Gregory A. Stainer, M.D., F.A.C.S. z Susan Rowe, M.D. z Glenn A. Kaprielian, O.D. z Cheree A. Wilhelmsen, O.D OPERATIVE CONSENT FOR FACIAL LASER RESURFACING SURGERY
Patient ________________________________________________ Date ___________________ I am aware that laser surgery is a relatively new procedure. My doctor has explained to me that much of what has been written about this method in newspapers, magazines, television, etc. has been sensationalized. I understand the nature, goals, limitations, and possible complications of this procedure, and I have discussed alternative forms of treatment. I have had the opportunity to ask questions about the procedure, its limitations, and possible complications (see below). I clearly understand and accept the following:
1. The goal of laser surgery, as in any cosmetic procedure, is improvement not perfection. 2. The final result may not be apparent for months postoperatively. 3. In order to achieve the best possible result, more than one procedure may be required. There will be a charge for any
4. Since adherence to the postoperative regimen (i.e. appropriate wound care and sun avoidence) is necessary in order to
5. The surgical fee is paid for the operation itself and subsequent postoperative office visits. There is no guarantee that
the expected or anticipated results will be achieved.
Although complications following laser surgery are infrequent, I understand that the following may occur:
1. Bleeding which, in rare instances, could require hospitalization. 2. Infection is rare, but should it occur, treatment with antibiotics might be required. 3. Objectionable scarring is rare, but various kinds of scars are possible. 4. Alterations of skin pigmentation may occur in the areas of laser surgery. These are usually temporary, but rarely can
In addition to these possible complications, I am aware of the general risk inherent in all surgical procedures and anesthetic administration outlined in the accompanying surgical consent form. I agree that Dr. Gregory Stainer or designated associates may take photographs of my procedure and may use these photographs without compensations for me for teaching or medical publication providing my identity is concealed. My signature certifies that I understand the goals, limitations, and possible complications of laser surgery, and that I wish to proceed with the operation. _______________________________________________ ______________________________________________ Patient Physician _______________________________________________ ______________________________ Witness Date
Gregory A. Stainer, M.D., F.A.C.S. z Susan Rowe, M.D. z Glenn A. Kaprielian, O.D. z Cheree A. Wilhelmsen, O.D. AFTER CARE INSTRUCTIONS LASER RESURFACING
Patient Name: ___________________________________________________ Date: _______________________
DAY OF SURGERY
1. Drink plenty of fluids at home beginning with SMALL AMOUNTS. 2. Food may be eaten as tolerated. Usually soft easily digestible foods. 3. Medications must be taken with a small amount of food or milk (i.e. soup, crackers, yogurt, etc.) 4. Your vision will be blurry for about 24 hours. This is normal. 5. The only care your face requires this day is to keep all lasered areas, not covered by the Silon or Flexan
6. Pinkish-yellow fluid will collect near the bottom of the mask and drip down the neck. Wipe as needed. A
towel can be draped around the neck to absorb fluid and protect clothing.
FIRST POSTOP DAY AND CONTINUING UNTIL MASK REMOVED
1. The day after surgery you will begin the vinegar and water soak or sprays. Mix 1 teaspoon of vinegar in 1
cup of cool water. You may dilute the mixture to ½ teaspoon vinegar to 1 cup of cool water if it stings too much. Spray or soak your face at least 6-8 times a day.
2. Continue to keep lasered areas not covered by mask coated with Vaseline or aquaphor. 3. If the mask shifts, gently push it back in place. 4. If your face is itching, you may take Benadryl 25 mg to 50 mg every 4-6 hours as needed for itching. Do
not drive if taking this medication. Benadryl may be purchased at any drugstore or grocery store.
5. You may shower or bathe starting today. Do not get water or soap on your face.
AFTER MASK IS REMOVED
1. You may shower this day and flush your face with cool water in the shower. Do not get soap or shampoo
2. Keep your face covered with Vaseline or Aquaphor ointment at all times. If your face begins to feel tight
you need more Vaseline or Aquaphor. Continue to spray or soak with vinegar and water solution 5-7 times a day for the next 5 days.
3. Finish all oral antibiotics and antivirals.
If you have any questions or concerns call (661) 833-4040. ____________________________________________ ____________________________________________ Patient Signature
Gregory A. Stainer, M.D., F.A.C.S. z Susan Rowe, M.D. z Glenn A. Kaprielian, O.D. z Cheree A. Wilhelmsen, OD LASER RESURFACING INSTRUCTION SHEET FOR MEDICATIONS TO BE TAKEN PRIOR TO SURGERY AND AFTER SURGERY
GLYQUIN: Apply small amount over entire face, avoiding eye area, two times a day. Start 2-4 weeks before surgery and discontinue the day of surgery. FAMVIR: One tablet 3 x a day.
Start 3 days prior to surgery and continue for 7 days after surgery.
BROMELAIN: One tablet a day
LEVAQUIN: One tablet 1 x a day
Start 3 days prior to the day of surgery and continue until prescribed
Bayer CropScience SAFETY DATA SHEET according to EC Directive 2001/58/EC PROPINEB WP 70R W U-WW 1. IDENTIFICATION OF THE SUBSTANCE/PREPARATION AND THE COMPANY/UNDERTAKING Product information Alfred-Nobel-Straße 50 40789 Monheim Germany Telephone +49(0)69-305-5748 Telefax +49(0)69-305-80950 Responsible Department Material and Transport Safety Management +49(0)69-305-82369/12588