• Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.

    I DECLARE THAT I UNDERSTAND THE FOLLOWING INFORMATION

    The goal of CO2 laser skin resurfacing surgery is to reduce or partially eliminate facial wrinkles or reduce scarring from skin conditions such as acne. Generally, the results of CO2 laser skin resurfacing demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.

    ALTERNATIVES TO CO2 LASER SKIN RESURFACING

    The alternatives to CO2 laser skin resurfacing surgery include dermabrasion and chemabrasion. The advantages and disadvantages (risks and benefits) of each of these alternatives to CO2 laser skin resurfacing surgery have been explained to me as well as the alternative of having no surgery, accepting my present skin condition, using cosmetics and considering other methods of skin rejuvenation surgery.

    POSSIBLE INTRA-OPERATIVE COMLICATIONS OF CO2 LASER SKIN RESURFACING SURGERY

    1. Blindness/Corneal Burns - There is a risk of accidental eye injury by the laser energy or beam, which could cause blindness or burns of the eyeball. This is unlikely since complete eye protection is provided at all times during the laser energy applications.
    2. Flash Fires - Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.

    POSSIBLE SHORT-TERM EFFECTS OF CO2 LASER SKIN RESRFACING SURGERY

    1. Pain - Discomfort, burning sensation or pain the first few days after surgery. A local anesthetic is usually used to block pain during the treatment, but some degree of discomfort will occur after the anesthetic effects have worn off and this pain may persist for several days.
    2. Redness of Skin - Erythema or redness of the skin for a two- to six-month period or possibly longer.
    3. Swelling - Temporary edema (swelling) or ecchymosis (bruising) of the tissue of the face and neck, usually subsiding in three to seven days.
    4. Wound Healing - Oozing, weeping, crusting and flakiness of the treated area, usually persisting for one to four weeks.
    5. Skin Thickening - Textural changes of the treated skin, such as skin thickening, which may persist for a variable time following the laser skin resurfacing treatment.
    6. Cysts - Milia or cysts, especially in the eyelid skin region (if the eyelid skin is included in the area of treatment by the laser energy), particularly if ointments were used in the postoperative phase for a protracted period.
    7. Skin Tightness - Sensation of skin tightness (peaks at 3-8 weeks postoperatively).
    8. Contact Dermatitis - Contact dermatitis due secondarily to topical preparations (ointments) used post- operatively.
    9. Herpes Simplex Dermatitis (Fever Blisters) - Occurrence or recurrence of herpes simplex dermatitis, particularly if not pre-, intra- and post-operatively treated with a systemic antiviral medication such as Zovirax.
    10. Skin Itchiness - Pruritis or itching in the early healing phase.
    11. Skin Hyperpigmentation - Transient hyperpigmentation (darkening of the skin), especially in darker- skinned people, occurring three to eight weeks after laser therapy.
    12. Cellulitis or Skin Infections - Cellulitis or infection of the skin and soft tissues, especially if careful post-operative hygiene is not practiced.
    13. Skin Hypopigmentation - Hypopigmentation (lightening of the skin), which occurs because of laser-induced injury to the melanocytes (pigment containing cells in the skin) and which can be permanent.

    POSSIBLE LONG-TERM EFFECTS OF CO2 LASER SKIN RESRFACING SURGERY

    1. Increased susceptibility to sun - Because of the permanent thinning of the epidermis and dermis and reduction in the number of melanocytes (pigment cells in the skin), there is probably a lifelong risk of greater susceptibility of CO2 laser skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.
    2. The risk of scarring exists in all cases. It is variable and is often related to an individual's genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.
    3. Skin Pigment Changes - Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.
    4. Infection - Infection is a risk that occurs in any invasive or surgical procedure. It is minimized by proper surgical technique and proper post-operative care.
    5. Ectropion - Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.
    6. Blepharoptosis - Blepharoptosis (drooping of the eyelid) can result from inadvertent injury to structures in the upper eyelid, especially in thin-skinned people.

    PATIENT CONSENT

    I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.

    I understand this is an elective procedure and that CO2 laser skin resurfacing surgery is not reversible.

    I also understand that more than one resurfacing procedure may be required to achieve the optimal obtain- able results.

    I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of CO2 laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after CO2 laser skin resurfacing surgery.

    My surgeon has explained CO2 laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the CO2 laser skin resurfacing surgical procedure. I therefore consent to having CO2 laser skin resurfacing surgery. 

    Patient signature
    Date