If you are considering surgery, below is the Consent form for you to read prior to your Surgery

Informed Consent 

Breast Lift (Mastopexy) 

William M. Jacobsen, M.D., FACS 

Cosmetic & Restorative Surgery 

2525 East Arizona Biltmore Circle  Suite C236  Phoenix, AZ  85016 

Phone 602.212.0100  Fax 602.279.1701 

www.drjsoffice.com                 

Secure Text: 623.888.8152 

©2020 American Society of Plastic Surgeons®. Purchasers of the Informed Consent Resource are given a limited license to modify documents contained herein and reproduce the modified version for use in the Purchaser’s own practice only. The American Society of Plastic Surgeons® does not authorize the use of these documents for purposes of any research or study. All other rights are reserved by the American Society of Plastic Surgeons®. Purchasers may not sell or allow any other party to use any version of the Informed Consent Resource CD, any of the documents contained herein or any modified version of such documents. 

INSTRUCTIONS 

This is an informed consent document to help you learn about breast lift (mastopexy) surgery. You will also learn about its risks and other treatment(s). 

It is important that you read the whole document carefully. Please initial each page. Doing so means you have read the page. Signing the consent agreement means that you agree to the surgery that you have talked about with your plastic surgeon.  

GENERAL INFORMATION 

Breast lift or mastopexy is done to lift and reshape sagging breasts. Pregnancy, nursing, weight change, aging, and gravity cause changes in the appearance of a woman’s breasts. As the skin loses elasticity, the breasts often lose shape and sag. This surgery can also reduce the size of the areola, the dark skin around the nipple. If your breasts are small or have lost volume after pregnancy, breast implants may be put in during a breast lift. Implants can make breasts firmer and bigger. There are many surgical methods for reshaping and lifting breasts. 

Breast lift surgery works well for women who are healthy, emotionally stable, and have realistic goals for their surgery. Breasts of any size can be lifted, but the results may not last as long in women with big breasts. Breast lift surgery leaves permanent, visible scars on the breasts. Your breasts will be smaller than your current size unless you get implants.  

Note: You will need separate consent forms for the use of breast implants in addition to breast lift or when a breast lift is performed during breast implant removal. Also, make sure to review the Breast Implant Surgery Checklist.  

OTHER TREATMENTS 

This surgery is a personal choice. You can also opt to not have surgery. You can wear supportive bras to lift sagging breasts. If your breasts are large and sagging, a reduction mammaplasty can be done. There are risks and potential complications with all surgeries.  

RISKS OF BREAST LIFT SURGERY 

All surgeries have some risk. It is important that you know these risks. You must also understand other issues that might come up during or after surgery. Every procedure has its limits. Choosing to have a surgery means comparing the risks and benefits Most people do not face problems, but you should talk about them with your plastic surgeon. Make sure you know all possible risks of breast lift surgery. 

SPECIFIC RISKS OF BREAST LIFT SURGERY 

Asymmetry: 

Most women have breasts of unequal size or shape. Surgery may also change the shape and size of the breast and nipple. More surgery may be needed to fix these differences. Even surgery may not give you exact symmetry.  

Change in Nipple and Skin Sensation:  

You may have less, more, or a total loss of sensitivity of the nipples and the skin of your breast. Partial or total loss of nipple and skin sensation can occur after a breast lift in one or both nipples. These changes in sensation may affect your sex life or the ability to breastfeed a baby. 

Breast Augmentation with Breast Lift:  

Risks of breast implants are listed in a separate informed consent document. Risks vary with the type of implant. Patients who go in for breast implants at the time of a breast lift may be at higher risk of necrosis of the nipples and breast tissue. Necrosis, or dead skin cells, is caused by decreased blood supply to the tissues. 

Breastfeeding:  

If you go in for a breast lift, you may not be able to breastfeed. You may not produce enough milk to nurse a baby. 

Breast Implant Removal Surgery with Mastopexy:  

Patients who choose to have breast implants and capsules removed at the time of a breast lift may be at increased risk for necrosis of the skin, nipples, and breast tissue. Necrosis can occur due to less blood supply to the tissues from an earlier surgery. Risks of removing breast implants are covered in a separate informed consent document. 

Nipple and Areolar Necrosis: 

In rare cases, the areola (area around the nipple) and nipple may have poor blood flow after surgery. This will result in death of the tissue, a wound, or slow healing. The nipple and areola can be reconstructed if necessary. 

Use of Acellular Dermal Matrix:  

Your plastic surgeon may choose to use other biological tissue in your surgery. Usually, these materials come from a human cadaver or pig skin. They help support the breast tissues. Your cells will move into the area, making it like your own tissue. You should ask your surgeon about this. This material may produce fluid which will need to be drained for a long time.  The particular risks associated with Acellular Dermal Matrix use are covered in a separate informed consent document. 

Changes in Skin Contour:  

Contour and shape changes may occur after a breast lift. You may see and feel wrinkles. One breast may be smaller than the other. Nipple position and shape will not be identical on each side. Skin may fold at the ends of the cuts forming “dog ears.” This is likely when there is extra loose skin. This may improve with time or you may need more surgery to fix it. 

Delayed Healing:  

The wound may not heal fast. Some areas of the breast or the area near the nipple may not heal normally. Some skin or nipple tissue may die. You may need to change the dressing often. More surgery may be needed to remove the dead tissue. If you have less blood supply to breast tissue due to a past surgery or radiation, you may be at higher risk for delayed healing and poor results. Smokers have a greater risk of skin loss and healing problems. 

Breast Disease: 

Breast disease and breast cancer can occur with or without a breast lift. A personal or family history of breast cancer may put you at a higher risk for breast cancer. All women should do regular breast self-exams. They should also get a mammogram following American Cancer Society guidelines. See your doctor at once if you find a breast lump. If a lump is found before or during surgery, more tests and treatment may be needed. 

DISCLAIMER 

Informed consent documents give you information about a surgery you are considering. These documents explain the risks of that surgery. They also discuss other treatment options, including not having surgery.  

However, informed consent documents can’t cover everything. Your plastic surgeon may give you more or different information. This may be based on the facts of your case. 

Informed consent documents are not meant to define or serve as the standard of medical care. Standards of medical care are determined based on the facts involved in an individual case. They may change with advances in science and technology. They can also change with the way doctors practice medicine.  

It is important that you read the above information carefully and get all your questions answered before signing the consent agreement on the next page. 

CONSENT FOR PROCEDURE OR TREATMENT 

1. IpermitDr. ​William Jacobsen​ and the doctor’s assistants to do the procedure Breast Lift (Mastopexy).  
2. Igot theinformation sheet on Breast Lift (Mastopexy). 
3. I understand that, during the surgery, an unexpected situation may require a different medical procedure than the surgery listed above. Ipermitthe doctor listed above, the assistants and/or designees to provide any treatment that my doctor thinks is needed or helpful. My permission includes all treatments that my doctor does not plan to do at the start of the surgery. 
4. I understand what my surgeon can and cannot do. I understand that no warranties or guarantees have been hinted at orstatedoutright about the outcome of the surgery. I have explained my goals. I understand which outcomes are realistic and which are not. All my questions have been answered. I understand the surgery’s risks. I am aware of other risks and possible issues, benefits, and options. I understand and choose to have the surgery. 
5. I agree to the anesthetics that are needed or helpful. I understand that all types of anesthesia have risks and may result in complications, injury, and even death.
6. I am aware of the serious risks to my health when blood products are used. I agreetomy doctor using them if my doctor, assistants, and/or designees think they are needed or helpful. 
7. I agree to the disposal of any tissue, medical devices, or body parts taken out during or after surgery. I also agreetoany additional surgeries or treatment that is needed or helpful. 
8. I agree to have parts of my body photographed or televised appropriately before, during, and after the surgery for medical, scientific, or educational reasons, if the pictures do not reveal my identity.
9. For medical education, I agree that onlookers can be in the operating room.
10. Ipermitmy Social Security Number to be given to the right agencies for legal reasons and medical device registration, when necessary. 
11. I agree to the charges for this surgery. I understand that the doctor’s charges are separate from the charges for the hospital and the anesthesia. I understand that there may be more charges if more procedures or treatments are needed or helpful. I agreetothose charges, if any. 
12. Iunderstand that not having the surgery is an option and that I can opt-out of having the surgery.  
13. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
14. THEABOVE SURGERY TO BE PERFORMED
15. THEREMAY BE OTHER SURGERIES OR TREATMENT OPTIONS
16. THEREARE RISKS TO THE SURGERY