Dermal fillers are used for the treatment of facial creases, wrinkles, folds,contour defects, depression scars, facial lipoatrophy (loss of fat) and enhancement purposes. These treatments involve multiple injections of filler into or below the skin to fill wrinkles and restore volume. The effects of dermal fillers are temporary and no guarantees can be made regarding how long correction will last in a specific patient
Alternatives to temporary fillers include, but are not limited to: permanent dermal fillers, laser resurfacing and skin tightening, surgical face-lift, or no treatment at all.
Possible risks, side-effects and complications with dermal fillers include, but are not limited to:
Bruising, redness and swelling.
Visible raised areas, or bumpiness at/around treated site.
Asymmetry, overcorrection or undercorrection.
Unpredictable persistence of filler, either shorter or longer than expected.
Prolonged discoloration of the skin such as brown, grayish, bluish or reddish coloration.
Filler may be extruded from the skin in rare cases.
Prolonged or severe swellingnInfection.
Rarely granulomas or firm nodules may form.
Benign tumor formation (keratoacanthomas).
Allergic reaction with itchiness, redness, and in extremely rare cases generalized allergic response such as whole body swelling, respiratory problems and shock.
Scarring is extremely rare.
Skin breakdown or ulceration.
Blindness.
A remote and rare risk is that of filler injection into a blood vessel (blood vessel occlusion) or overfilling tissue that can block blood flow to the treated area or to distant areas, causing tissue damage or tissue death (necrosis) which can be seen as skin breakdown or ulceration. Blood vessel occlusion near the eye.
The administration of anesthetics may be necessary or advisable in association with dermal filler treatments to reduce pain. This includes, but is not limited to: local anesthetic injections with lidocaine 1-2%with or without epinephrine: and/or topical anesthetics such as benzocaine/lidocaine/tetracaine; and/or topical oral benzocaine preparations.Complications of these anesthetics include, but are not limited to: skin irritation (itching or redness), lightheadedness, rapid heart rate, visual disturbance, tongue numbness, and seizure.
Photographs taken shall be part of the medical record and used for documentation of response to treatment.
Pricing is dertermined by the type of product used and ranges from about $650 up to $800 per 1cc syringe used. Your provider will estimate how many syringes may be needed to achieve desired results.
My signature below certifies that I have fully read this consent form and understand the written information provided to me regarding the procedure. I have been adequately informed about the procedure including the potential benefits, risks, limitations and alternate treatments, and I have had all questions and concerns answered to my satisfaction.