Book NowINFORMED CONSENT-TIP RHINOPLASTY SURGERY
INSTRUCTIONS
This document contains information about tip rhinoplasty surgery, its risks, and alternative treatment. Please read each paragraph completely. If you have questions, need more information, or see words you don’t know, ask Dr. Laverson. Your signature below confirms your understanding and indicates your desire for tip rhinoplasty surgery.
INTRODUCTION
Tip rhinoplasty is a surgical procedure that can produce changes in the appearance and structure of the tip of the nose. Tip rhinoplasty can reduce or increase the size of the nasal tip, change the shape of the tip, narrow the width of the nostrils, or change the angle between the nose and the upper lip. This operation can also help correct birth defects and nasal injuries.
There is not a universal type of tip rhinoplasty surgery that will meet the needs of every patient. Tip rhinoplasty surgery is customized for each patient, depending on his or her needs. Incisions may be made within the nose or concealed in inconspicuous locations of the nose in the open tip rhinoplasty procedure. Some techniques of tip rhinoplasty use cartilage grafts or other man-made materials to enhance the projection of the nasal tip. Internal nasal surgery to improve nasal breathing can be performed at the time of the tip rhinoplasty.
The best candidates for this type of surgery are individuals who are looking for 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 tip rhinoplasty surgery. Tip rhinoplasty can be performed in conjunction with other surgeries.
ALTERNATIVE TREATMENT
Alternative forms of treatment consist of not undergoing the tip rhinoplasty surgery. Risks and potential complications are associated with alternative forms of treatment that involve surgery such as a standard rhinoplasty that changes the appearance of the nasal region.
RISKS of TIP RHINOPLASTY SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand the risks involved with tip rhinoplasty surgery. 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 all possible consequences of tip rhinoplasty surgery.
Bleeding– It is possible, though unusual, to have problems with bleeding during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to stop the bleeding or drain an accumulation of blood (hematoma). Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this contributes to a greater risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the risk of surgical 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 quite unusual after surgery. Should an infection occur, additional treatment including antibiotics may be necessary. Cartilage grafts, if used, may require removal should an infection occur.
Scarring– Although good wound healing after a surgical procedure is expected, abnormal scars may occur both within the skin and the 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 including surgery may be needed to treat scarring.
Damage to deeper structures– Deeper structures such as nerves, blood vessels and cartilage may be damaged during the course of surgery. The potential for this to occur varies with the type of tip rhinoplasty procedure performed. Injury to deeper structures may be temporary or permanent.
Numbness– There is the potential for permanent numbness within the nasal skin after tip rhinoplasty. The occurrence of this is not predictable. Diminished (or loss) of skin sensation in the nasal area may not totally resolve after tip rhinoplasty.
Unsatisfactory result– You may not like the result from tip rhinoplasty surgery. The surgery may result in unacceptable visible deformities. You may be disappointed in the appearance of your nose, may lose function, or may have structural malposition after tip rhinoplasty surgery. The results of tip rhinoplasty surgery may not meet your expectations. Additional surgery may be necessary should the result of tip rhinoplasty be unsatisfactory.
Cartilage grafts– Cartilage grafts may inserted to augment projection of the nasal tip. These grafts can be obtained from donor locations within the nose (nasal septum) or from other parts of the body. Complications including nasal septal perforation may occur from the procurement of cartilage graft material. More than one location may be needed in order to obtain sufficient amounts of cartilage.
Asymmetry– The human face is normally asymmetric. Variation from one side to the other may result from a tip rhinoplasty procedure.
Chronic pain– Very infrequently, chronic pain may occur very infrequently after tip rhinoplasty.
Skin disorders/skin cancer– Skin disorders and skin cancer may occur independently of a tip 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 result from drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.
Delayed healing– Wound disruption or delayed wound healing is possible. Some areas of the nose may heal abnormally or slowly. Areas of skin may die, requiring 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 tip rhinoplasty surgery. Future surgery or other treatments may be necessary to maintain the results of a tip rhinoplasty operation.
Nasal septal perforation– Rarely, a hole in the nasal septum will develop. Additional surgical treatment may be necessary to repair the nasal septum. In some cases, it may be impossible to correct this complication.
Nasal airway alterations– Changes may occur after a tip rhinoplasty or septoplasty operation that may interfere with normal passage of air through the nose.
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.
HEALTH INSURANCE
Most 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, or a birth defect, a portion may be covered. Please carefully review your health insurance subscriber-information pamphlet.
ADDITIONAL SURGERY NECESSARY
Many conditions influence the result of tip rhinoplasty surgery. Even though complications occur infrequently, the above problems are particularly associated with tip rhinoplasty surgery. Other complications may occur but are less common. If 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, good results, or any particular result, cannot be guaranteed. Infrequently, it is necessary to perform additional surgery to improve your results.
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 meet the needs of most patients in most circumstances.
However, this 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 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 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 surgery consent below.
CONSENT FOR TIP RHINOPLASTY SURGERY / CHANGE TO SHAPE AND/OR SIZE OF NASAL TIP
1. Dr. Steve Laverson and assistant(s) are requested and authorized to perform TIP RHINOPLASTY SURGERY on me. I have read the above information about tip rhinoplasty, and I understand there are risks of this procedure, and alternative treatments.
2. During the course of the operation unforeseen conditions can (rarely) mandate different or additional procedures to those above. Dr. Laverson is authorized to perform such other procedures that are in the exercise of his best 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 unknown at the commencement of surgery.
3. I consent to the administration of such anesthetics considered necessary or advisable. All forms of anesthesia involve some risk and the possibility of complications, injury, and extremely rarely, death.
4 No guarantee is expressed or implied with respect to the final result of the procedure.
5. I consent to photography before and after the procedure, including appropriate portions of my body, for medical, scientific or educational purposes, provided my name is not revealed by the pictures.
6. I consent to the disposal of any tissue, medical devices or body parts which may be removed.
7. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE TIP RHINOPLASTY PROCEDURE
b. ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. RISKS OF TIP RHINOPLASTY
I REQUEST AND CONSENT TO SURGERY TO CHANGE THE APPEARANCE OF THE TIP OF MY NOSE, AND THE ABOVE LISTED ITEMS (1-7). I AM SATISFIED WITH THE EXPLANATION.
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Patient Date
Date____________________ ____________________________________Witness
