Rationale
I am aware that when a small amount of purified botulinum toxin (Botox / Xeomin / Nuceiva / Dysport ) is injected into a muscle it causes weakness or paralysis of that muscle. This appears in 2-6 days and usually lasts 3-4 months but can be shorter or longer. In most cases, repeated treatments are recommended to maintain the effects.

Visible lines of aging on the face, such as frown lines between the eyebrows, crow's feet lines, horizontal forehead lines, and others are due to contraction of muscles of facial expression. Injecting botulinum toxin into these area may result in the relaxation of these muscles causing temporary improvement or even disappearance of the associated lines and wrinkles.

Lines and wrinkles at rest may not improve with neuromodulator alone since not all lines are caused by facial muscle action.  Volume loss and other age-related changes may be contributors.

I understand that Botulinum A Toxin (Botox) injection has been approved by Health Canada for use in the cosmetic treatment for glabellar (frown) lines only – the wrinkles between the eyebrows.  Use in other areas are considered off-label and performed at the discretion of the treatment physician based upon my aesthetic goals as discussed during my consultation.

 

Results and Post-treatment Care

I understand that I must not manipulate the area of injection for 3-4 hours post-injection. I will not wear any tight-fitting headgear for 4-6 hours after receiving BOTOX injections.

I understand that I will not be able to move the targeted muscles as vigorously while the injection into this area is effective, but that it will reverse itself after a period of months, at which time retreatment may be  appropriate to maintain the desired effect.

Risks and Complication
This list is not meant to be inclusive of all possible risks associated with Botox as there are both known and unknown side effects associated with any medication or procedure. The possible side effects of Botox include but are not limited to:

Most people have lightly swollen pinkish bumps where the injections went in, for a couple of hours or even several days.  Swelling, rash, headache, local numbness, pain at the injection site, bruising, respiratory problems, and allergic reaction.  Infections are rare, but may occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.

Although many people with chronic headaches or migraines often get relief from Botox, a small percent of patients get headaches following treatment with Botox, for the first day. In a very small percentage of patients these headaches can persist for several days or weeks.

Local numbness, rash, pain at the injection site, flu like symptoms with mild fever, back pain.

Respiratory problems such as bronchitis or sinusitis, nausea, dizziness, and tightness or irritation of the skin.

Bruising is possible with any injection into the skin. This bruising can last for several hours, days, weeks, months.

While local weakness of the injected muscles is representative of the expected pharmacological action of Botox, weakness of adjacent muscles may occur as a result of the spread of the toxin.

I understand more than one injection may be needed to achieve a satisfactory result.

Another risk when injecting Botox around the eyes included corneal exposure because people may not be able to blink the eyelids as often as they should to protect the eye. This inability to protect the eye has been associated with damage to the eye as impaired vision, or double vision, which is usually temporary. This reduced blinking has been associated with corneal ulcerations.

BOTOX treatment of frown lines can cause minor temporary droop of one eyelid or eyebrows in less than 3% of injections. This usually lasts 2-4 weeks. There are medications that can help lift the eyelid, however, if the drooping is too great the eye drops are not that effective.

I will follow all aftercare instructions as it is crucial I do so for healing.
As Botox is not an exact science, there might be an uneven appearance of the face with some muscles more affected by the Botox than others. In most cases this uneven appearance can be corrected by injecting Botox in the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks or onths. Occasionally, numbness of a small area on the forehead lasting 2-3 weeks, bruising, asymmetry, twitching, and transient headache have also occurred. Other reported side effects have included nausea, flu-like symptoms, double vision, and elevation of the outer part of the eyebrow, swelling of the lower eyelid, drooping of an eyebrow, and muscle weakness.

The number of units injected is an estimate of the amount of Botox required to paralyze the muscles.

Photographs
I authorize the taking of clinical photographs and their use for scientific purposes both in publications and presentations. I understand my identity will be protected.

Pregnancy, Nursing, Neurologic Disease, and Medications
I am not aware that I am pregnant nor that I have any significant neurologic disease. If taking amino glycoside antibiotics, Penicillin, or Quinine, these medications may potentate the effect of BOTOX Cosmetic.

Payment
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost.  I understand there is no guarantee of results of any treatment. I understand that a follow-up visit for touchups may be necessary to achieve optimal results.  I understand that although minor touchups may be complimentary at the discretion of the provider, the regular charge applies to all subsequent treatments.

I have read the above consent form and understand all of it. The medical advisor has answered all my questions to my satisfaction. I understand the risk and complications and give my informed consent for this procedure.