Informed Consent for CO2 Laser Skin Resurfacing

Informed Consent for CO2 Laser Skin Resurfacing

Patient Name: DOB: Patient ID#:

I DECLARE THAT I UNDERSTAND THE FOLLOWING INFORMATION:

The goal of CO₂ laser skin resurfacing surgery is to reduce or partially eliminate facial wrinkles or reduce scarring from skin conditions such as acne. Generally, the results of CO₂ laser skin resurfacing demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.

Alternatives to CO₂ Laser Skin Resurfacing:

The alternatives to CO₂ laser skin resurfacing surgery include dermabrasion and chemabrasion. The advantages and disadvantages (risks and benefits) of each of these alternatives to CO₂ laser skin resurfacing surgery have been explained to me as well as the alternative of having no surgery, accepting my present skin condition, using cosmetics and considering other methods of skin rejuvenation surgery.

Possible Short-term Effects of CO₂ Laser Skin Resurfacing Surgery:

_____ Pain - Discomfort, burning sensation or pain the first few days after surgery. A local anesthetic is usually used to block pain during the treatment, but some degree of discomfort will occur after the anesthetic effects have worn off and this pain may persist for several days.

_____ Redness of Skin - Erythema or redness of the skin for a two- to six-month period or possibly longer.

_____ Swelling - Temporary edema (swelling) or ecchymosis (bruising) of the tissue of the face and neck, usually subsiding in three to seven days.

_____ Wound Healing - Oozing, weeping, crusting and flakiness of the treated area, usually persisting for one to four weeks.

_____ Skin Thickening - Textural changes of the treated skin, such as skin thickening, which may persist for a variable time following the laser skin resurfacing treatment.

_____ Cysts - Milia or cysts, especially in the eyelid skin region (if the eyelid skin is included in the area of treatment by the laser energy), particularly if ointments were used in the postoperative phase for a protracted period.

_____ Contact Dermatitis - Contact dermatitis due secondarily to topical preparations (ointments) used post-operatively.

_____ Skin Hyperpigmentation - Transient hyperpigmentation (darkening of the skin), especially in darker-skinned people, occurring three to eight weeks after laser therapy.

_____ Herpes Simplex Dermatitis (Fever Blisters) - Occurrence or recurrence of herpes simplex dermatitis, particularly if not pre-, intra- and post-operatively treated with a systemic antiviral medication such as Zovirax.

_____ Cellulitis or Skin Infections - Cellulitis or infection of the skin and soft tissues, especially if careful post-operative hygiene is not practiced.

_____ Skin Hypopigmentation - Hypopigmentation (lightening of the skin), which occurs because of laser-induced injury to the melanocytes (pigment containing cells in the skin) and which can be permanent.

_____ Skin Itchiness - Pruritis or itching in the early healing phase.

_____ Skin Tightness - Sensation of skin tightness (peaks at 3-8 weeks postoperatively).

Possible Intra-operative Complications of CO₂ Laser Skin Resurfacing Surgery:

_____ Blindness/Corneal Burns - There is a risk of accidental eye injury by the laser energy or beam, which could cause blindness or burns of the eyeball. This is unlikely since complete eye protection is provided at all times during the laser energy applications.

_____ Flash Fires - Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.

Possible Long-term Complications of CO₂ Laser Skin Resurfacing Surgery:

_____ Increased susceptibility to sun - Because of the permanent thinning of the epidermis and dermis and reduction in the number of melanocytes (pigment cells in the skin), there is probably a lifelong risk of greater susceptibility of CO₂ laser skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.

_____ Scaring - The risk of scarring exists in all cases. It is variable and is often related to an individual's genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.

_____ Skin Pigment Changes - Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.

_____ Infection - Infection is a risk that occurs in any invasive or surgical procedure. It is minimized by proper surgical technique and proper post-operative care.

_____ Ectropion - Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.

_____ Blepharoptosis - Blepharoptosis (drooping of the eyelid) can result from inadvertent injury to structures in the upper eyelid, especially in thin-skinned people.

I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.

I understand this is an elective procedure and that CO₂ laser skin resurfacing surgery is not reversible. I also understand that more than one resurfacing procedure may be required to achieve the optimal obtainable results.

I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of CO₂ laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after CO₂ laser skin resurfacing surgery.

My surgeon has explained CO₂ laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the CO₂ laser skin resurfacing surgical procedure. I therefore consent to having CO₂ laser skin resurfacing surgery.

This is an elective procedure – you do not have to proceed with surgery unless you feel comfortable with the healing process and the possible risks.

By signing below, I am confirming that Dr. Cockerham has answered all of my questions and that I understand and accept the risks and the costs associated with this surgery and future treatments.

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Revised 03/25/14

Patient Name: DOB: Patient ID#:

Possible Intra-operative Complications of CO₂ Laser Skin Resurfacing Surgery:

_____ Blindness/Corneal Burns - There is a risk of accidental eye injury by the laser energy or beam, which could cause blindness or burns of the eyeball. This is unlikely since complete eye protection is provided at all times during the laser energy applications.

_____ Flash Fires - Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.

Possible Long-term Complications of CO₂ Laser Skin Resurfacing Surgery:

_____ Increased susceptibility to sun - Because of the permanent thinning of the epidermis and dermis and reduction in the number of melanocytes (pigment cells in the skin), there is probably a lifelong risk of greater susceptibility of CO₂ laser skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.

_____ Scaring - The risk of scarring exists in all cases. It is variable and is often related to an individual's genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.

_____ Skin Pigment Changes - Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.

_____ Infection - Infection is a risk that occurs in any invasive or surgical procedure. It is minimized by proper surgical technique and proper post-operative care.

_____ Ectropion - Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.

_____ Blepharoptosis - Blepharoptosis (drooping of the eyelid) can result from inadvertent injury to structures in the upper eyelid, especially in thin-skinned people.

I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.

I understand this is an elective procedure and that CO₂ laser skin resurfacing surgery is not reversible.

I also understand that more than one resurfacing procedure may be required to achieve the optimal obtainable results.

I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of CO₂ laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after CO₂ laser skin resurfacing surgery.

My surgeon has explained CO₂ laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the CO₂ laser skin resurfacing surgical procedure. I therefore consent to having CO₂ laser skin resurfacing surgery.

This is an elective procedure – you do not have to proceed with surgery unless you feel comfortable with the healing process and the possible risks.

By signing below, I am confirming that Dr. Cockerham has answered all of my questions and that I understand and accept the risks and the costs associated with this surgery and future treatments.

Page 2 of 2

Revised 03/25/14