Informed Consent

Hyaluronic Acid Filler Injection

®
©2016 American Society of Plastic Surgeons . Purchasers of the Informed Consent Resource are given a limited license to modify documents
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 Informed Consent – Hyaluronic Acid Filler Injection

INSTRUCTIONS
This is an informed-consent document which has been prepared to help inform you about hyaluronic acid-
based (non-animal stabilized) tissue filler injection therapy, its risks, and alternative treatments.
Hyaluronic acid is a naturally occurring sugar that is found within all mammals. It is a material that is
contained in various soft tissues. Unlike other fillers, hyaluronic acid fillers may be undone by injecting an
enzyme to dissolve them in the body.

This consent covers injection using:

___Hylaform® - Hyaluronic acid is a naturally occurring sugar that is found within all mammals. It is a
material that is contained in various soft tissues. Hyaluronic acid can be synthetically produced from
animal tissues, chemically stabilized, and purified for use as an injectable soft tissue filler (animal-origin,
stabilized hyaluronic acid, INAMED). Hylaform has been FDA approved to treat areas of facial wrinkling
and soft tissue depressions.

___Juvederm & Voluma Products® - Juvederm JUVÉDERM™ Ultra /Ultra Plus/Voluma injectable gel is
a colorless hyaluronic acid gel that is injected into facial tissue to smooth wrinkles and folds, especially
around the nose and mouth. Hyaluronic acid is a naturally occurring sugar found in the human body. The
role of hyaluronic acid in the skin is to deliver nutrients, hydrate the skin by holding in water, and to act as
a cushioning agent.

___Restylane Products® - Restylane, Restylane Silk, Restylane Lyft is a naturally occurring substance
that is found within all mammals. It is a material that is contained in various soft tissues. Restylane can
be synthetically produced from a process of bacterial fermentation, chemically stabilized, and purified for
use as an injectable soft tissue filler (non-animal, stabilized hyaluronic acid, Medicis Aesthetics). The
hyaluronic acid in Restylane is biocompatible and is a totally non-animal product; there is little risk of
animal-based disease transmission or allergic reaction. Restylane has been FDA approved for the
cosmetic treatment of moderate to severe facial wrinkles and soft tissue depressions.
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 this procedure as proposed by your plastic surgeon
and agreed upon by you.

GENERAL INFORMATION
The injection will utilize a stabilized hyaluronic acid used to smooth moderate to severe facial wrinkles
and folds around the nose and mouth or shape facial contours. Hyaluronic acid has been FDA approved
for the cosmetic treatment of moderate to severe facial wrinkles and soft tissue depressions.

Filler injections are customized for every patient, depending on his or her particular needs. These can be
performed in areas involving the face and eyelid region, forehead, and lips. Fillers cannot stop the
process of aging. They can, however, temporarily diminish the look of wrinkles and soft tissue
depressions.

Filler injections may be performed as a singular procedure, in combination with other treatments such as
®
BOTOX , or as an adjunct to a surgical procedure. Filler injections require regional nerve blocks or local
anesthetic injections to diminish discomfort. Soft tissue fillers produce temporary swelling, redness, and
needle marks, which resolve after a few days’ time.

Continuing treatments are necessary in order to maintain the effect of fillers over time. Once injected,
fillers will be slowly absorbed by the body. The length of effect for injections is variable.

ALTERNATIVE TREATMENTS
Alternative forms of management include not treating the skin wrinkles or soft tissue depressions by any
means. Improvement of skin wrinkles and soft tissue depressions may be accomplished by other
treatments: laser treatments, chemical skin-peels, dermabrasion, or other skin procedures, alternative

Page 1 of 13 ______ Patient Initials ©2015 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

types of tissue fillers, or surgery such as a blepharoplasty, face or brow lift when indicated. Risks and
potential complications are associated with alternative forms of medical or surgical treatment.

INHERENT RISKS OF HYALURONIC ACID FILLER INJECTIONS

Every procedure involves a certain amount of risk and it is important that you understand these risks and
the possible complications associated with them. In addition, every procedure has limitations. An
individual’s choice to undergo this procedure is based on the comparison of the risk to potential benefit.
Although the majority of patients do not experience the following, you should discuss each of them with
your physician to make sure you understand the risks, potential complications, limitations, and
consequences of hyaluronic acid filler injections. Additional information may be obtained from the
package-insert sheets supplied by the manufacturers.

SPECIFIC RISKS OF HYALURONIC ACID FILLER INJECTIONS

Bleeding and Bruising:

It is possible, though unusual, to have a bleeding episode from a filler injection or local anesthesia used
during the procedure. Injury to the blood supply and bruising in soft tissues may occur. Should you
develop post-injection bleeding, it may require emergency treatment or surgery. Aspirin, anti-
inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba and other “herbs /
homeopathic remedies” may contribute to a greater risk of a bleeding problem. Do not take any of these
for seven days before or after filler injections.

Swelling:
Swelling (edema) is a normal occurrence following the injections. It decreases after a few days. If
swelling is slow to resolve, medical treatment may be necessary.

Pain:
Discomfort associated with injections is normal and usually of short duration.

Needle Marks:
Visible needle marks from the injections occur normally and resolve in a few days.

Acne-Like Skin Eruptions:

Acneiform skin eruptions can occur following the injection of tissue fillers. This generally resolves within a
few days.

Skin Sensitivity:
Skin rash, itching, tenderness and swelling may occur following injections. After treatment, you should
minimize exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather
until any initial swelling or redness has gone away. If you are considering laser treatment, chemical skin
peeling or any other procedure based on a skin response after filler treatment, or you have recently had
such treatments and the skin has not healed completely, there is a possible risk of an inflammatory
reaction at the implant site. Damage to the skin or the lips may occur.

Erythema (Skin Redness):

Erythema in the skin occurs after injections. It can be present for a few days after the procedure.

Vision Abnormalities:
Vision abnormalities, including blindness, may occur in rare instances.

Infection:

Page 2 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

Although infection following injection of tissue fillers is unusual, bacterial, fungal, and viral infections can
occur. Herpes simplex virus infections around the mouth can occur following a tissue filler treatment.
This applies to both individuals with a past history of herpes simplex virus infections and individuals with
no known history of herpes simplex virus infections in the mouth area.
_____I have a history of cold sores (please notify your physician)
Specific medications must be prescribed and taken both prior to and following the treatment procedure in
order to suppress an infection from this virus. Should any type of skin infection occur, additional
treatment including antibiotics may be necessary.

Stroke:
In rare cases, dermal fillers can block oxygen supply to the brain, resulting in a stroke.

Under / Over Correction:

The injection of soft tissue fillers to correct wrinkles and soft tissue contour deficiencies may not achieve
the desired outcome. The amount of correction may be inadequate or excessive. It may not be possible
to control the process of injection of tissue fillers due to factors attributable to each patient’s situation. If
under correction occurs, you may be advised to consider additional injections of tissue filler materials.

Asymmetry:
The human face is normally asymmetrical in its appearance and anatomy. It may not be possible to
achieve or maintain exact symmetry with tissue filer injections. There can be a variation from one side to
the other in terms of the response to injection. This may require additional injections.

Damage to Deeper Structures:

Deeper structures such as nerves and blood vessels may be damaged during the course of injection.
Injury to deeper structures may be temporary or permanent.

Skin Lumpiness:
Lumpiness can occur following the injection of fillers. This tends to smooth out over time. In some
situations, it may be possible to feel the injected tissue filler material for long periods of time.

Visible Tissue Filler Material:

It may be possible to see any type of tissue filler material that was injected in areas where the skin is thin.

Granulomas:
Painful masses in the skin and deeper tissues after a filler injection are extremely rare. These may occur
weeks or months after your injection. Should these occur, additional treatments including surgery may be
necessary. Fillers should not be used in areas with active inflammation or infections (e.g., cysts, pimples,
rashes or hives).

Migration of Filler:
The filler substance may migrate from its original injection site and produce visible fullness in adjacent
tissue or other unintended effects.

Leakage or Rupture of the Filler Material:

In rare cases. leakage or rapture of the filler material at the injection site or through the skin may occur,
which may be caused by tissue reaction or infection.

Skin Necrosis:

Page 3 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

It is very unusual to experience death of skin and deeper soft tissues after injections. Skin necrosis can
produce unacceptable scarring. Should this complication occur, additional treatments, or surgery may be
necessary.

Open or Draining Wounds:

Rarely, the filler substance may cause an infection (biofilm formation) or possible necrosis of the area
from blood-vessel occlusion, resulting in decreased blood flow to the affected area which causes poor
healing.

Allergic Reactions and Hypersensitivity:

As with all biologic products, allergic and systemic anaphylactic reactions may occur. Fillers should not
be used in patients with a history of multiple severe allergies, severe allergies manifested by a history of
anaphylaxis, or allergies to gram-positive bacterial proteins. Severe allergic reaction is rare but may
occur. Allergic reactions may require additional treatment.

Drug and Local Anesthetic Reactions:

There is the possibility that a systemic reaction could occur from either the local anesthetic or epinephrine
used for sensory nerve block anesthesia when tissue filler injections are performed. This would include
the possibility of light-headedness, rapid heartbeat (tachycardia), and fainting. Medical treatment of these
conditions may be necessary.

Antibodies to Fillers:
Presence of antibodies to hyaluronic acid tissue fillers may reduce the effectiveness of this material or
produce a reaction in subsequent injections. The health significance of antibodies to hyaluronic acid
tissue fillers is unknown.

Accidental Intra-Arterial Injection:

It is extremely rare that during the course of injection, fillers could be accidentally injected into arterial
structures and produce a blockage of blood flow. This may produce skin necrosis in facial structures or
damage blood flow to the eye, resulting in loss of vision. The risk and consequences of accidental
intravascular injection of fillers is unknown and not predictable.

Scarring:
Fillers should not be used in patients with known susceptibility to keloid formation or hypertrophic
scarring. The safety of patients has not been studied.

Unsatisfactory Result:
Filler injections alone may not produce an outcome that meets your expectations for improvement in
wrinkles or soft tissue depressions. There is the possibility of a poor or inadequate response from filler
injection(s). Additional injections may be necessary. Surgical procedures or other treatments may be
recommended along with additional treatments. Unsatisfactory results may NOT improve with each
additional treatment.

Unknown Risks:
The long term effect of hyaluronic acid filler beyond one year is unknown. The possibility of additional risk
factors or complications attributable to the use of hyaluronic acid filler as a soft tissue filler may be
discovered.

Combination of Procedures:
The safe use of tissue fillers with Botox or other dermal therapies has not been evaluated in a controlled,
clinical study.

Pregnancy and Nursing Mothers:

Page 4 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

Animal reproduction studies have not been performed to determine if hyaluronic acid filler could produce
fetal harm. It is not known if hyaluronic acid filler or its breakdown products can be excreted in human
milk. It is not recommended that pregnant women or nursing mothers receive hyaluronic acid filler
treatments.

Drug Interactions:
It is not known if hyaluronic acid filler reacts with other drugs within the body.

Long-Term Effects:
Hyaluronic acid filler injections should not be considered as a permanent treatment for the correction of
wrinkles and soft tissue depressions. Over time, the hyaluronic acid filler material is slowly absorbed by
the body and wrinkles or soft tissue depressions will reappear. Continuing hyaluronic acid filler treatment
(injections) is necessary in order to maintain the effect of hyaluronic acid filler. Subsequent alterations in
face and eyelid appearance may occur as the result of aging, weight loss or gain, sun exposure, or other
circumstances not related to hyaluronic acid filler injections. Future surgery or other treatments may be
necessary. Hyaluronic acid filler injection does not arrest the aging process or produce permanent
tightening of the skin or improvement in wrinkles.

Additional Treatment Necessary:

There are many variable conditions in addition to risks and potential complications that may influence the
long-term result of filler injections. Even though risks and complications occur infrequently, the risks cited
are the ones that are particularly associated with hyaluronic acid filler injections. 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.

GENERAL WARNINGS:
Dermal Fillers should NOT be Used if Any of the Following Apply:
• Skin is infected or inflamed. Soft tissue filler injection should be delayed until the inflammatory
condition has been managed.
• Skin is prone to excessive scarring (keloids) and /or thick scarring (hypertrophic scars).
• Bleeding disorder is known.
• History of severe allergies or anaphylaxis is known.
• Allergy to collagen or eggs is known.
• Allergy to animal product is known.
• Allergy to lidocaine is known.
• Allergy to bacteria is known.

Although these fillers may be removed through surgery or by injection of a medication to "dissolve" the
hyaluronic acid filler, the same adverse events typically associated with surgery may occur. It may be
difficult to remove the filler material.

The safe use of tissue fillers repeatedly over a long period of time has not been evaluated in a controlled,
clinical study.

The safety of these products is unknown when used during pregnancy, while breast feeding, or in patients
under 18 years of age.

GENERAL RISKS OF SURGERY

Page 5 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

Healing Issues:
Certain medical conditions, dietary supplements and medications may delay and interfere with healing.
Patients with massive weight loss may have a healing delay that could result in the incisions coming
apart, infection, and tissue changes resulting in the need for additional medical care, surgery, and
prolonged hospitalizations. Patients with diabetes or those taking medications such as steroids on an
extended basis may have prolonged healing issues. Smoking will cause a delay in the healing process,
often resulting in the need for additional surgery. There are general risks associated with healing such as
swelling, bleeding, possibility of additional surgery, prolonged recovery, color changes, shape changes,
infection, not meeting patient goals and expectations, and added expense to the patient. There may also
be a longer recovery due to the length of surgery and anesthesia. Patients with significant skin laxity
(patients seeking facelifts, breast lifts, abdominoplasty, and body lifts) will continue to have the same lax
skin after surgery. The quality or elasticity of skin will not change and recurrence of skin looseness will
occur at some time in the future, quicker for some than others. There are nerve endings that may become
involved with healing scars from surgery such as suction-assisted lipectomy, abdominoplasty, facelifts,
body lifts, and extremity surgery. While there may not be a major nerve injury, the small nerve endings
during the healing period may become too active producing a painful or oversensitive area due to the
small sensory nerve involved with scar tissue. Often, massage and early non-surgical intervention
resolves this. It is important to discuss post-surgical pain with your surgeon.

Bleeding:
It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-
operative bleeding occur, it may require emergency treatment to drain accumulated blood or you may
require a blood transfusion, though such occurrences are rare. The collection of blood that can occur
under your skin following surgery is referred to as a hematoma. Increased activity too soon after surgery
can lead to increased chance of bleeding and additional surgery. It is important to follow postoperative
instructions and limit exercise and strenuous activity for the instructed time. Non-prescription “herbs” and
dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually
in the first three weeks following injury to the operative area. If blood transfusions are necessary to treat
blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Your surgeon
may provide medications after your surgery to prevent blood clots. Medications that are used to prevent
blood clots in veins can produce bleeding and decreased blood platelets.

Infection:
Infection, although uncommon, can occur after surgery. Should an infection occur, additional treatment
including antibiotics, hospitalization, or additional surgery may be necessary. It is important to tell your
surgeon of any other infections, such as a history of MRSA infections, an open wound, recent upper
respiratory infection/ pneumonia, ingrown toenail, insect bite, tooth abscess, or urinary tract infection.
Infections in other parts of the body, may lead to an infection in the operated area. Post-operative
infections often result in more extensive scarring and predispose to revision surgery.

Scarring:
All surgery leaves scars, some more visible than others. 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 a different color than the surrounding skin tone. Scar appearance may also vary
within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body).
There is the possibility of visible marks in the skin from sutures. In some cases, scars may require
surgical revision or treatment.

Firmness:
Excessive firmness can occur after surgery due to internal scarring. The occurrence of this is not

Page 6 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

predictable. Additional treatment including surgery may be necessary.

Skin Sensitivity:
Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery.
Usually this resolves during healing, but in rare situations it may be chronic.

Major Wound Separation:

Wounds may separate after surgery. Should this occur, additional treatment including surgery may be
necessary.

Sutures:
Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures
may spontaneously poke through the skin, become visible or produce irritation that requires suture
removal.

Damage to Deeper Structures:

There is the potential for injury to deeper structures including nerves, blood vessels, lymphatics, muscles,
and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according
to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.

Fat Necrosis:
Fatty tissue found deep in the skin might die. This may produce areas of firmness within the skin.
Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour
irregularities in the skin that may result from fat necrosis.

Surgical Anesthesia:
Both local and general anesthesia involves risk. There is the possibility of complications, injury, and even
death from all forms of surgical anesthesia or sedation.

Shock:
In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or
extensive procedures are performed. Although serious complications are infrequent, infections or
excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization
and additional treatment would be necessary.

Pain:
You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist
after surgery. If you are a chronic pain patient followed by a Pain Therapy Practitioner, you may be asked to
see this practitioner pre operatively to assist you in the management of your pain disorder in the post-
operative period. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or
due to tissue stretching.

There are nerve endings that may become involved with healing scars from surgery. While there may not
be a major nerve injury, the small nerve endings during the healing period may become too active
producing a painful or oversensitive area due to the small sensory nerve involved with scar tissue. Often,
massage and early non-surgical intervention resolves this. It is important to discuss post-surgical pain
with your surgeon.

Cardiac and Pulmonary Complications:

Pulmonary complications may occur secondarily to blood clots (pulmonary emboli), fat deposits (fat
emboli), pneumonia, or partial collapse of the lungs after general anesthesia. Pulmonary emboli can be
life-threatening or fatal in some circumstances. Inactivity and other conditions may increase the
incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is

Page 7 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

important to discuss with your physician any past history of swelling in your legs or blood clots that may
contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in
patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats,
seek medical attention immediately. Should any of these complications occur, you may require
hospitalization and additional treatment.

Venous Thrombosis (Clot) and Sequelae:

Thrombosed veins, which resemble cords, occasionally develop in the area of the breast or around IV
sites, and usually resolve without medical or surgical treatment. It is important to discuss with your
surgeon any birth control pills you are taking. Certain high estrogen pills may increase your risk of
thrombosed veins, personal history of bleeding and clotting problems may also increase your risk of
thrombosed veins.

Allergic Reactions:
In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or
injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur
in response to drugs used during surgery and prescription medicines. Allergic reactions may require
additional treatment. It is important to notify your physician of any previous allergic reactions.

Drug Reactions:
Unexpected drug allergies, lack of proper response to medication, or illness caused by the prescribed
drug are possibilities. It is important for you to inform your physician of any problems you have had with
any medication or allergies to medication, prescribed or over the counter, as well as medications you now
regularly take. Provide your surgeon with a list of medications and supplements you are currently taking.

Surgical Wetting Solutions:

There is the possibility that large volumes of fluid containing dilute local anesthetic drugs and epinephrine
that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to
these medications. Additional treatment including hospitalization may be necessary.

Fat/Air Embolism:
In rare cases, fat particles or air can enter the vascular system and can travel to the heart, lungs or brain.
This can result in significant complications including death.

Persistent Swelling (Lymphedema):

Persistent swelling can occur following surgery.

Unsatisfactory Result:
Although good results are expected, there is no guarantee or warranty expressed or implied, on the
results that may be obtained. The body is not symmetric and almost everyone has some degree of
unevenness which may not be recognized in advance. One side of the face may be slightly larger, one
side of the face droopier. The breast and trunk area exhibits the same possibilities. Many of such issues
cannot be fully corrected with surgery. The more realistic your expectations as to results, the better your
results will appear to you. Some patients never achieve their desired goals or results, at no fault of the
surgeon or surgery. You may be disappointed with the results of surgery. Asymmetry, unanticipated
shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur after
surgery. Size may be incorrect. Unsatisfactory surgical scar location or appearance may occur. It may be
necessary to perform additional surgery to improve your results. Unsatisfactory results may NOT improve
with each additional treatment.
ADDITIONAL ADVISORIES

Medications and Herbal Dietary Supplements:

There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or

Page 8 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

prescription medications. Aspirin and medications that contain aspirin interfere with forming blood clots,
and therefore may contribute to more bleeding issues. If you have a medical condition (such as heart
arrhythmia, heart stent, blood vessels with blockages, or blood clots) and are taking medications to thin
your blood and prevent clotting such as Plavix, Warfarin, Coumadin, Xarelto, Effient or Pradaxa, discuss
management of these medications around the time of surgery with your plastic surgeon. Your plastic
surgeon may sometimes coordinate a plan for these medications with the doctor that prescribed them for
your medical condition. If you have been prescribed drugs for a medical condition, do not stop them
without discussing it first with your plastic surgeon. Stopping these medications abruptly may result in a
heart attack, stroke, or death. Be sure to check with your physician about any drug interactions that may
exist with medications which you are already taking. If you have an adverse reaction, stop the drugs
immediately and call your plastic surgeon for further instructions. If the reaction is severe, go immediately
to the nearest emergency room.

When taking the prescribed pain medications after surgery, realize that they can affect your thought
process and coordination. Do not drive, do not operate complex equipment, do not make any important
decisions and do not drink any alcohol while taking these medications. Be sure to take your prescribed
medication only as directed.

Sun Exposure – Direct or Tanning Salon:

The effects of the sun are damaging to the skin. Exposing the treated areas to sun may result in
increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon,
should inform their surgeon and either delay treatment, or avoid tanning until the surgeon says it is safe to
resume. The damaging effect of sun exposure occurs even with the use sun block or clothing coverage.

Travel Plans:
Any surgery holds the risk of complications that may delay healing and your return to normal life. Please
let the surgeon know of any travel plans, important commitments already scheduled or planned, or time
demands that are important to you, so that appropriate timing of surgery can occur. There are no
guarantees that you will be able to resume all activities in the desired time frame. Allow at least 10-14
days to travel via airplane.

Long-Term Results:
Subsequent alterations in the appearance of your body may occur as the result of aging, sun exposure,
weight loss, weight gain, pregnancy, menopause or other circumstances not related to your surgery.

Interference with Sentinel Lymph Node Mapping Procedures:

Breast surgery procedures that involve cutting through breast tissue, similar to a breast biopsy, can
potentially interfere with diagnostic procedures to determine lymph node drainage of breast tissue to stage
breast cancer.

Body-Piercing:
Individuals who currently wear body-piercing jewelry in the surgical region are advised that an infection
could develop from this activity. Body-piercing jewelry should be removed prior to your surgical
procedure.

Nails:
To determine your vitals status during surgery your anesthesia provider may require access to your finger
nails for monitoring. Make sure to have at least two finger nails free of nail polish or acrylic nails on the
date of your surgery.

Jewelry:

Page 9 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

Jewelry should not be brought with you at the time of your surgical procedure. Items such as earrings,
wedding rings, necklaces, etc. should be removed and placed in a safe place. Do not bring your jewelry
with you for your surgery.

Future Pregnancy and Breast Feeding:

This procedure is not known to interfere with pregnancy. If you are planning a pregnancy, your breast
skin may stretch and offset the results of surgery. You may have more difficulty breast feeding after this
operation.

Female Patient Information:

It is important to inform your plastic surgeon if you use birth control pills, estrogen replacement, or if you
suspect you may be pregnant. Many medications including antibiotics may neutralize the preventive
effect of birth control pills, allowing for conception and pregnancy.

Intimate Relations After Surgery:

Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels
leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional
bruising, swelling, and the need for return to surgery to control bleeding. It is wise to refrain from intimate
physical activities until your physician states it is safe.

Mental Health Disorders and Elective Surgery:

It is important that all patients seeking to undergo elective surgery have realistic expectations that focus
on improvement rather than perfection. Complications or less than satisfactory results are sometimes
unavoidable, may require additional surgery and often are stressful. Please openly discuss with your
surgeon, prior to surgery, any history that you may have of significant emotional depression or mental
health disorders. Although many individuals may benefit psychologically from the results of elective
surgery, effects on mental health cannot be accurately predicted.

REVISION POLICY
Revisional surgery is a common part of elective surgery. Your procedure will not stop you from aging,
sagging, scarring, or experiencing ongoing skin changes that are more genetically controlled. If revisional
surgery is either desired or advisable, there may be a physician’s fee. Additionally, there may be fees
associated with the hospital, facility, anesthesia, pathology, lab, and any supplies such as implants, etc.

ADDITIONAL SURGERY NECESSARY (Re-Operations)

There are many variable conditions that may influence the long-term result of surgery. It is unknown how
your tissue may respond or how wound healing will occur after surgery. Secondary surgery may be
necessary to perform additional tightening or repositioning of body structures. Should complications
occur, additional surgery or other treatments may be necessary. Even though risks and complications
occur infrequently, the risks cited are associated with this surgery. Other complications and risks can
occur but are less common. 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. In some situations, it may not be possible to achieve optimal results with a single
surgical procedure. You and your surgeon will discuss the options available should additional surgery be
advised. There may be additional costs and expenses for such additional procedures, including surgical
fees, facility and anesthesia fees, pathology and lab testing.

PATIENT COMPLIANCE
Follow all physician instructions carefully; this is essential for the success of your outcome. It is important
that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the
time of healing. Personal and vocational activity needs to be restricted. Protective dressings and drains
should not be removed unless instructed by your plastic surgeon. Successful post-operative function
depends on both surgery and subsequent care. Physical activity that increases your pulse or heart rate

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This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

may cause bruising, swelling, fluid accumulation and the need for return to surgery. It is important that
you participate in follow-up care, return for aftercare, and promote your recovery after surgery.

ATTESTATIONS

Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray):
Patients who are currently smoking or use tobacco or nicotine products (patch, gum, or nasal spray) are
at a greater risk for significant surgical complications of skin loss and delayed healing and additional
scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications
attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on
anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals
who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of
these type of complications. Please indicate your current status regarding these items below:

I am a non-smoker and do not use nicotine products. I understand the potential risk of second-
hand smoke exposure causing surgical complications.

I am a smoker or use tobacco / nicotine products. I understand the risk of surgical complications
due to smoking or use of nicotine products.

I have smoked and stopped approximately _________ ago. I understand I may still have the
effects and therefore risks from smoking in my system, if not enough time has lapsed.

___ I have been advised to stop smoking immediately and have been informed of the risks, benefits,
expectations and alternatives to my surgery if I continue smoking.

It is important to refrain from smoking at least 6 weeks before surgery and until your physician states it is
safe to return, if desired. I acknowledge that I will inform my physician if I continue to smoke within this
time frame, and understand that for my safety, the surgery, if possible, may be delayed.

Smoking may have such a negative effect on your surgery that a urine or blood test just before surgery
may be done which will prove the presence of Nicotine. If positive, your surgery may be cancelled and
your surgery, scheduling fee, and other prepaid amounts may be forfeited. Honestly disclose smoking to
your surgeon.

COMMUNICATION ACKNOWLEDGEMENT – CONSENT

There are many ways to communicate with you. It is important to keep appointments and let us know if
problems or issues arise. Methods of communicating are by telephone, text, pager, answering service if
available, email, and regular mail. If an emergency arises, keep us alerted to your progress so we may
aid in any necessary treatments. Please do not leave a message after hours or on weekends on the office
answering machine if any urgent or emergent situation exists, as there is a delay in retrieving such
messages. All attempts will be made to preserve your privacy in accordance with HIPAA rules.

Please confirm below all acceptable ways of communicating with you:

____ Telephone
____ Home ( - - )
____ Work ( - - )
____ Cell ( - - )
____ Text
____ Pager – Answering Service if available
____ Email – with up to date email address ( @ )
____ Regular Mail and Delivery

Page 11 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

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),
including a decision not to proceed with surgery. This document is based on a thorough evaluation of
scientific literature and relevant clinical practices to describe a range of generally acceptable risks and
alternative forms of management of a particular disease or condition. 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 current 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.

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.

Page 12 of 13 ______ Patient Initials ©2016 American Society of Plastic Surgeons

®

This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
 Informed Consent – Hyaluronic Acid Filler Injection

CONSENT FOR SURGERY / PROCEDURE or TREATMENT

1. I hereby authorize Dr. Medhanie Berhane and such assistants as may be selected to perform Hyaluronic Acid Filler
Injection.

I have received the following information sheet: Hyaluronic Acid Filler Injection.

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 involve risk and the possibility of complications, injury, and sometimes death.

4. I understand what my surgeon can and cannot do, and understand there are no warranties or guarantees, implied or
specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes
are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific)
risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives.
Understanding all of this, I elect to proceed.

5. I consent to be photographed or televised before, during, and after 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 authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device
registration, if applicable.

8. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are
agreeable to me. If a secondary procedure is necessary, further expenditure will be required.

9. I realize that not having the operation is an option. I opt out of having this procedure _____.

10. 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 (1-12).
I AM SATISFIED WITH THE EXPLANATION.

Patient or Person Authorized to Sign for Patient

Date/Time __________________________ Witness

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