Gen Surgical Checklist

Surgical Risk Checklist

It is important that you read this information carefully and completely. Please initial each line, indicating that you have read and fully understand each possible risk of the procedure.

General Risks (Applicable to All Procedures):

• _____ Infection, delayed healing, or poor wound healing

• _____ Bleeding, swelling, bruising, or hematoma formation

• _____ Reaction to medications, including anaphylaxis requiring life-saving measures

• _____ Abnormal reaction to sutures, with possible extrusion months later

• _____ Scarring (hypertrophic, widened, keloid) or scar migration/displacement

• _____ Skin necrosis, requiring additional treatments such as grafting or hyperbaric therapy

• _____ Sensory or motor nerve damage, leading to temporary or permanent weakness, numbness, or pain

• _____ Vascular compromise to the skin, possibly requiring advanced therapy or surgical intervention

• _____ Deep venous thrombosis (DVT) or pulmonary embolism (blood clot in the lungs)

• _____ Pneumothorax (collapsed lung)

• _____ Fat embolism (life-threatening risk)

• _____ Seroma (fluid collection) requiring aspiration or revision

• _____ Need for blood transfusion

• _____ Death

Tummy Tuck and Mini Tuck Risks:

• _____ Recurrence of diastasis (abdominal muscle separation)

• _____ Bulging in the upper abdomen

• _____ Risk of pinching or damage to the lateral femoral cutaneous nerve, leading to numbness or pain in the upper thigh, which may require further procedure

• _____ Scar hypertrophy, widening, or keloid formation

• _____ High or vertical scars

• _____ Need for additional liposuction or correction of 'dog ears'

• _____ Elevation of the pubis or vaginal vault

• _____ Persistent nerve pain or neuroma formation

• _____ Umbilical (belly button) asymmetry or deformity

Liposuction Risks:

• _____ Fat embolism (life-threatening risk)

• _____ Seroma or prolonged need for drains due to fluid collection

• _____ Micro-seromas, which can create localized fluid collections requiring prolonged steroids, reduced compression, aspiration, revision, or permanent deformity

• _____ Skin irregularities, indentations, or asymmetry

• _____ Skin loss, requiring grafting, scar revision, or hyperbaric therapy

• _____ Dehydration

Fat Grafting Risks:

• _____ Unpredictable fat graft survival; possible loss of all or some of the transferred fat

• _____ Unpredictability of the amount of fat that can be transferred to specific areas, especially hip dips, due to anatomical limitations

• _____ Aspiration of cysts, which may cause scarring or indentation

• _____ Fat necrosis, causing firmness, chronic infections, or cyst formation

• _____ Fat overgrowth at the grafted site, requiring further correction

• _____ Fat embolism (life-threatening risk)

Facial Procedure Risks:

• _____ Nerve and vessel damage, leading to weakness or numbness in facial muscles

• _____ Difficulty closing the eye, lifting the eyebrow, or a crooked smile due to motor nerve injury

• _____ Skin damage or vascular compromise requiring further treatment

• _____ Seroma requiring aspiration or revision

• _____ Salivary gland leakage requiring multiple aspirations or revision surgery

• _____ Persistent asymmetry; faces are never perfectly symmetrical

• _____ Risk of relapse, requiring a secondary procedure

• _____ Keloid or thickened scars

• _____ Unsatisfactory results or outcomes below expectations

Eyelid Surgery Risks:

• _____ Dry eyes, corneal abrasions, conjunctivitis, colitis, or other eye inflammation

• _____ Ectropion (outward turning of the eyelid)

• _____ Eyelid drooping (ptosis) requiring revision surgery

• _____ Loss of lashes

• _____ Asymmetry or hollow appearance (e.g., A-frame deformity)

• _____ Need for skin grafting or referral to a specialist for advanced care

• _____ Double vision requiring referral to a specialist

• _____ Unsatisfactory results or outcomes below expectations

Brow Lift Risks:

• _____ Nerve damage to the frontal branch of the facial nerve (temporary or permanent)

• _____ Pneumocephalus or brain bleed, such as subdural hematoma

• _____ Scalp and forehead numbness

• _____ Hair loss near incision sites, potentially requiring further treatment

• _____ Headaches following surgery

Laser Procedure Risks (Including CO2 Lasers):

• _____ Infection or acne outbreaks

• _____ Herpes simplex (HSV) outbreaks leading to scarring

• _____ Fungal infections

• _____ Hyperpigmentation or hypopigmentation

• _____ Prolonged redness or sensitivity

• _____ Unsatisfactory results such as residual wrinkles or pigmentation

• _____ Damage to the eye, which may affect vision and require further treatment

Additional Points to Consider:

• _____ It is essential to have a responsible caregiver available during the recovery period. Patients must ensure they have adequate support for transportation, daily care, and assistance with tasks as physical limitations may temporarily impact their ability to manage independently.

• _____ Patients must share all relevant medical information, including current medications, changes in medical history, or new diagnoses, during the preoperative appointment or as soon as possible before surgery.

• _____ Cancellation or rescheduling may incur additional costs, and prices may vary depending on the timing of the request and expenses already incurred by the practice.

• _____ It is highly recommended that patients maintain medical health insurance in case hospitalization, further procedures, or additional care is required due to complications.

• _____ Patients understand that if revision surgery is required, they may be responsible for the full cost of the revision or for specific expenses such as anesthesia and facility fees.

• _____ Patients must attend all scheduled follow-up appointments and adhere to postoperative instructions. Failure to do so may result in suboptimal results, complications, or the need for additional procedures.