INFORMED CONSENT for RHINOPLASTY SURGERY
(Change in Shape and/or Size of the Nose)
This document contains information about rhinoplasty surgery, associated risks, alternatives, and expected outcome. Please read each paragraph completely. If you have questions or see words you don’t know, ask Dr. Laverson, or return for another appointment. Your signature below confirms your understanding and indicates your desire to proceed with rhinoplasty (nose re-shaping).
Surgery of the nose (rhinoplasty) is an operation developed and advanced by plastic surgeons during the past century. This procedure can change the appearance, structure, and function of the nose. Rhinoplasty can reduce or increase the size of the nose, lower a bump on top of the nose, change the size and shape of the tip, narrow the base or the top of the nose, lift the tip of the nose, make the nose more or less prominent, change angles between the nose and the forehead or upper lip, and produce other changes. This operation can help correct birth defects, nasal injuries, and help relieve some breathing problems.
No single type of rhinoplasty will satisfy every patient. The rhinoplasty procedure is customized for each individual to meet his or her needs. Incisions are made within the nose and/or concealed in inconspicuous locations on the nose. Cartilage grafts from the nose or from other areas of the body may be used to add dimension. Implants may be used to refine contour instead of or in addition to grafts. Internal nasal surgery to improve breathing may also be part of rhinoplasty.
The best candidates for this type of surgery are women or men seeking improvement, not perfection, in the appearance of their nose. In addition to realistic expectations, good health and psychological stability are important qualities for a patient considering rhinoplasty surgery. Rhinoplasty can be performed in conjunction with other surgeries. Perfection, an ill-defined concept in aesthetics and variable between individuals, is never achieved by rhinoplasty.
Alternative possibilities consist of not undergoing the rhinoplasty surgery. Injectable fillers and limited office procedures can improve or correct some aspects of nasal appearance. Internal nasal airway disorders may not require surgery on the exterior of the nose. Risks and potential complications are associated with alternative surgical treatments (such as septoplasty) to correct nasal airway disorders.
RISKS of RHINOPLASTY SURGERY
Every surgical procedure has risks. Your decision for rhinoplasty should be based on a comparison of risk to expected benefit. Although most patients do not experience complications, if you have specific questions about your risk profile, ask Dr. Laverson. Risks discussed below are particularly associated with rhinoplasty.
Bleeding– Abnormal bleeding is possible, though unusual, during or after rhinoplasty. Should post-operative bleeding occur, emergency treatment may be required to stop the bleeding. Blood transfusion is possible, but rare. Do not take any aspirin or anti-inflammatory medications for ten days before surgery because this increases the risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the 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 rhinoplasty. Should an infection occur, additional treatment including antibiotics may be necessary. If a silicone, Teflon®, polyethylene, or other synthetic implant is placed in your nose, it may become infected months or years after rhinoplasty. When infected, these implants need to be removed.
Scarring– Although good wound healing after rhinoplasty is expected, abnormal scars may occur both within the skin and the deeper tissues. Scars may be unattractive and of different color than surrounding skin. There is the possibility of visible marks from sutures. Additional treatments including surgery may be needed to treat scarring. Scarring within the nose may cause visible deviation or crookedness to develop.
Damage to deeper structures– Deeper structures such as nerves, tear ducts, blood vessels and muscles may be damaged during the course of rhinoplasty. The potential for this to occur varies with the type of rhinoplasty procedure performed. Injury to deeper structures may be temporary or permanent.
Unsatisfactory result / Disappointing result– A disappointing result from rhinoplasty is possible. One or more aspects of the result may be unsatisfactory. The surgery may result in unacceptable visible or tactile deformities, loss of function, or structural malposition. You may be disappointed that the results of rhinoplasty surgery do not meet your expectations. Additional surgery or other procedures may be necessary if the outcome of rhinoplasty is unsatisfactory. Additional surgery may or may not be able to correct the unsatisfactory result.
Numbness– There is the potential for permanent numbness within the nasal skin after rhinoplasty. The occurrence of this is not predictable. Diminished or absent skin sensation on the nose may not totally resolve after rhinoplasty.
Asymmetry– The human face is normally asymmetric. There is always variation from one side to the other both before and after rhinoplasty. Differences in size and shape of the nose between right and left sides may be slight, moderate, or remarkable. Further treatment may be desired to improve symmetry after rhinoplasty.
Swelling, and the need for patience – Most patients look presentable in public by one to three weeks after rhinoplasty. However, your rhinoplasty result evolves for many months following the procedure. Resolution of swelling, development of structural strength, and scar contracture occurs for one to two years after nasal surgery. Healing is individualized, but it is important to be patient before rushing to judgment about the result of your rhinoplasty. Visibility of improvements built into your procedure may be delayed for over one year following rhinoplasty.
Chronic pain– Chronic headaches or pain may occur very infrequently after rhinoplasty.
Skin disorders/skin cancer– Rhinoplasty is a surgical procedure to reshape both internal and external elements of the nose. Skin disorders and skin cancer may occur independently of a rhinoplasty.
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.
Delayed healing– Wound disruption or delayed wound healing is rare. Some areas of the face may not heal normally and may take a long time to heal. Areas of skin may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue.
Long term effects– Subsequent alterations in nasal appearance may occur as the result of aging, sun exposure, or other circumstances not related to rhinoplasty surgery. Future surgery or other treatments may be necessary to maintain the results of a rhinoplasty operation.
Nasal septal perforation– There is the possibility that surgery will cause a hole in the nasal septum to develop. The occurrence of this is rare. However, If it occurs, additional surgical treatment may be necessary to repair the hole in the nasal septum. In some cases, it may be impossible to correct this complication.
Nasal airway alterations– Changes may occur after a rhinoplasty or septoplasty operation that may interfere with normal passage of air through the nose. This may or may not be correctable.
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.
Substance abuse disorders– Individuals with substance abuse problems that involve the inhalation of vasoconstrictive drugs such as cocaine are at risk for major complications including poor healing and nasal septal perforation.
Health insurance companies exclude coverage for cosmetic surgical operations or any complications that might occur from cosmetic surgery. If the procedure corrects a breathing problem or marked deformity after a nasal fracture, a portion may be covered. Many insurance plans exclude coverage for secondary or revision surgery. Please carefully review your health insurance contract for more information.
ADDITIONAL SURGERY NECESSARY
Although complications occur infrequently, those described above are particularly associated with rhinoplasty. Other complications can occur but are less likely. Should unpredicted complications occur, additional surgery or other treatments may be necessary. Medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied regarding the final results. Occasionally, it is necessary to perform additional surgery to improve your results.
The cost of surgery involves several charges for services provided. The total includes local, state, and federal taxes, licensing and accreditation, administrative expenses, fees charged by Dr. Laverson, your anesthesiologist, the surgery center for pre and post-surgical nursing, sterile processing, specialized equipment and supplies, and implants or special devices needed. If part of your procedure is a benefit included in your health insurance, you are responsible for co-payments, deductibles, and charges not covered. Additional costs may be incurred if complications develop. Additional charges often apply if surgical revision is necessary.
This document communicates information about planned surgical treatment, discloses risks, and describes alternative possible treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.
This informed consent document should not be considered all inclusive in defining other methods of care and risks encountered. Dr. Laverson may provide you with additional or different information 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 care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
Understand the above information before signing the consent below.
CONSENT FOR RHINOPLASTY SURGERY
1. Dr. Steve Laverson and assistant(s) are requested and authorized to perform RHINOPLASTY (NOSE RESHAPING) surgery upon me. I have read and understand the above information, and my questions have been answered to my satisfaction.
2. Rarely, during the course of the procedure, unforeseen conditions may necessitate additional or different procedures than those above. Dr. Laverson is authorized to perform such other procedures that are in the exercise of his professional judgment necessary , desirable, and in my own best interest. The authority granted under this paragraph shall include all conditions that require treatment and are not known to Dr. Laverson at the commencement of surgery.
3. I consent to the administration of such anesthetics considered necessary or advisable. All forms of anesthesia involve a small risk and the possibility of complications, injury, and rarely death.
4. No guarantee has been offered by anyone with respect to the final results.
5 I consent to the disposal of any tissue, medical devices or body parts which may be removed.
6 IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE RHINOPLASTY (NOSE RESHAPING) PROCEDURE
b. ALTERNATIVE PROCEDURES OR OTHER POSSIBLE TREATMENTS
c. RISKS OF RHINOPLASTY
I CONSENT TO RHINOPLASTY SURGERY AND THE ABOVE LISTED ITEMS (1-6) I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient