Liposuction Consent Request for Surgical Services
I authorize the surgeon, associate surgeons, and staff to perform liposuction surgery on the following areas (*indicates that less than a 50% improvement can be expected):
|Approximate duration, 1st surgery (hours)||Approximate duration, 2nd surgery (hours)|
|(Total $) – (Consult $) = $ Due||(Total $) – (Consult $) = $ Due|
|Deposit & (date paid)||Deposit & (date paid)|
|Balance & (due date)||Balance & (due date)|
|Preoperative examination time & date||Preoperative examination time & date|
|Time/day/date of surgery||Time/day/date of surgery|
I understand that if I gain excessive weight after the time of the initial consultation or preoperative examination and the day of surgery, the physician reserves the right to change the areas to be treated if the planned areas would result in too much surgery.
The quoted surgical fee remains valid provided that (1) surgery is scheduled and the deposit is paid within 4 months of the date the quote was made, (2) the surgery is done within 1 year of the quote, and (3) the patient’s weight does not increase excessively after the time of the quote. The balance of the fee must be paid at least 14 days before surgery. There is no charge for routine follow-up care after the surgery. However, in the unlikely event of complications, the patient is responsible for fees charged by other physicians or hospitals. In the event of a secondary procedure to correct an unsatisfactory result, the surgical fee will be no more than 50% of the above.
I agree to allow the surgeon and staff to photograph or video me before, during, and after the operation. The photographs, videos, and tapes shall be the property of the surgeon, and may be used for teaching, publication, or scientific research purposes. The patient’s identity will not be revealed. I agree to routine preoperative laboratory blood tests, including a test for HIV (AIDS). I agree to allow laboratory blood specimens to be obtained to evaluate the amount of anesthetic solution that has reached the circulation and to measure the amount of blood lost during surgery. I request local anesthesia and other medications deemed necessary by the surgeon.
Liposuction is associated with certain expected temporary side effects, including soreness, inflammation, bruising, swelling, numbness, and minor irregularities of the skin. Some of these effects can take several months to resolve. Scars, pigment changes, or an irregularity that persists for more than 6 months may or may not be correctable by a secondary procedure. Any surgery may involve risks of more serious and unexpected problems. Although rare, examples of such complications include blood clots, excessive bleeding, scarring, infection, seroma (temporary accumulation of fluid under the skin), injury to other tissues, and allergic or toxic reactions to drugs.
The surgeon and staff have explained the nature, purpose, possible alternative methods of treatment, the risks involved, and possible complications associated with liposuction surgery. I acknowledge that no guarantee has been made as to the results. I agree to have any issue of medical malpractice decided by neutral arbitration rather than by jury or court trial. I know that liposuction should not be done if a woman patient is pregnant; I have no reason to suspect that I might be pregnant.
Plausible risks have been discussed, the 8 pages of this document reviewed, and all of patient’s questions have been answered.
Surgeon’s signature & date:
Patient’s signature & date:
Witness’s signature & date:
To be signed on the day of surgery: I have carefully read all eight (8) pages of this document, including a copy of the postoperative care instructions, and all of my questions have been well answered. I hereby request and give authorization to the above surgery.
Day of surgery (1st surgery) | Day of surgery (2st surgery)
Patient’s signature & date:
Witness’s signature & date:
Patient’s signature & date:
Witness’s signature & date:
Important Information about Tumescent Liposuction
1. Risks of liposuction surgery. Any surgery involves the risk of thromboembolism (blood clots), infection, bleeding, scarring, or serious injury; however, tumescent liposuction has an amazingly good safety record. One of the reasons that tumescent liposuction is so safe is that neither general anesthesia nor intravenous (IV) sedation is required. A recent survey involving over 15,000 patients who had tumescent liposuction without general anesthesia revealed no serious complications, no serious infection, no hospitalizations, no blood transfusions, and no deaths. The greatest risks of liposuction are those associated with general anesthesia. By eliminating general anesthesia, the risks of liposuction are dramatically reduced.
Patients can minimize the risk of surgical complications by not taking medications or over-the-counter preparations that might adversely affect the surgery. Patients should inform the surgeon of any medications being taken either regularly, or occasionally, including herbal remedies.
2. Risk of irregularities of the skin. Tumescent liposuction using microcannulas is the least likely to cause any significant or noticeable postsurgical irregularities of the skin. By magnifying the fatty compartment, the tumescent technique permits more accurate removal of fat, with greater assurance that the liposuction cannula will not inadvertently approach too near the undersurface of the skin, which would cause irregularities. Thus the tumescent technique helps to minimize the risk of postsurgical irregularities or rippling of the skin. Liposuction might improve preexisting irregularities of the skin, such as dimpling or “cellulite,” but prospective patients should not assume that there will be significant improvement. It is unrealistic to expect perfectly smooth skin. Patients should expect that their skin will have approximately the same degree of dimpling and irregularities as existed before tumescent liposuction surgery. Ultimately, after liposuction the skin texture should be within normal limits. A casual observer should not notice any evidence of surgical irregularities of the skin. However, it is possible that a noticeable skin irregularity may result and require a little touch-up liposuction.
3. Risk of scarring of the skin. Incisions for liposuction may result in scarring. The incisions made for inserting the cannulas are usually less than 2 to 3 mm in length and are usually virtually invisible once healed. Although you may be able to find them on close examination, most other people would not be able to see them. Some patients may experience temporary hyperpigmentation (darkening), which usually fades after several months. Some patients may have a genetic predisposition for persistent discoloration at incision sites. Patients that have experienced hyperpigmentation or hypopigmentation (pale or light-colored scars) in the past might expect also to experience it with these incisions. Certain areas of the body, such as the back or upper flanks, may be more likely to have pigmentation changes.
4. Cellulite. Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle “puckering” of the skin, often called “cellulite.” Cellulite results from the pull of fibrous tissue that connects skin to underlying muscle. Although tumescent liposuction may reduce the degree of cellulite, it is unlikely to eliminate it. Liposuction should not worsen cellulite.
5. Liposuction and obesity. Liposuction is not an appropriate treatment for obesity. Liposuction is not a substitute for a prudent diet, good nutrition, and regular exercise. Obese patients may be good candidates for limited liposuction if their goal is simply to improve the shape of certain limited areas of the body.
6. Postoperative healing. Normal healing after tumescent liposuction involves a limited but definite degree of soreness, swelling, bruising, and lumpy firmness. A temporary mild numbness (paresthesia) of the skin may persist for up to 4 months. Most patients can actually see some improvement of their silhouette within one week after surgery. However, because of the slow resolution of postsurgical swelling, the ultimate results following liposuction usually require 12 to 20 weeks to be achieved.
7. Realistic expectations. Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. It is impossible to guarantee the precise amount of improvement that will result from liposuction. Patients should not have unrealistic expectations. Although patients can usually expect to achieve at least a 50% improvement, it is unreasonable to expect 95% improvement or near perfection. For the perfectionist, or for liposuction of a very large area, maximum improvement may require a second procedure, for which there would be an additional fee.
Patients who would be satisfied with a 50% improvement would be reasonably good candidates for liposuction.
The “50% improvement” is intentionally a vague measure. It indicates a definite perceptible improvement, but something short of perfection. If a 50% improvement would make a patient happy, it is likely that these expectations will be met. Our patients generally achieve more than a 50% improvement.
8. Longevity of results. The fat cells that are removed by liposuction do not grow back. If the patient later gains or loses weight, the change tends to be distributed proportionately over the entire body. Although one can expect some changes with aging, provided that the patient does not gain large amounts of weight, the patient’s new, more pleasing silhouette is relatively permanent. If there is a large weight gain after liposuction surgery, new fat cells may be created.
Tumescent Liposuction Preoperative Checklist
Please initial each item to confirm your agreement. Print “NO” if you disagree.
_______ Please circle the following locations where we can telephone you (crossout if NO): Home Work Other
_______ Please circle the following locations where we can leave a message (crossout if NO): Home Work Other
If we cannot telephone you at home or work, please provide other number(s) where we can reach you by telephone:
Other Telephone Number:
_______ You permit visiting physicians or nurses to observe your surgery.
_______ You permit us to show your preoperative and postoperative photos to prospective patients (no name will identify the photos).
_______ You agree to avoid aspirin, ibuprofen, and decongestants for one (1) week before surgery; not to take thyroid medication on the day of surgery; and not to take Fastin (phentermine), Zoloft (setraline), and herbal remedies (unless specifically approved by your surgeon) two (2) weeks before surgery.
We recommend that you remove all aspirin and ibuprofen products from your medicine chest.
_______ If another physician prescribes new medications for you, you will notify the surgical facility’s staff.
_______ You agree not to drive yourself home after surgery and not to drive an automobile until the day after surgery.
_______ If you develop a rash, skin infection, open wound, or illness any time before surgery, you will notify the surgical facility’s staff.
_______ If your preoperative examination and laboratory studies are done out of town by your own primary care physician, you guarantee that the results will arrive at our office at least 1 month before surgery.
Cosmetic Surgery Policies
_______ Payment schedule.
_______ Schedule changes or cancellations. If it is necessary to change or cancel the date of the surgical procedure, at least 1-week notice is required. It is the patient’s responsibility to document both the date and the time, as well as the name of our office staff member who received the notice of cancellation or change. If all preoperative laboratory results and any necessary preoperative clearance letters are not received by 14 days before surgery, your date will be forfeited and rescheduled. Last-minute cancellations due to illness must be well documented in writing by a physician, including a copy of the physician’s physical examination and diagnosis. If you want to revise the plan of body areas designated for liposuction, you will need to notify us at least 1 week before surgery.
_______ Cancellation charges. Once the initial down payment is made, your preoperative physical examination and laboratory studies will be completed. Next, our staff will begin the administrative task of scheduling the surgery. This includes scheduling nurses and preparation of numerous documents, which are required of any state-licensed facility. If your surgery date is rescheduled more than a total of two times for your convenience or by us because you have not completed the preoperative work or other medical clearance in a timely manner, there will be a fee for each additional reschedule. Any reschedule that is done with less than 1-week notice will result in a rescheduling fee. If the surgery is canceled with adequate notice, for any reason, there will be a fee to cover administrative, laboratory, and additional overhead expenses. If you cancel without adequate notice, or if the surgeon must cancel the surgery because you have not complied with explicit instructions, half the total surgical fee will be retained. Thank you for your understanding in this matter.
_______ Preoperative telephone calls. Our staff routinely telephones patients for confirmation 2 to 4 days before surgery. If we are unable to reach you, we would appreciate it if you would telephone us 48 hours before the surgery to confirm the exact date and time of arrival.
I have read the above policy and consent to the routine preoperative laboratory studies, including an HIV test.
The results of these tests will be placed in the patient’s chart and will remain strictly confidential.
Before Liposuction Instructions
Our office wants to provide you with the very best surgical care. You can help to minimize the risk of complications by carefully reading and following your preoperative and postoperative instructions. Please ask us to clarify any item about which you have questions.
1. Do not take aspirin (Anacin, Bufferin, baby aspirin), ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), or any other nonsteroidal antiinflammatory drugs (NSAIDs) similar to these medications, for 1 week before surgery; these will promote bleeding and bruising. It is permissible to take acetaminophen (Tylenol, Anacin-3).
2. Do not drink alcohol for 4 days before surgery, this might decrease resistance to infections. Similarly red wine, garlic powder supplements, and vitamin E impairs normal clotting and can predispose to excessive bleeding, and bruising.
3. Do not take decongestants, such as Sudafed or Actifed, for 1 week before surgery. Do not take appetite suppressants, such as Fastin (phentermine), for at least 2 weeks before surgery. Do not take thyroid medication, such as Synthroid (levothyroxine), on the day of surgery. These drugs can cause the heart to beat too rapidly. Do not take antidepressants, such as Zoloft (setraline), and herbal remedies, unless specifically approved by your surgeon, for 2 weeks before surgery.
4. Do not drive home. Before the day of surgery, make arrangements to have someone drive you home from the surgical facility.
5. Do not wear unnecessary jewelry; do not apply perfume (deodorant permissible); and minimize use of cosmetics.
6. Diet before surgery. If your surgery is scheduled to begin before 9:30 AM, do not eat solid food after midnight prior to surgery. If surgery is scheduled to begin after 9:30 AM, you may have a light breakfast before 8 AM, but only clear liquid for lunch. Please minimize caffeine the day of surgery. You will be given a snack as soon as surgery is completed.
7. Dressings. Changing your dressing the morning after surgery can usually be accomplished without assistance, but it is easier if you have someone to help you.
8. Loose clothing. There is usually considerable drainage of slightly blood-tinged anesthetic solution after surgery. Since this drainage might stain clothing, we suggest that you choose your clothing with this in mind. Because we will apply elastic support garments on top of some bulky absorbent gauze padding, your clothing should be very loose and comfortable.
a. Women. Wear a comfortable bra that you would not mind getting stained from the blue ink that is used to mark the surgical areas. Do not wear an exercise sports bra if you are having liposuction on your abdomen or torso.
b. Men. For liposuction of the abdomen or flanks, Speedo-type swim trunks are the easiest type of garment to wear into the operating room for surgery. Jockey-type underpants are acceptable. Boxer-type underpants are less convenient and may prevent optimal results. Bring extra underpants to wear after surgery.
9. Socks and mittens. You will be provided with cloth foot covers, but if your feet easily become cold, bring warm socks to prevent cold toes during surgery. If you tend to get cold hands, you are welcome to bring clean mittens (no leather gloves) to wear during the surgery. The operating room is kept relatively warm, about 72° to 75° F.
10. Moisturizers. Do not use moisturizers or soap that contains moisturizers for at least a week before surgery. The ink markers used to outline the areas on your body to be treated by liposuction will rub off too easily if you have recently applied a moisturizer to your skin.
11. Towels and plastic sheets. Plan ahead and avoid staining the car seat with blood-tinged anesthetic solution. Bring a towel and a plastic sheet (such as a trash can liner) to cover the car seat during your ride home. Before surgery, pad your bed at home and your living room chair with towels and plastic. Be careful to avoid allowing drainage to stain carpets.
12. Weight and diet. Do not fast or undergo dramatic weight loss just before surgery. All patients should be on a stable, healthy, well-balanced diet for at least 2 weeks before surgery. Liquid diets, extreme low-calorie diets, and rapid weight loss diets may predispose to cardiac irregularities, surgical complications, and poor wound healing.
13. Music. Patients usually enjoy listening to soothing quiet music during surgery. We have a large selection of compact discs (CDs). If you have any favorite CDs that you would like to share with us on the day of surgery, you are welcome to bring them with you. Please write your name on the plastic case that holds your CD.
Medications and Beverage that Potentially Interact with Tumescent Anesthetic
Consult your surgeon if you are taking any of the following:
Anti–cardiac arrhythmia (antidysrhythmic) drugs
quinidine (Quinaglute, Quinidex)
valproic acid (Depakene)
Calcium channel blockers
cyclosporine (Neoral, Sandimmune)
Steroidal Antiinflammatory drugs
Information About Prescriptions and Medications
1. Antibiotics, such as cefadroxil and cephalexin (relatives of penicillin) or doxycycline (relative of tetracycline), are to be taken twice daily to minimize the risk of a surgical infection. Antibiotics should be taken with food to reduce the risk of gastric upset. Please start taking your antibiotic the day before surgery, and continue until the entire supply is completed. If your surgery is scheduled to begin in the early morning (before 9 AM), taking your antibiotic and eating should be postponed until after surgery.
2. Lorazepam is a mild sedative and a mild sleeping pill that does not make one feel “drugged.” Surgery is more easily tolerated if the patient is well rested and relaxed. We suggest that you take one lorazepam the night before surgery.
3. Mephyton (vitamin K) will theoretically minimize bleeding and postoperative bruising. Although it is not essential to take vitamin K, we do recommend it. Take one 5-mg tablet daily, beginning 2 weeks before the surgery.
4. Acetaminophen (extra-strength Tylenol, 500-mg capsules or tablets) does not require a prescription. Taking two tablets three or four times daily, beginning after surgery should help minimize postoperative swelling. Take two tablets as needed to treat any minor pain before surgery. If for some reason Tylenol is not acceptable, notify us so that we can arrange for a suitable substitute.
5. Diphenhydramine (Benadryl 25-mg capsules or tablets) does not require a prescription. Taking as directed can help to reduce postoperative itching. Be aware that Benadryl may cause drowsiness.
Medication Precautions for Surgery Patients
1. Do not take aspirin (Anacin, Bufferin), ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), or any medications that contain these drugs or any similar antiinflammatory medications for 1 week before and 3 days after surgery. These drugs will promote bleeding and bruising. Check the labels of all your medications, even those which you purchase without a prescription, to be sure you are not taking any aspirin or aspirin-like substances. Remove any products containing aspirin from your medicine chest so that you do not inadvertently take it during the week before your surgery. Consult your physician before you stop taking any prescribed medicines. Please inform us if you are taking any medications to treat arthritis or any blood-thinning anticoagulant medications. The following medications must be stopped:
|Alcohol||Children’s Aspirin||Endodan||Ketorolac||Oxyphenbutazone||Sodium thiosalicylate|
|Alka-Seltzer||Choline salicylate||Excedrin||Lortab ASA||Oxybutazone||Soma Compound|
|Anacin||Congesprin||Fenoprofen||Magnesium salicylate||Pamprin||Synalgos DC|
|Argesic||Darvon ASA||4-Way Cold Tabs
|Arthra G||Darvon Compound||Gelpirin||Midol||Piroxicam||Trendan|
|Ascriptin||Diclofenac||Goody’s Body Pain||Nabumetone||Relafen||Tusal|
|Baby Aspirin||Doan’s Pills||Ibuprofen||Norgesic||Rufin||Warfarin|
2. Do not take decongestant medication containing pseudoephedrine (Sudafed, Actifed) for 1 week before surgery. These can cause the heart rate to beat too rapidly.
3. Do not take thyroid hormone such as Synthroid (levothyroxine) on the day of the surgery. Thyroid medication might interact with the anesthetic solution and cause a rapid heart rate.
4. Appetite suppressant drugs such as Fastin (phentermine) should not be taken for at least 2 weeks before surgery. Do not stop appetite suppressants abruptly because you may have side effects. To avoid side effects such as depression, it is better to begin decreasing the dose gradually 2 weeks before surgery. Maintain a healthy diet. Do not attempt an aggressive weight loss diet before surgery.
5. Do not take antidepressants, such as Zoloft (setraline) or tricyclics for 2 weeks before surgery. Please consult your prescribing physician before discontinuing any of your prescribed medications.
What to Expect on the Day of Tumescent Liposuction
1. On arriving in the surgical facility reception area, you will be greeted and asked to sign your surgical-consent forms. You will then change into a surgical gown and be escorted to the operating room. After one last trip to the bathroom, preoperative photographs will be taken, and the areas on your body that are to be treated with liposuction are marked with a felt-tip pen. Next, you will lie down on the surgical table, and the nurse will show you the various positions you will be required to assume during the surgery. Practicing these positions before the surgery helps make the surgery go faster and easier. It usually takes about 30 to 45 minutes after arrival before the surgery begins.
2. For safety purposes, we routinely place an intravenous (IV) access in your arm; it consists of a small plastic IV tube with a rubber stopper on the outside through which medication can be injected if needed. The IV access is much like the car seat belt; it is put in place routinely but it is only rarely needed. A blood pressure cuff is placed on your opposite arm, and cardiac monitor leads are placed on your chest. Next, using extremely thin and short little needles, the physician or the nurse will anesthetize the skin at sites where the longer needles will be inserted to anesthetize the subcutaneous fat. Patients usually experience a slight pricking sensation as the skin becomes “numb.”
3. A large volume of dilute tumescent anesthetic solution is carefully and gently injected into the targeted fat. Once an area has been well infiltrated with the anesthetic solution, the fat is usually completely numb. The infiltration of the local anesthetic is a slow, careful process that can occasionally take as long to complete as the liposuction itself. After the infiltration of the anesthetic is complete, but before beginning liposuction, you will be escorted to the bathroom one more time.
4. Experience has shown that giving a sedative by mouth permits better local anesthesia than when IV sedatives are used. This is because an alert patient is more capable of detecting subtle areas of incomplete anesthesia. A patient who is too sedated might easily ignore an incompletely anesthetized area, then feel more discomfort when liposuction is actually done. Therefore minimizing sedation actually maximizes patient comfort.
5. After completing liposuction, patients are offered a snack. Absorbent pads are placed over the incisions. The incisions are so small that no stitches are required. Finally, after the IV line is discontinued and the compression garments are pulled on, you are ready to go home. Because of residual local anesthetic, no significant soreness begins for several hours after completing the liposuction. Although you will feel well enough after surgery to drive yourself home, you must not do so because large amounts of local anesthetic may cause some drowsiness.
6. The tumescent technique minimizes postoperative discomfort. Because the residual local anesthesia lasts for 18 to 36 hours, plain Tylenol is sufficient to treat postoperative discomfort. With the tumescent technique the patient has no postsurgical nausea and no unpleasant feeling of a “hangover” usually associated with general anesthesia.
After Liposuction Instructions
1. Going home. You should not plan to drive yourself home. It is recommended but not essential that you have a responsible adult be with you on the day of surgery. Resume your usual diet immediately. Drink adequate amounts of water, fruit juices, or soft drinks to prevent dehydration. Avoid drinking alcoholic beverages for 4 days before surgery and 48 hours after surgery.
2. Activities. Quiet rest is recommended immediately after surgery. After surgery do not drive or operate hazardous machinery the rest of the day. Do not make any important personal decisions for 24 hours after surgery. Later in the day or the evening of surgery you may take a short walk if desired. The day after liposuction surgery you should feel well enough to drive your car and engage in light to moderate physical activities. You may carefully resume exercise and vigorous physical activity 2 to 4 days after surgery. It is suggested that you begin with 25% of your normal workout and then increase your activity daily as tolerated. Most people can return to a desk job within 1 to 2 days after surgery, although one must expect to be sore and easily fatigued for several days.
3. Postoperative garments. After tumescent liposuction, postoperative garments (two garments or one garment plus elastic binders) are worn to hold the absorbent pads in place and to provide sufficient compression to accelerate the drainage of the blood-tinged anesthetic solution. The morning after surgery, when the garments are first removed in order to take a shower, the patient may experience a brief sensation of dizziness. Feeling lightheaded is similar to what you might experience when standing up too quickly. It is the result of rapid decompression of the legs as the garments are initially removed. Should dizziness occur, simply sit or lie down until it passes. Dizziness may be prevented by removing the first (top) garment 10 to 15 minutes before removing the second garment.
Beginning the day after surgery the garments are to be removed daily to permit you to wash the garments and to shower and change the absorptive pads. Do not be concerned if you drain for several days. The garments and binders should be worn day and night until all drainage has ceased, plus an additional 24 hours. Discontinuing the use of the garments and binders too soon may result in prolonged drainage. Subsequently, garments and binders can be worn for comfort but are not essential. Wearing garment for more than the minimal number of days is of no significant advantage in terms of the ultimate cosmetic results, but some patients wear the garment for additional days or weeks because of the comfort provided by the support.
4. Postoperative drainage. One should expect a large volume of blood-tinged anesthetic solution to drain from the small incisions during the first 24 to 48 hours following tumescent liposuction. In general, the more drainage there is, the less bruising and swelling there will be. For the first 24 to 36 hours, bulky superabsorbent dressings are worn under the garment. After most of the drainage has stopped, patients need only place thin, absorbent gauze dressings over the incision sites that continue to drain. During the first 36 hours after surgery there is a risk that drainage may leak beyond the pads. To prevent staining furniture or fabric, it is advisable to sit or lie on a plastic sheet covered by towels.
5. Wound care and bathing. Keep incisions clean. Shower once or twice daily. First, wash your hands, then wash incisions gently with soap and water; afterward, gently pat incisions dry with a clean towel. Apply new absorbent dressings. Incisions that have stopped draining for more than 24 hours need not be covered with absorptive pads. Take antibiotics as directed until the prescription is finished. Take antibiotics with food. Call our office if you notice signs of infection, such as fever, foul-smelling drainage, or focal redness, swelling, or exceptional pain in a treated area.
a. Do not apply ice packs or a heating pad to skin overlying the areas treated by liposuction.
b. Do not apply hydrogen peroxide or plastic Band-Aids to incision sites.
c. Do not soak in a bath, Jacuzzi, swimming pool, or the ocean for 7 days after surgery.
6. Common side effects of tumescent liposuction. Menstrual irregularities with premature or delayed onset of monthly menstruation are common side effects of any significant surgery. Flushingof the face, neck, and upper chest may occur after liposuction surgery and usually lasts for 1 or 2 days. Slight temperature elevation during the first 48 hours after surgery is a natural consequence of the body’s reaction to surgical trauma. Discomfort and soreness is worse the second day after surgery, then improves daily. Two extra-strength Tylenol every 4 hours, while awake, for the first 48 hours, will reduce the inflammation, swelling, and soreness associated with surgery. Do not take aspirin, ibuprofen, or medications that contain these drugs, (Bufferin, Anacin, Advil, Nuprin) for at least 4 days after surgery; these can promote bleeding. Bruising is minimal with tumescent liposuction. Nevertheless, the more extensive the liposuction surgery, the more bruising one can expect.Pain and swelling due to an inflammatory reaction to surgical trauma may occur and increase 5 to 10 days after surgery; this is treated with antibiotics and antiinflammatory drugs. Itching of the treated areas several days after surgery may occur as part of the normal healing process. To help relieve the itching, you may try taking Benadryl as directed on the packaging. Be aware that Benadryl causes drowsiness. Benadryl may be purchased without a prescription at most drugstores.
7. Schedule a follow-up appointment at our office for approximately 6 weeks after surgery. You are welcome to return to our office for follow-up visits at no charge as often as you like. Please contact us by telephone or beeper if you have any urgent questions.
Name of surgeon, MD #1:
Name of surgeon, MD #2:
Name of Nurse, RN:
|During office hours||After hours||After hours||or supervisor|
|After office hours:||Home tel:||Home tel:|
Patient’s telephone number immediately after surgery:
Short History and Physical Examination
Patient’s name: ____________________________________________________ Age _________
Chief concern/complaint:__________Localized adiposity: ___________
Maximum weight: _______ Maximum weight pregnant: _______ Present weight: _______
Significant past medical history:
Medications causing adverse or allergic reactions:
Prescription medications, regular/intermittent:
Over-the-counter and, nonprescription medication, herbal remedies, vitamins, and weight loss drugs:
Review of systems:
|( )||( )||Prior liposuction?|
|( )||( )||Any complications with previous surgeries?|
|( )||( )||Hepatitis or liver disease?|
|( )||( )||Heart problems or irregular heartbeat?|
|( )||( )||Problems with high blood pressure?|
|( )||( )||Abdominal or inguinal hernias?|
|( )||( )||Asthma or lung problems?|
|( )||( )||Kidney or thyroid problems or diabetes?|
|( )||( )||Previous back injury or nerve injuries?|
|( )||( )||History of seizures or neurologic or psychiatric problems?|
|( )||( )||History of lightheadedness or fainting?|
|( )||( )||History of excessive bleeding or scarring?|
|( )||( )||Personal or family history of blood clots in legs or lungs or leg swelling?|
|( )||( )||History of a transfusion?|
|( )||( )||History of chronic viral infection?|
|( )||( )||Are you pregnant?|
|( )||( )||Any family history of severe reactions to anesthesia or malignant hyperthermia?|
Preoperative examination vital signs: Blood pressure: Temperature: Heart Rate: Respiratory rate: Height: Weight:
|( )||( )||General appearance|
|( )||( )||Head, eyes, ears/nose/throat|
|( )||( )||Heart: cardiac rhythm, heart sounds|
|( )||( )||Lung sounds|
|( )||( )||Abdominal examination (periumbilical hernia)|
|( )||( )||Genitourinary examination (if indicated)|
|( )||( )||Neurologic, spinal, or extremity examination|
Tumescent Anesthesia Operating Room (OR) Record
|Allergies:||ASA status: I or II||Preoperative hematocrit:||Circulating nurse:||Infiltrating nurse:||Prepared by:||Diagnosis: Localized adiposity|
|Time arrived in OR:||OR #||Anesthesia start:||Surgery start:||Surgery stop:||Anesthesia stop:|
|Surgeon:||IV saline lock: 22-gauge 1-inch, left/right antecubital fossa, started by:||Observer:|
|Initial medications in bag of 0.9% NaCl||1||2||3||4||5||6||7||TOTALS|
|Epinephrine (mg ordered & hung)|
|Sodium bicarbonate||10 mEq||10 mEq||10 mEq||10 mEq||10 mEq||10 mEq||10 mEq|
|Lidocaine (mg ordered & hung) [A]|
|Milliliters (ml) of bag infiltrated [B]|
|Initial ml in bag [C]|
|Lidocaine mg infiltrated [A × (B/C)]|
|Intraoperative medications||Dosage||Route||Time||Given by||Reason given||Effect|
Physician informed of patient’s lidocaine dosage ____________ mg/kg at ____________ by
|□ Patient’s ID checked||200|
|□ Consent signed||180|
|□ Preoperative laboratory studies in chart||170|
|□ History and physical exam complete||140|
|□ Temperature ______||110|
|□ Preoperative medications||100|
|□ IV saline lock||80|
|□ Blood pressure and ECG monitor||70|
|ECG rhythm oximeter %||50|
|Areas treated||Begin End||Begin End||Areas Treated||Begin End||Begin End|
|Volume total aspirate: ml||Total ml anesthetic solution:_______||Total lidocaine dose:_______ mg|
|Volume supranatant fat:_______ml||Total volume IV fluids infused:_______ml||Patient’s weight:_______lb; _______kg|
|Volume infranatant blood-tinged anesthetic:_______ml||Urine voided ×||Lidocaine dosage:_______mg/kg|
Patient recovered in OR at _____________.
See Postoperative care plan for further charting and orthostatic blood pressure and vital signs
|Abdomen lower||Thighs, lateral||Hips||Date and patient information:|
|Abdomen upper||Inferolateral buttocks||Waist|
|Female breasts||Thighs, inner||Female flanks|
|Male flanks||Knees, inner||Postaxillary areas|
|Male breasts||Thighs, anterior||Arms|
|Chin, jowls, neck||Knees, anterior||Buttocks|
Tumescent Liposuction Orders
1. Patient’s name: ___________ Account no: _____________ Date of surgery: __________
2. Diagnosis: Lipodystrophy/localized adiposity (278.1)
3. Signed surgical consent for liposuction
4. Anticipated duration of case:
5. Preoperative laboratory test results in chart: chem panel, CBC, PT, PTT, HCV, HIV
6. Diet: Patient may take clear liquids before and during surgery
7. Start IV access: PRN adapter (saline lock)
8. Photo consent signed and in chart
9. On arrival to surgical facility, give preoperative oral medications: acetaminophen, 500 mg, two tablets; clonidine, 0.1 mg if blood pressure greater than 100/60 and heart rate greater than 60; after markings, give lorazepam, 1 or 2 mg, as necessary for anxiety only.
10. Give atropine, 0.3 to 0.4 mg IV before surgery, only with physician’s signature.
Physician signature: _______________________
11. Do not prepare anesthetic solution until surgeon has written and signed the orders below.
12. Additional orders:
1. Recipe for anesthetic solution: (today’s preoperative weight ______ kg).
Lidocaine administered by RN should be less than __________ mg/kg.
Area(s): __________________: Lidocaine __________(mg) Epi _________(mg)
Area(s): __________________: Lidocaine __________(mg) Epi _________(mg)
Area(s): __________________: Lidocaine __________(mg) Epi _________(mg)
Area(s): ___________________: Lidocaine _________(mg) Epi _________(mg)
Add sodium bicarbonate 10 mEq per 1000-ml bag of 0.9% NaCl or Ringer’s lactate.
2. May give midazolam, 1 mg slow IV push over 1.5 minutes or IM, as necessary for anxiety. May repeat in 15 minutes.
3. If midazolam is required, place pulse oximeter on patient before administration.
4. Inform physician of lidocaine dosage (mg/kg) before suction.
5. Additional orders:
1. After orthostatic blood pressure and pulse are taken and within normal limits, may discontinue IV access (PRN adapter).
2. Postoperative dressings: Apply standard sterile absorbent pads and compression garment.
3. Give to patient written aftercare instructions. Instruct patient to avoid taking lorazepam for 24 hours.
4. Patient in recovery area until discharge criteria met and orthostatic vital signs stable; may discharge 30 minutes after surgery. If midazolam or narcotic analgesics have been given, discharge 60 minutes after last dose.
5. Acetaminophen, 500 mg, two tablets orally, every 4 hours, while awake, as necessary for pain.
Signature ___________________________________ Date/Time _________________________
Tumescent Liposuction Preoperative and Postoperative Care Record
Preoperative Nursing Evaluation Liposuction of: ________________________________________
|Admission date & arrival time:||Driver’s name/phone no:______________________ Time will call us: __________|
|Vital signs:Temp: BP: HR: RR: Wt: LOC:||General appearance/major complaints:|
|Regular medications taken:||Any SSRI antidepressants, erythromycin, or antifungal drugs taken within 10 days?|
|Occasional medications taken:||Any ASA, baby aspirin, ibuprofen, red wine, or vitamin E taken within 10 days?|
|Preoperative medications taken:||Drug Allergies:|
|Previous surgeries:||Any Complications:|
|History and physical exam present and complete||Chronic cough/lung problems||Hearing aid|
|Consent signed||Heart problems/palpitations/HTN||Glasses|
|Laboratory results complete/date drawn||Gastrointestional problems||Contact lenses|
|NPO except liquids since _______||Liver problems||Necklace(s)|
|Recent skin injuries or rash||Kidney problems||Ring(s)|
|History of bleeding disorder||Diabetes||Earrings|
|History of bad reaction to anesthesia, self/family||Hypoglycemia||Wristwatch|
|History of serious back or nerve injury||Breast implants||Music CDs|
|Nursing diagnosis: Alteration in body image with regard to localized fat and/or obesity||Belongings locked; (*) if taken to OR|
Preoperative Teaching Plan
|Description of drawings and photos||Time at which patient entered OR:|
|Description of IV access and therapy||Signature of RN who admitted patient:|
|Description of infiltration of local anesthetic|
|Description of pain control||Signature of RN who gave preoperative teaching:|
|Preoperative medications given:|
Postoperative Care and Discharge Plan (See Anesthesia/OR Record for vital signs)
Recovered in OR or recovery room (circle one) with RN in constant attendance
Medications given in recovery period:_________________________________
Signature of RN giving medications: _________________________________
|Patient tolerated procedure well|
|Fruit plate/snack and oral fluids offered (______ % taken, ______ ml taken)|
|Moderate blood-tinged anesthetic fluid draining from incision sites|
|Absorbent dressings applied and explained (two extra sets given)|
|Compression garments applied: garment(s), binders, Ace wrap; sizes: ______|
|IV access disconnected with cannula intact and no redness or edema noted||Postoperative orthostatic vital signs:Supine—BP: ___ HR ____Time: ____Sitting—BP: ___HR ____Time: ___
Standing—BP: __HR ____Time: ____
|Verbal and written postoperative instructions given|
|Ambulatory, steady gait, to lavatory to void, to dressing room, dressed self (time: ________)|
|Skin warm, dry, color normal; alert and oriented × __________|
Discharged from surgical facility to: __________________________ Time: __________
RN signature: _______________________