Friday, July 1, 2011

Consent form for Rhinoplasty (Nose Job)


CONSENT INFORMATION – PATIENT COPY

RHINOPLASTY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Rhinoplasty. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What is “Rhinoplasty”?
Rhinoplasty is surgery to reshape the nose. It is one of the most common of all plastic surgery procedures.
Why is it done?
* To reduce or increase the size of your nose
* To change the shape of the tip or the bridge
* To narrow the span of the nostrils or change the angle between your nose and your upper lip
* To correct a birth defect or injury
* To help relieve some breathing problems.
Am I a good candidate for rhinoplasty?
The factors to determine whether you are a good candidate for Rhinoplasty are:
* In comparison to your face your nose appears too large

* A bump on the nasal bridge is visible when viewed in profile
* When viewed from the front your nose appears too wide
* Drooped or plunged the nasal tip
* Thickened or enlarged nose tip
* Excessively flared nostrils
* Off-center or crooked nose
* Asymmetrical nose due to previous injury
Rhinoplasty can enhance your appearance and your self-confidence, but it won't necessarily change your looks to match your ideal, or cause other people to treat you differently. The best candidates for rhinoplasty are people who are looking for improvement, not perfection, in the way they look. If you're physically healthy, psychologically stable, and realistic in your expectations, you may be a good candidate.
How do I prepare for the procedure?
Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, taking or avoiding certain vitamins and medications, and washing your face.
Aspirin and Vitamin E containing medications must be avoided at least 7days prior to your surgery. Specific instructions on this will be given by your surgeon. Carefully following these instructions will help your surgery go more smoothly.
While you're making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days if needed.
Will it hurt?
Rhinoplasty can be performed under local or general anesthesia, depending on the extent of the procedure and on what you and your surgeon prefer.
With local anesthesia, you'll usually be lightly sedated, and your nose and the surrounding area will be numbed; you'll be awake during the surgery, but relaxed and insensitive to pain. With general anesthesia, you'll sleep through the operation.
Techniques – open vs. closed
Rhinoplasty surgery can be performed entirely from within the nose using hidden incisions internally (closed rhinoplasty). However a small external incision across the bridge of skin that runs between the nostrils is sometimes necessary to allow fuller exposure of the underlying nasal skeleton (open or external rhinoplasty).
This procedure is favored in cases where the anatomy is complex and difficult to define in a closed approach, where the nose is severely twisted or in cases of revision rhinoplasty where increased access is advantageous.
The use of an open approach has become increasingly popular in recent years. The incision does lead to some numbness of the tip of the nose which is usually transient and perhaps slightly greater swelling of the tip postoperatively. Your surgeon should discuss his/her preferences with the reasons why a particular approach is used.
What happens during the procedure?
There is not a universal type of rhinoplasty that will meet the needs of every patient. 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 rhinoplasty procedure. Internal nasal surgery to improve nasal breathing can be performed at the time of rhinoplasty.
After the rhinoplasty, the cuts inside or between your nostrils will be closed up with dissolvable stitches. Your nose may be filled with surgical packing to help control any bleeding. You may also have a nasal splint or plaster which may be kept for a week to 10days.


What happens after the procedure?
After surgery-particularly during the first twenty-four hours-your face will feel puffy, your nose may ache, and you may have a dull headache. You can control any discomfort with the pain medication prescribed by your surgeon. Plan on staying in bed with your head elevated (except for going to the bathroom) for the first day.
You'll notice that the swelling and bruising around your eyes will increase at first, reaching a peak after two or three days. Applying cold compresses will reduce this swelling and make you feel a bit better. In any case, you'll feel a lot better than you look. Most of the swelling and bruising should disappear within two weeks or so. (Some subtle swelling-unnoticeable to anyone but you and your surgeon-will remain for several months.)
A little bleeding is common during the first few days following surgery, and you may continue to feel some stuffiness for several weeks. Your surgeon will probably ask you not to blow your nose for a week or so, while the tissues heal.
If you have nasal packing, it will be removed after a few days and you'll feel much more comfortable. By the end of one or, occasionally, two weeks, all dressings, splints, and stitches should be removed.
After the surgery contact your Doctor if:
* You develop a fever over 100°F (37.8°C).
* You have drainage from your incision, or the incision separates.
* You become dizzy or faint.
* You have nausea and vomiting.
* You have chest pain.
* You become short of breath.
Expectations from the surgery:
Rhinoplasty aims at a nose that not only looks natural but blends harmoniously with your other facial features as well. Because of the gradual healing process you should expect to wait up to one year to see the final results of your surgery.
You might experience some unexpected reactions from family and friends. They may say they don't see a major difference in your nose. If that happens, try to keep in mind why you decided to have this surgery in the first place. If you've
General Risks of having the procedure:
These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.
What are the risks of the procedure?
While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost
(b) Infection which may require antibiotics and may cause bleeding
(c) Persistence or recurrence of the original problem with an unsatisfactory cosmetic appearance or lack of satisfaction with the new cosmetic appearance of the nose
(d) Rhinoplasty may lead to a poorer nasal airway which may require revision surgery
(e) Abnormal healing of external wounds with abnormal scar formation
(f) Impaired or lost sense of smell and taste
(g) Adhesions or scar tissue forming inside the nose requiring further surgery
(h) Numbness of the top lip and / or upper front teeth
(i) CSF leaks/Orbital Hematoma (bruising)/Septal Abscess/Hematoma
(j) May cause increase in snoring or sleep disturbance
Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………










INFORMED CONSENT: RHINOPLASTY


Patient Identification Label to be affixed here








A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Rhinoplasty” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost
(b) Infection which may require antibiotics and may cause bleeding
(c) Persistence or recurrence of the original problem with an unsatisfactory cosmetic appearance or lack of satisfaction with the new cosmetic appearance of the nose
(d) Rhinoplasty may lead to a poorer nasal airway which may require revision surgery
(e) Abnormal healing of external wounds with abnormal scar formation
(f) Impaired or lost sense of smell and taste
(g) Adhesions or scar tissue forming inside the nose requiring further surgery
(h) Numbness of the top lip and / or upper front teeth
(i) CSF leaks/Orbital Hematoma (bruising)/Septal Abscess/Hematoma
(j) May cause increase in snoring or sleep disturbance

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………



Page 1 of 9 NDA / Physician/ Consent Rhinoplasty/ Ver.1/ Dec.2007
Patients Initials ______________

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