162 168 174 180 210 240

66 118 124 130 136 142 148 155 161 167 173 179 186 216 247

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67 121 127 134 140 146 153 159 166 172 178 185 191 223 255

68 125 131 138 144 151 158 164 171 177 184 190 197 230 262

69 128 135 142 149 155 162 169 176 182 189 196 203 236 270

70 132 139 146 153 160 167 174 181 188 195 202 207 243 278

71 136 143 150 157 165 172 179 186 193 200 208 215 250 286

72 140 147 154 162 169 177 184 191 199 206 213 221 258 294

73 144 151 159 166 174 182 189 197 204 212 219 227 265 302

74 148 155 163 171 179 186 194 202 210 218 225 233 272 311

75 152 160 168 176 184 192 200 208 216 224 232 240 279 319

76 156 164 172 180 189 197 205 213 221 230 238 246 287 328

Body weight in pounds according to height and body mass index. Your Body Mass Index (BMI) is __________. Based on this index you will / will not have an elevated risk of minor / major complications. Moderate complications include infection, and seroma / hematoma. Major complications include wounds that need dressing changes, hospital admission and / or need for second surgery. Patient Initials _______ NEED FOR ADDITIONAL SURGERY 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 abdominoplasty. Other complications and risks can occur but are even uncommon. The practice of medicine and surgery is not an exact science. Although good results are to be expected, there is no guarantee or warrantee expressed or implied, on the results that may be obtained. Patient Initials _______ HEALTH INSURANCE Most health insurance companies exclude coverage for cosmetic surgical operations such as abdominoplasty or any complications that might occur from surgery. Please carefully review your health insurance subscriber information pamphlet. Patient Initials ______ 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, anesthesia, laboratory tests, and possible outpatient hospital charges depending upon 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 reversionary surgery would also be your responsibility. Further, any specimens sent to pathology may result in additional fees for which you will also be responsible. Patient Initials ______

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DISCLOSURE Dr. Goldschmidt has provided me with both written and verbal documentation of his training in cosmetic surgery, background, and credentials. I have had the opportunity to discuss any issues with regards to his expertise in cosmetic surgery. Patient Initials ______ 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. 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. Patient Initials ______ CONSENT FOR SURGERY / PROCEDURE or TREATMENT 1. I hereby authorize Dr. Goldschmidt and such assistants as may be selected to perform the

following procedure or treatment:

ELECTIVE ABDOMINOPLASTY (TUMMY-TUCK) 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 (i.e. biopsy, etc.). 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 involve risk and the possibility of complications, injury, and sometimes death. I will not operate a motor vehicle, machinery, or make important decisions for at least 48 hours after any drug is administered.

4. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. 5. I consent to the photographing or televising of the operation(s) or procedure(s) to be performed,

including appropriate portions of my body, for medical, scientific or educational purposes, provided the pictures do not reveal my identity.

6. For purposes of advancing medical education, I consent to the admittance of observers to the operating room.

7. I consent to the disposal of any tissue, medical devices or body parts which may be removed. 8. I authorize the release of my Social Security number to appropriate agencies for legal reporting

and medical-device registration if applicable. 9. I have been advised that this elective procedure is performed through external incisions in the skin,

which leave permanent scars. I have been advised that scars take several years to mature. My physician has indicated the potential locations and extent of the scars to me.

10. 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 (1-10). I HAVE RECEIVED IN SUBSTANTIAL DETAIL AN EXPLANATION OF THE PROCEEDURE,

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OTHER ALTERNATIVE PROCEEDURES OR METHODS OF TREATMENT AND INFORMATION ABOUT THE MATERIAL RISKS OF THE PROCEDURE OR TREATMENT. Patient or Person Authorized to Sign for Patient _______________________________ Physician _______________________________ __________________________________ _______________________________ Date Witness

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RISK OF DVT (Deep Vein Thrombosis)/ PE (Pulmonary Embolism) A rare but serious risk of cosmetic surgery is DVT / PE that consists of blood clots in the deep leg veins that may travel to the lungs and become life threatening.

RiskFactorsforDVTThese are factors that may put a person at risk for developing DVT. The more factors a person has, the greater the risk: Age greater than 40, and increases with age: Birth control pills Cancer and chemotherapy Certain congenital heart defects Congestive heart failure Chronic respiratory failure Hormone replacement therapy Obesity Prior DVT Prolonged immobility or paralysis Smoking Stroke Surgery: including orthopedic, pelvic, and abdominal surgeries (which can trigger the formation of blood clots) Trauma Varicose veins

SymptomsofDVTSymptoms of DVT may include: pain, tenderness, swelling, discoloration, and warmth of the leg. Half the cases show no symptoms. Symptoms of PE are: shortness of breath, a feeling of apprehension, rapid pulse, sweating, and/or sharp chest pain that worsens with deep breathing. Some patients may cough up bloody sputum. Others may develop very low blood pressure and pass out. Anyone experiencing these symptoms should contact Dr. Goldschmidt immediately at (216) 264-8100 or (216) 410-0618. If you are unable to reach Dr. Goldschmidt, call an ambulance and/or go immediately to the nearest Emergency Room.

PreventionofDVTBefore surgery: Avoid long flights or automobile trips a few days before surgery Drink plenty of fluids to maintain adequate hydration Have meat only once a day for one week prior to surgery Take vitamin B complex one week prior to surgery Stop smoking before surgery

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Consider stopping oral contraceptives and using other birth control methods for one week During surgery: We may use special devices, garments, or medications during surgery to decrease your risk. After surgery: Drink plenty of fluids to maintain adequate hydration Walk four or five times a day If you were given TED hose wear them at all times except to bathe Take vitamin B complex Don't smoke Always lay down with your feet elevated above the level of your heart Always have your legs elevated if sitting in a chair Do not sit in a chair with knees bent and feet on the floor Avoid long flights or automobile trips After 10 days you may resume all normal activities, medications, and habits _______________________________ ______________________________ Patient Signature Physician _______________________________ ______________________________ Date Witness