INDICATIONSRestylane® is a sterile gel consisting of stabilized hyaluronic acid; Medicis, the manufacturer, states thatit is biodegradable, and safely and completely metabolized by the body. Restylane® injections are givento correct facial wrinkles and/or for lip augmentation. Restylane® has been approved by the FDA (Foodand Drug Administration) for correction of facial wrinkles in the nasolabial area (nose-lips) and the foldbetween the cheek and the nose/upper lip (“on-label” use). I understand that the safety andeffectiveness of treating facial areas other than the nasolabial folds has not been studied; however,Restylane® has been used to enhance the appearance of lips in over 60 other countries. This “off-label”aspect of the treatment has been explained to me.ALTERNATIVESThere are alternatives to Restylane® injections, including no treatment, collagen for lip or other facialsoft tissue augmentation, and cosmetics, Botox, laser skin resurfacing, chemical peels, or plastic surgeryfor wrinkle reduction.RESULTSI understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, Iunderstand that the effect will gradually wear off and additional treatments may be necessary tomaintain the desired effect.SIDE EFFECTS AND COMPLICATIONS
include but are not limited to: Potential allergic reaction. As with any product, allergies can develop during or after injection. Injection site reactions: a lumpy or “thick” feeling at or just under the skin, bruising, redness,itching, pain, tenderness, or slight swelling. Injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections)for patients with a history of prior cold sores.
PREAUTIONS AND CONTRAINDICATIONS Due to the potential for an allergic reaction, Restylane® is not recommended for patients withsevere allergies or a history of anaphylaxis. The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such asaspirin and non-steroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), highdoses of Vitamin E, and certain herbs (Ginkgo Biloba, St. John’s Wart).
PLACE LETTERHEAD HERE AND REMOVE NOTENote: This form is intended as a sample form of the information that you as the surgeon should personallydiscuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy andsend this form to the hospital or surgery center as verification that you have obtained informed consent.
The safety of Restylane® in pregnant or breast-feeding women has not been established, and istherefore not recommended for these women.
CONSENTI understand the need for local anesthesia to reduce the discomfort of the procedure and consent tothe topical application of anesthetic gel and/or injections for a nerve block or local infiltrativeanesthesia. I understand the above, and have had the risks, benefits, and alternatives explained to me,and have had the opportunity to ask questions. No guarantees about results have been made. To thebest of my knowledge, I am not pregnant, and I am not breastfeeding. I give my informed consent forRestylane® injections today as well as future treatments as needed._____________________________________________________________________________________