This is an informed consent document
that has been prepared to help inform you concerning tip
rhinoplasty 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.
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- There is the possibility of an
unsatisfactory result from tip rhinoplasty surgery. The
surgery may result in unacceptable visible or tactile
deformities, loss of function, or structural malposition
after tip rhinoplasty surgery. You may be disappointed that
the results of tip rhinoplasty surgery do not meet your
expectations. Additional surgery may be necessary should the
result of tip rhinoplasty be unsatisfactory.
Cartilage grafts- Cartilage grafts may be needed if the goal
of surgery is to change the 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 asymmetrical.
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 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
There are many variable conditions in addition to risk and
potential surgical complications that may influence the long
term result from tip rhinoplasty surgery. Even though risks
and complications occur infrequently. The risks cited are
particularly associated with tip rhinoplasty 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 as to the results that may be obtained.
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, 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 of the facts
involved in an individual case and are subject to change as
scientific knowledge and technology advance and as practice
patterns evolve.
My Brazil plastic surgery reminds you that all cosmetic surgery carries a
risk, has limitations which could include disappointment
with the results.
You should agree about the anticipated outcome of your
surgery and concur about your expectations of the results.
You should discuss alternative treatments and thoroughly
understand the risk of the procedures
If any dispute may arise the surgeon is only liable if
litigation takes place in Brazil, under Brazilian Law.
It is important that you read the above information
carefully and have all of your questions answered before
signing the consent.
________________________________________
CONSENT FOR SURGERY / PROCEDURE or TREATMENT
1. I hereby authorize Dr. _______________________ and such
assistants as may be selected to perform the following
procedure or treatment:
_____________________________________________________
I have received the following information sheet:
INFORMED CONSENT for TIP RHINOPLASTY 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
including My Brazil plastic surgery or any of the staff employed by
My Brazil plastic surgery as to the results that may be obtained.
If any litigation may arise as result of the surgery it can
only be done in Brazil under Brazilian Law and that
My Brazil plastic surgery, its management or staff can not be held liable
in any way what so ever.
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 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 (1-6). I AM SATISFIED WITH THE EXPLANATION.
______________________________________________________
Patient or Person Authorized to Sign for Patient
Date____________________ Witness________________________
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