Free Fat Transfer (Fat Grafting) Consent Form Template

Informed Consent for Autologous Fat Transfer (Fat Grafting) Surgery

Patient Informed Consent Documentation

Patient and Surgical Information

1. Clinical Indications for Surgery

2. Description of the Surgical Technique

Autologous fat transfer (fat grafting) involves moving fat from one area of your body to another. (1) Harvesting: The surgeon injects a sterile numbing fluid (tumescent solution) into the donor site (e.g., abdomen or thighs) and uses a small, blunt tube (liposuction cannula) to gently harvest the fat. (2) Processing: The harvested fat is centrifuged, filtered, or washed to separate pure, intact fat cells from blood, oil, water, and dead cells. (3) Grafting: The purified fat cells are loaded into small syringes and injected into the target area in tiny droplets (micrografting) using specialized cannulas. This allows the transferred fat cells to be close to blood vessels in the host tissue to establish a new blood supply.

3. Fat Graft Survival and Absorption Disclosures

I understand that not all of the transferred fat cells will survive in the new location. On average, only 50 to 70 percent of the injected fat remains permanently. The rest is naturally absorbed by the body in the first 3 to 6 months. To compensate for this loss, the surgeon may slightly overfill the target area during the procedure, which can cause temporary swelling or over-correction. The final volume and shape cannot be evaluated until 6 months after surgery. If absorption is higher than expected, additional fat grafting procedures may be needed to achieve the desired volume, which are billed separately.

4. Short-Term Risks and Side Effects

5. Long-Term and Permanent Risks

6. Anesthesia Disclosures

The procedure is performed under local anesthesia with sedation or general anesthesia. Risks include temporary nausea, vomiting, throat soreness, or breathing changes. The anesthesia team monitors your vital signs continuously throughout the procedure.

7. Alternatives to Fat Transfer

8. Detailed Post-Operative Care Guidelines

To support the survival of the transferred fat cells: (1) Do NOT apply pressure, ice, or heat directly to the target injection sites for the first 3 weeks. Pressure can kill the newly transplanted fat cells before they establish a blood supply. (2) Avoid sleeping on the treated areas (e.g., sleep on your back if facial or breast grafting was done; use a specialized pillow if buttock grafting was done). (3) Wear the compression garment on the donor liposuction areas as instructed to minimize swelling and support skin contraction. (4) Avoid strenuous exercise and heavy lifting for 3 to 4 weeks.

9. When to Seek Emergency Medical Care

10. Right to Refuse or Postpone Surgery

You have the right to cancel or postpone the procedure at any time before it begins. Deposit and planning fees are subject to the clinic's refund policy.

11. Patient Understanding and Questions

I confirm that I have read this document and understand the fat transfer procedure, its risks (including fat necrosis, asymmetry, and over-absorption), the post-op care guidelines (specifically pressure avoidance), and the alternatives. All my questions have been answered.

12. Language Access Services

If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.

13. Patient Authorization

I voluntarily consent to undergo autologous fat transfer surgery. I authorize liposuction fat harvesting from the donor sites, processing, and injection into the target sites. I agree to follow the post-operative pressure avoidance and care guidelines.

Signatures and Verification