Hyaluronidase Consent Form
Treatment/Product Information:
Hyaluronidase is a naturally occurring enzyme found in mammalian tissues.
Hyaluronidase is a prescription-only medication containing hyaluronidase enzymes from sheep testes. We prescribe and administer this "off licence," based on general medical practitioner consensus for breaking hyaluronic acid dermal fillers down (dissolving). Treating "off Licence" may carry additional unknown risks or side effects.
Hyaluronidase is reconstituted with bacteriostatic saline containing Benzoyl Alcohol. Once reconstituted, it is administered by injection into the soft tissues where dermal filler or an occlusion pathway is located.
Anaesthetic cream is not usually required, however, in non-emergency situations you may opt to have this applied 30 minutes prior to the procedure. In emergencies, time is essential, and anaesthetic cream will not be used.
In a non-emergency:
Hyaluronidase is used in non-emergency cases where the dermal filler has an undesired effect and requires refinement or complete removal from the soft tissues. Prior to completing hyaluronidase treatment, you will be required to have a test patch for allergy. This could result in an allergic reaction or anaphylactic shock that may require medication and/or hospitalisation. In the case of allergy or anaphylactic shock, hyaluronidase cannot be administered as a remedial treatment of hyaluronic acid dermal filler.
In an emergency situation (such as blood vessel blockage):
Hyaluronidase is primarily used in aesthetic medicine as an emergency medication for emergency situations, such as when dermal filler material blocks a blood vessel (vascular occlusion), where prompt dermal filler breakdown is required to restore local blood circulation.
Time is of the essence, and a test patch will not be performed to ensure skin tissue recovery. This could result in an anaphylactic or allergic response that may require medication and/or hospitalisation.
It is essential to know:
Hyalase, much like your own native hyaluronidase, will remove your own native hyaluronic acid as well as the hyaluronic acid of other dermal fillers that may be present in the area. The implication of this means that any other dermal filler you have in the region is at risk of being removed, and you may experience skin laxity, uneven contours, and dry, crepey skin quality for a period of up to 6 weeks post hyaluronidase administration. We do not accept liability for the breakdown of the previous hyaluronic acid derma filler breakdown and the associated cost to replace this.
Alternative Options
In an emergency situation where dermal diller requires immediate breakdown to save tissue, Hyaluronidase is the only option available, except surgical intervention, which would carry a greater degree of risk.
For non-emergency situations, you may wish to do nothing and wait for the hyaluronic acid dermal filler to break down over time or have your practitioner attempt manual manipulation of the product.
Contraindications:
You cannot have hyaluronidase treatment if:
You have had an anaphylactic reaction (potentially fatal swelling of the mouth, throat and airway) to Hyaluronidase/Hyalase before.
You have an active infection or inflammation near the intended treatment area.
You think you could be pregnant, are pregnant, or are lactating or breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You tend to react with local swelling after bee or wasp stings. Bees and wasps use hyaluronidase in their sting, and you could have an allergy to it. This means you could have an allergic reaction to Hyaluronidase administration.
You have ever experience a cold sore (herpes virus). Hyalase administration may activate the cold sore virus, forming cold sores.
You are an alcoholic or have an alcohol allergy. Benzoyl Alcohol is within bacteriostatic saline, which is used to reconstitute hyaluronidase.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Injection site bruising. This is usually mild and lasts less than a week but can last longer. Patients using medications that prolong bleeding, such as aspirin, warfarin, steroids and ibuprofen (and other NSAIDs), may experience increased bruising or bleeding at the injection site. Certain vitamins and supplements can also have this effect.
Pain, swelling, rash, local numbness or itching. The simple action of the needle passing into the soft tissue can cause these effects, which are usually mild and short-lived. It could also be a sign of allergy or anaphylaxis.
Hypersensitivity/Allergy/Anaphylaxis Reaction. Most medications carry a potential risk of allergic reactions. Allergic reactions have been reported with Hyaluronidase, such as anaphylaxis, skin itching, skin swelling, and difficulty breathing. You should contact your practitioner if you feel unwell or have had an allergic reaction. You should seek immediate emergency medical care in cases of a severe allergic reaction (anaphylaxis).
Asymmetry of appearance. Hyaluronidase may lead to temporary asymmetry where some dermal filler has dissolved, and other areas have not. This may mean that further administration of Hyaluronidase is required to dissolve other dermal fillers present or the replacement of dermal fillers that have broken down. Any dermal filler replacement will be at your own cost.
Lumpiness or irregularity in the contour of the treated area. This may occur as some dermal filler is broken down and other aspects are not. Your practitioner will work with you to rectify this, however it may not be possible to resolve without further administration of Hyaluronidase and total dermal filler dissolving. Any dermal filler replacement will be at your own cost.
Textural changes to the skin may last for weeks. Hyaluronidase is not specific to breaking down dermal filler and may remove your own native hyaluronic acid from the skin. Thankfully, the skin can restore its own levels of hyaluronic acid within six weeks.
Little to no effect. Very rarely, hyaluronidase is unable to break the hyaluronic acid dermal filler, and alternative treatment, including firm massage, blood thinning medication, vasodilation medication and even surgery, may be required to restore blood circulation, refine or remove the dermal filler.
Infection. As with any procedure that involves a break to the skin’s surface, there is a risk that an injection of any material could introduce an infection which may require treatment. Contact your practitioner if you experience skin redness, irritation or pain in the treatment area following hyaluronidase treatment.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
Informed Consent:
This consent form is not meant to include all possible risks associated with hyaluronidase treatment, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, the reasons why you may not be able to receive treatment and the known risks of hyaluronidase treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of a hyaluronidase treatment with your practitioner, and your questions have been answered satisfactorily.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results. We cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following hyaluronidase treatment. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive a treatment with hyaluronidase medication for the removal of hyaluronic acid dermal filler under the terms of this consent form, and understand that you have the right not to consent to this treatment and that your consent is voluntary.
