The following forms are similar to the information Dr. Hudson will ask you to sigh before you have a facelift. The forms you actually sign will be similar but may not be exactly the same. They are provided here so you have time to read them carefully and understand the material before you give your consent for your facelift. If you have questions you can email Dr. Hudson or call his office at 505-242-0070.
Similar material is also available as a pdf file.
INSTRUCTIONS
This is an informed-consent document that has been prepared to help your plastic surgeon inform you concerning face lift surgery, its risks, and alternative treatment. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your plastic surgeon. This form has six (6) pages
INTRODUCTION
Facelift or rhytidectomy is a surgical procedure to improve visible signs of aging on the face and neck. As individuals age, the skin and muscles of the face region begin to lose tone. The facelift cannot stop the process of aging. It can improve the most visible signs of aging by tightening deeper structures, re-draping the skin of face and neck, and removing selected areas of fat. A facelift can be performed alone, or in conjunction with other procedures, such as a brow-lift, liposuction, eyelid surgery, or nasal surgery. Facelift surgery is individualized for each patient. The best candidates for facelift surgery have a face and neck line has begun to sag, but whose skin has elasticity and whose bony structure is well defined.
ALTERNATIVE TREATMENT
Alternative forms of management consist of not treating the laxness in the face and neck region with a facelift (rhytidectomy). Improvement of skin laxity, skin wrinkles and fatty deposits may be attempted by other treatments or surgery such as chemical face peels or liposuction. Risks and potential complications are associated with alternative forms of treatment.
RISKS of FACELIFT (Rhytidectomy) SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand the risks involved with facelift (rhytidectomy). An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your plastic surgeon to make sure you understand the risks, potential complications, and consequences of facelift (rhytidectomy).
Bleeding - It is possible, though unusual, that you may have problems with bleeding during or after surgery. Should postoperative bleeding occur, it may require emergency treatment to drain accumulated blood or blood transfusion. Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this contributes to a greater risk of bleeding. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the skin may delay healing and cause scarring.
Infection - Infection is unusual after this surgery. Should an infection occur, additional treatment including antibiotics or surgery may be necessary.
Scarring - Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin. There is the possibility of visible marks from sutures. Additional treatments may be needed to treat scarring.
Damage to deeper structures - Deeper structures such as blood vessels, muscles, and particularly nerves may be damaged during surgery. The potential for this to occur varies with the type of facelift procedure performed. Injury to deeper structures may be temporary or permanent.
Asymmetry - The human face is normally asymmetrical. There can be a variation from one side to the other in the results obtained from a facelift procedure.
Nerve injury - Motor and sensory nerves may be injured during a facelift operation. Weakness or loss of facial movements may occur after facelift surgery. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to sensory nerves of the face, neck and ear regions may cause temporary or more rarely permanent numbness. Painful nerve scarring is very rare.
Surgical anesthesia - Both local and general anesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation. You should discuss the risk of general anesthetic with the anesthesiologist before surgery.
Chronic pain - Chronic pain is a very rare complication after a facelift.
Skin disorders or skin cancer - A facelift is a surgical procedure for the tightening of skin and deeper structures of the face. Skin disorders and skin cancer may occur independently of a facelift.
Unsatisfactory result - There is the possibility of a poor result from the facelift surgery. This would include risks such as unacceptable visible deformities, loss of facial movement, wound disruption, and loss of sensation. You may be disappointed with the results of surgery. Infrequently, it is necessary to perform additional surgery to improve your results.
Allergic reactions - In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions which are more serious may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.
Hair loss and Hairline change - Hair loss may occur in areas of the face where the skin was elevated during surgery. The occurrence of this is not predictable. The hairline may also change.
Delayed healing and loss of skin - Wound disruption or delayed wound healing is possible. Some areas of the face may not heal normally or may take a long time to heal. Areas of skin may die. Frequent dressing changes or further surgery may be required to remove the non-healed tissue.
Liposuction of face - liposuction may be performed in the face and neck and surface irregularity can occur.
Puckering - skin puckering or pleating may occur after surgery, it usually resolved within two weeks but in rare cases may last longer or be permanent
Smokers have a greater risk of skin loss and wound healing complications.
Long term effects - Subsequent alterations in facial appearance may occur as the result of aging, weight loss or gain, sun exposure, or other circumstances not related to facelift surgery. Facelift surgery does not arrest the aging process or produce permanent tightening of the face and neck. Future surgery or other treatments may be necessary to maintain the results of a facelift operation.
Neck muscles - additional surgery may be needed to tighten neck muscles
HEALTH INSURANCE
Most health insurance companies exclude coverage for cosmetic surgical operations such as the facelift or any complications that might occur from surgery. Please carefully review your health insurance subscriber-information pamphlet.
ADDITIONAL SURGERY NECESSARY
There are many variable conditions besides the risk and potential surgical complications that may influence the long term result from facelift surgery. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with facelift surgery. Other complications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained.
FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional costs may occur should complications develop from the surgery. Secondary surgery or hospital day-surgery charges involved with revisionary surgery would also be your responsibility.
DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally satisfy most patients in most circumstances.
However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your plastic surgeon may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page.
name: _______________________________________
date: ______________________________
witness: ______________________________________
CONSENT FOR SURGERY - PROCEDURE or TREATMENT
1.I hereby authorize Dr. Patrick Hudson and such assistants as may be selected to perform the following procedure or treatment:
I have received the following information sheet: INFORMED-CONSENT for FACELIFT (RHYTIDECTOMY) SURGERY
2.I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.
3.I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involves risk and the possibility of complications, injury, and sometimes death.
4.I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
5.I consent to the photographing or televising of the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.
6.For purposes of advancing medical education, I consent to the admittance of observers to the operating room.
7.I consent to the disposal of any tissue, medical devices or body parts which may be removed.
8.I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable.
9.IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a.THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-9). I AM SATISFIED WITH THE EXPLANATION.
______________________________________ ____________________
Patient Date
____________________________________
Witness
Permit form for rhytidectomy or facelift (including short scar facelift)
I give Dr. Patrick Hudson permission to perform an operation called rhytidectomy or facelift.
My diagnosis (what is wrong with me) is rhytids or loose skin and lines due to aging.
I understand that surgery is not exact and that there has not been a guarantee of a particular end result nor of the length of time the results will last.
I give permission for an anesthetic which will be given by Dr. Hudson if I am awake (local anesthetic) or under the direction of the hospital anesthesiologist if I go to sleep (general anesthetic). I know that all anesthetics have risk and I will discuss the risk of general anesthetic with the anesthesiologist before surgery.
I have been told the risks of the operation and my questions have been answered to my satisfaction.
I understand the risks of rhytidectomy or facelift to include but not be limited to: nerve damage (weakness and/or numbness), hematoma, loss of skin, some problems will not be corrected such as cheek folds (nasolabial folds). I understand that in a small number of patients (about 5%) additional surgery may be needed within the first year.
Patients who smoke are at increased risk of losing the blood supply to part of the skin and this can cause that area of skin to die.
If during the operation Dr. Hudson finds something which was not expected I give permission for him to do what he thinks is the best medical treatment at that time.
I understand that all operations have some risk such as bleeding, bruising, infection, scarring, swelling, asymmetry and poor healing. The hair line may be changed and men may need to shave behind or on the ears. I also realize that there is a risk to any anesthetic and these risks include abnormal reaction to the medicine.
I understand that liposuction may be performed in the neck and that surface irregul.airty can occur.
I understand that it is sometimes necessary to perform more than one operation to complete my treatment or if complications occur. I accept that the costs for such operations would be paid for by me.
My signature indicates that I have read all of the above and understand it to my satisfaction. I give permission for the operation to be performed. I have received postoperative instructions.
Signature: _____________________________
Witness: _______________________________
Date: _____________________________