CONSENT FOR SCAR REVISION

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

1. I hereby request the above named surgeon(s) and/or their associates to perform a surgical procedure known as “removal” or revision of scars. This procedure has been explained to me and I completely understand its nature and consequences.

2. I understand that every surgical procedure involves certain risks and possibilities of complications such as bleeding, infection, poor healing, etc and that these and other complications may follow even when the surgeon uses the utmost care, judgment and skill. These risks have been explained to me and I accept them. The following points have been explained in detail:

a. Normal healing is with scar tissues and scars cannot be completely removed. The purpose of this operation is to rearrange or revise the scars and to improve them, making them as inconspicuous as reasonably possible.
b. Firmness in the area and redness of the scar are expected for an indefinite period of time. Most scars do not reach their maximum improvement for at least one year.
c. If additional surgery is necessary following this planned operation, it would probably be deferred for three to six months, and an additional fee would be charged for an additional surgery.
d. There may or may not be sutures (stitches) requiring removal. Sutures are placed deep in the skin and other tissues, and occasionally a “stitch” will work to the surface, have to be removed or require laser resurfacing.
e. If “sanding” “planing” is required, this may be deferred for six to twelve weeks following the surgical correction of the scar and the area so sanded will be red for an indefinite period of time. A difference in pigmentation between the sanded and the unsanded areas would also be noticed for an indefinite period of time and, occasionally permanently.
f. The amount of improvement varies greatly in individuals and the result or the possible need for additional surgery in an attempt to gain maximum improvement cannot be predicted.
g. It is possible though unusual, to experience a bleeding episode during or after the surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood (haematoma). Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this may contribute to a greater risk of bleeding.
h. Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics or additional surgery may be necessary.
i. Until wound healing is complete, it is possible to split open the surgical wound where the scar revision was performed. Wound disruption can produce a poor surgical result. If this occurs, additional treatment may be necessary.

3. I have an understanding of the operation which includes but is not limited to the above items. I understand that secondary revisions may be required in some cases. I also understand that charges will be made for the use of the operating room, whether in the day surgery or in the hospital. I agree to be responsible for these charges.

4. I recognise that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those outlined. I, therefore, further authorise and request that the above-named surgeon or his/her assistants perform such procedures as are, in his or her professional judgment, necessary and desirable. The authority granted under this Paragraph 4 shall extend to remedying conditions that are not known to or could not reasonably be anticipated by the above doctor(s) at the time the operation is commenced.

5. I consent to the administration of local or general anaesthetic agents by or under the direction and supervision of the above doctor(s), anaesthetist working with them.

6. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure; nor are there any guarantees against unfavourable results.

7. I consent to be photographed before, during and after the surgery; that these photographs shall be the property of the above doctors and may be used as they deem proper for scientific and educational purposes.

8. I agree to keep the above doctor(s) informed of any change of address, and I agree to cooperate with them in my care after surgery until completely discharged.

9. I understand that the doctors’ fees are separate from the anaesthesia and hospital charges and the doctors’ fees are agreeable to me. There may be a fee if a secondary procedure is required. Personal expectations vary; please ensure that you have liaised with your doctor and he has understood your expectations of surgery. Some operations require secondary or multiple procedures to obtain a better result.

10. Secondary surgical procedures are much more difficult than primary procedures. The operations for repair are much more complex than the primary operations because of scarring and more bleeding and bruising. The possibility of nerve damage and poor healing is greater and most importantly, the results are unpredictable. It is important for the patient to realise that the results of secondary surgery will never be as predictable as those of primary surgery. If a secondary procedure is necessary, further expenditure will be required, namely surgeon’s fees, the use of the operating room, anaesthesia and possibly hospitalisation. Before embarking on secondary surgery, you should be aware of your possible future commitments to multiple procedures in order to gain an acceptable result for yourself.

11. I have read a copy of the foregoing consent for the operation, understand it, accept these facts, and hereby authorise the above doctor(s) to perform this surgical procedure on me.

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036