Of course you are not expected to ask all of these questions but you are entitled to if you want to. For ease of reference highlight the numbers of the questions you do wish to ask at your consultation.
Surgeon : _____________________________________
Date : ________________ Time : ______________ am/pm
Telephone : ___________________________
Address : __________________________________________
Web site : _________________________________________
Referred by : _________________________________________
Certified by:
American Board of Plastic Surgery (ABPS) :
[ ] yes [ ] no
American Board of Surgery (ABS) :
[ ] yes [ ] no
Royal College of Physicians and Surgeons of Canada (RCPSC) :
[ ] yes [ ] no
Other : _______________________________________________
Rating:
-
Office appearance:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
-
Attitude of staff:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
-
Appearance of surgeon:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
-
Communication skills of the surgeon:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
-
Bedside manner:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
-
Patient referral list available:
[ ] yes [ ] no
-
All questions answered:
[ ] yes [ ] no
Overall Rating:
[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent
General Questions About Your Surgeon
- What made you decide to become a Cosmetic Plastic Surgeon?
______________________________________________________ - How long have you been practicing as a Cosmetic Plastic Surgeon?
______________________________________________________ - Are you certified by the American Board of Plastic Surgery?
[ ] yes [ ] no If no, Why not?
______________________________________________________ - Have you ever been disciplined by the board or by the state?
______________________________________________________ - Have you been involved in any medical malpractice suits? If so how many?
______________________________________________________ - How long have you been performing mastopexy? How many mastopexies do you perform per month (or week)?
______________________________________________________ - Have you performed mastopexy on anyone of your staff? May I speak to her?
______________________________________________________ - How many revisions of your own work, on average, do you perform?
______________________________________________________ - Have you or would you be willing to perform this procedure on a loved one or family member?
[ ] yes [ ] no
Surgical Techniques
- Which techniques do you perform?
[ ] crescent [ ] periareolar [ ] Le jour [ ] anchor [ ] scarless
______________________________________________________ - Am I a candidate for the circum-areolar lift (peri-areolar, Benelli)?
[ ] yes [ ] no - What technique would you recommend for my needs and what key factors decide this?
______________________________________________________
______________________________________________________
______________________________________________________ - Which general breast shape will I have post-operatively? 9check all that apply)
[ ] cone-shaped [ ] sloped [ ] higher [ ] flattened [ ] rounder [ ] other - What size do you think I will be post-op?
______________________________________________________ - Do you keep the nipple and areola complex attached via a pedicle or detach it completely?
______________________________________________________ - How long does it take to perform breast lift surgery?
_____ hours _____ minutes - If I need augmentation with my lift will you use the lift incisions to insert my implants (if not prefilled)?
[ ] yes [ ] no - Do I need an areolae reduction?
[ ] yes [ ]no - How many centimeters post-op will my areolae be?
__________ cm - Will you be using sutures, staples or tissue glue to close the external sutures?
[ ] yes [ ]no - Do you encourage the use of a pain pump?
[ ] yes [ ]no
Risks, Contraindications & Complications
- Make sure they discuss the risks & complications for mastopexy.
- Make sure they discuss the risks & possible complications of anesthesia.
- What percentage of patients develop fat or skin necrosis?
______________________________________________________ - What are the chances of my incision line opening back up?
______________________________________________________ - I have heard that the areolae (skin around the nipple) get larger or stretch out. What can be done about this. If I am getting a lift will you use permanent sutures such as Mersilene or Prolene?
______________________________________________________
______________________________________________________ - What happens if an internal suture "pops" or extrudes from my breast, what can be done?
______________________________________________________ - What if I develop "dog ears" -- will you correct this problem? If so, at what cost to me?
______________________________________________________
Surgery Preparation
- Must I abide by a special diet before surgery? If so, starting at how many days before surgery?
______________________________________________________
______________________________________________________ - I smoke (if applicable), must I quit before surgery? If so, for how long before and after should I?
______________________________________________________ - Should I get a mammogram beforehand?
[ ] yes [ ] no - Do I have to buy special post-operative supplies such as:
[ ] gauze [ ] Hibiclens [ ] Q-tips [ ] cotton balls [ ] ice packs or frozen peas [ ] antibiotic creams [ ] other
______________________________________________________
______________________________________________________ - Do you suggest vitamins and supplements, such as:
[ ] Vit. C [ ] Vit. K [ ] Vit. A [ ] Vit. K [ ] Zinc [ ] Coenzyme Q-10 [ ] L-Carnitine [ ] Alpha Lipoic Acid (ALA) [ ] MSM (Methyl Sulfonyl Methane) [ ] other ______________________________________________________
______________________________________________________ - I have heard Arnica montana helps with the swelling and bruising if taken before and after my surgery. Do you recommend it?
______________________________________________________ - What about Bromelain tablets (derived from pineapple)?
______________________________________________________ - What about the topical arnica gels?
______________________________________________________ - What preliminary tests are required before surgery (i.e. CBC, Chem-7, pregnancy test, etc)
______________________________________________________ - Will I be receiving a medications to avoid list? [ ] yes [ ] no
If not, have them check over our print out at www.breastlift4you.com/medication_list.htm - What types of medications will I be given and which pain medications do you normally prescribe?
______________________________________________________ - I am sensitive to Vicodin and Codeine (if applicable - it makes some people nauseated), what alternative medications do you offer?
______________________________________________________ - I take (birth control, diet pills, antidepressants, etc.) will I have any adverse reactions from the prescribed medications or anesthesia? Please view a medication & supplement list example at http://www.breastimplants4you.com/medication_list.htm
______________________________________________________ - Will I need to use cold compresses or ice packs to alleviate pain and swelling after surgery? How long, and often, must they be used?
______________________________________________________ - Must I provide and bring the day of surgery, two front closure bras or a front closure sportsbra in my desired size, or slightly bigger. Where is the best place to purchase these bras; any particular brand names that you recommend?
______________________________________________________
______________________________________________________
Surgical Procedure & Other Surgery Day Questions
- Will I have to be catheterized?
[ ] yes [ ] no - If so, will you wait until I am anesthetized to do so?
[ ] yes [ ] no - Do you have hospital privileges should I choose to undergo my procedure in a hospital?
[ ] yes [ ]no - If not, did you lose those privileges (if so, the surgeon must disclose this information)? [ ] yes [ ]no
______________________________________________________ - Do you have an on-site accredited Surgery Center? If so, may I see it? Which organization is it accredited by?
[ ] AAAASF - American Association for Accreditation of Ambulatory Surgery Facilities
[ ] AAAHC - Accreditation Association for Ambulatory Health Care
[ ] JCAHO - Joint Commission on Accreditation of Healthcare Organizations
[ ] Medicare
[ ] State - How is a medical emergency handled? (Make sure the facility has a "crash cart" with the medications and equipment to handle a life-threatening emergency.)
______________________________________________________
______________________________________________________ - What anesthetic will you use? (check one)
[ ] Light Sleep/Twilight [ ] General IV [ ] General Gaseous Sedation - Who will administer anesthesia? (check one)
[ ] anesthesiologist MD [ ] certified registered nurse anesthetist (CRNA) [ ] surgeon [ ] nurse - I have heard that general anesthesia can make a patient sick to their stomach, is this true? If so, what can you do to lessen this effect?
- Do you have the following monitoring machines in your operating room (check all that apply)?
[ ] EKG [ ] Pulse Oximetry [ ] Blood Pressure, [ ] Capnograph (CO2) [ ] pneumatic leg sleeves - Do you have transfer privileges (to admit a patient) at a nearby hospital?
[ ] yes [ ] no - Will I have drains inserted? [ ] yes [ ] no If yes, where are they placed and when are they removed?
______________________________________________________
Recovery Questions
- Recovery room monitors (circle all that apply)?
[ ] EKG [ ] Pulse Oximetry [ ] Blood Pressure [ ] heating blankets or lamps - What is the certification of the person that will be present in the recovery room? (check all that apply)
[ ] MD [ ] RN [ ] PA [ ] certified in CPR [ ] certified in Advanced Cardiac Support? - Will this person have other duties during my recovery?
[ ] yes [ ]no - Will there be a lot of swelling and bruising?
[ ] yes [ ] no - Will there be much pain?
[ ] yes [ ] no - What suggestions do you have for me to ease discomfort and pain?
______________________________________________________ - What should I expect during recovery?
______________________________________________________ - If I need anything after-hours, how will I be able to get in touch with you or your staff?
______________________________________________________
______________________________________________________ - If I have an emergency the night after surgery, what should I do?
______________________________________________________ - If such an emergency arises, will you be the attending physician?
[ ] yes [ ] no
- What are your policies on post-operative care?
______________________________________________________ - When will my sutures (stitches) be removed?
- When will I be able to shower again?
______________________________________________________
______________________________________________________ - When can I suntan afterwards?
______________________________________________________ - Can I go braless after? [ ] yes [ ] no Should I? [ ] yes [ ] no
- Will I still have sensitivity in my nipples and breast envelope post-operatively?
[ ] yes [ ] no - Will I have visible scaring? [ ] yes [ ] no If so, how bad will it be?
______________________________________________________ - Do you recommend silicone sheeting, topical gels, silicone sheeting-backed foam squares or use "steri-strips" for lessening of scars? [ ] yes [ ] no Do you think this helps?
______________________________________________________ - How long do you recommend that I take off from work, school, etc. to heal properly?
______________________________________________________ - How long until I will be able to walk, exercise, run or participate in contact sports?
______________________________________________________ - Must I abide by any special diet post-operatively? What about supplements?
[ ] yes [ ] no
______________________________________________________ - How long will it be before I can lift objects over 5 lb?
______________________________________________________ - Will I be able to breastfeed?
[ ] yes [ ] no
Results
- Do you believe my expectations can be met? [ ] yes [ ] no
- If my results are not what I wanted, what is your policy on a revision?
______________________________________________________
______________________________________________________ - What would you do if I were to choose to undergo the surgery and I had a complication?
______________________________________________________
______________________________________________________ - How long will it take to see my true results? __________ months
- If I need an additional surgery to correct significant asymmetry, what will the costs be and will I be responsible?
______________________________________________________
Request for Information
- Do you have a video tape available of mastopexy that I may check out?
[ ] yes [ ] no - May I view your before & after photos? [ ] yes [ ] no Do you have sequential sets? [ ] yes [ ] no
- May I speak with some of your patients who have had mastopexy performed by you?
[ ] yes [ ] no
Financial Issues
- Are there any hidden costs that I should know about? For lab work, post-operative check-ups, additional medications? [ ] yes [ ] no If yes, please explain.
______________________________________________________ - Will my procedure be covered by my insurance?
[ ] yes [ ] no - Do your require a deposit to hold my surgery date? [ ] yes [ ] no If so, how much? $ _____________
- Do you offer financing (if applicable)?
[ ] yes [ ] no - Do you expect full payment up front?
[ ] yes [ ] no - Do you take credit cards? [ ] yes [ ] no May I pay in increments? [ ] yes [ ] no
- Other Financial Questions?
______________________________________________________
______________________________________________________
______________________________________________________ - What if I change my mind and back out, will my money be refunded?
[ ] yes [ ] no
Miscellaneous
- How far in advance is it necessary to schedule a surgery date? I'm want have the surgery done on or by _______________________ (your-desired-date), would this be possible?
______________________________________________________
______________________________________________________
Notes:
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