Hyaluronidase treatment (filler dissolver)

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Purpose: This form is to ensure that you understand the risks and benefits of the injection of hyaluronidase so that you can make an informed decision about whether to proceed with treatment with Hyaluronidase for the purpose of dissolving hyaluronic acid dermal fillers. It is very important that you take your time to read this form carefully and discuss any questions you have with your provider before providing your consent.

Rationale: Hyaluronic acid (HA) fillers are sterile gels consisting of non-animal stabilised hyaluronic acid for injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours. Occasionally these fillers need to be dissolved when the aesthetic treatment has not produced the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death) which could lead to compromise of healthy tissue.

Hyaluronidase is an enzyme which dissolves or “breaks down” hyaluronic acid fillers. It can also break down naturally occurring hyaluronic acid present in the body. The results may not be entirely predictable in regard to how much filler dissolves depending on the type and amount of filler present.

Alternatives to treatment: Do nothing (observation); anti-inflammatory treatments with oral or injected steroids; other anti-inflammatory medication; local massage.

Trauma: caused by needles passing through tissue, including bleeding, bruising, hematoma (a larger collection of blood in the tissue, outside of the blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle, and other soft tissue structures. In rare cases this could cause ongoing problems with appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own. Please enter your initials to accept this risk:Enter initials here* .
Reactions: Allergic reaction including anaphylactic shock are possible, they occur at a rate of between 1/2000 and 1/100 depending on the data source. Anaphylactic shock has a mortality rate 0.3 to 5% depending on the study. An allergy test can often identify this risk prior to full exposure. Local reactions include edema, erythema, pain and itching, urticaria and angioedema. Enter your initials to accept this risk: Enter initials here*
Side Effects: Hyaluronidase dissolves hyaluronic acid including molecules made by your body and previous treatments that you may wish to preserve could also be dissolved. You therefore could notice a reduction in skin elasticity and volume and associated asymmetry which typically would last a few days, but sometimes up to several weeks or months. It is common to cause bleeding, bruising, some swelling or edema and redness near the injection site. Enter your initials to accept this risk: Enter initials here*
Treatment failure: It is possible that the procedure will fail to remedy the problem as often HA is not the sole cause of lumps, bumps or reactions, which may be caused by other reasons including processes. Enter your initials to accept this risk:  Enter initials here*
No guarantee: I understand and accept that, like other cosmetic treatments, results cannot be guaranteed, will never be perfect, and may never be as good as I would like them to be. Enter your initials to accept this risk: Enter initials here*
Complications from infection:  There is a small risk of introducing an infection, and a theoretical risk that pre-existing infection could spread further if hyaluronidase is injected into the area, risking septicemia though there are no recorded cases. Enter your initials to accept this risk:    Enter initials here*
Delayed results: I understand that some results may occur within the first 24-48 hours, it can take up to 14 days for full results to be noticeable and that repeat treatments may be required. Enter your initials to accept this risk:
Follow up: I understand that adjustments requiring more product incur a charge. Fields and text. Enter your initials here: Enter your initials*

Dissatisfaction: I understand that with all treatments the precise degree of improvement cannot be guaranteed. The outcome’s subjective nature also means dissatisfaction is a possible outcome regardless of effectiveness of treatment. I understand that the effect of all treatments may gradually wear off, additional treatments may be necessary to acquire the desired effect, and further charges may apply if more product is required. Initial here to indicate you acceptance: enter your initials* .

Agreement: By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to you overall favour the use of the treatment described. You understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. You understand photographs are taken and stored as part of the clinical record.

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Consent for Hyaluronidase (filler dissolver)