You are being asked to sign a confirmation that we have discussed the nature of your condition,
your contemplated operation or medical procedure, the general nature of the proposed
treatment/surgery, the request of the proposed treatment/surgery, the prospects for success, the
reasonable therapeutic alternatives to the treatment/surgery, and the risks of such alternatives.
Your physician has discussed with you the common problems or risks. We wish to inform you as
completely as possible. You are also being asked to sign a confirmation that you have been given
the opportunity to ask whatever questions you had and that your questions have been answered
in a satisfactory manner. Please read the form carefully. Ask about everything you do not
understand and we will be pleased to explain it.
Sculptra Aesthetic is a safe, synthetic, and biocompatible material that is
injected below the surface of the skin. It’s made up of microspheres (a spherical shell that is
usually made of a biodegradable or resorbable plastic polymer, that has a very small diameter
usually in the micrometer or nanometer range, and that is often filled with a substance, as a drug
or antibody, for release as the shell is degraded) of poly-L-lactic acid forty to sixty microns in size.
Because poly-L-lactic acid is the main ingredient in Sculptra Aesthetic, patients don’t require a
test for allergic reactions. The results of Sculptra Aesthetic are not immediate. At your first
treatment visit, it may appear that Sculptra Aesthetic worked immediately because of swelling
from the injections and the water used to dilute Sculptra Aesthetic. A few days following the
treatment, when the swelling goes down and the water is absorbed by your body, you may look
as you did before your treatment. Sculptra Aesthetic takes time to gradually correct the
depression in your skin. Your doctor will decide the appropriate number of treatment sessions
and the amount of Sculptra Aesthetic you will need at each session. Multiple sessions are often
required and patients with severe facial fat loss may require 3 to 6 treatments (with 2-6 vials
Side effects of Sculptra Aesthetic may include: delayed appearance of small
bumps under the skin in the treated area, bleeding, tenderness or discomfort, redness, bruising,
or swelling at the site of injection(s). You may also experience any of the following: Poor
cosmetic result, infection, unevenness, swelling, granuloma formation (lumps), and allergic
reaction, firm hard areas on lips, folds, or lines, inadequate augmentation. The augmentation is
not permanent. The practice of medicine and surgery is not an exact science, and, therefore,
reputable practitioners cannot guarantee results. The results of the injections may not last for as
long or as well as expected. There are no promises or guarantees regarding the degree of
improvement when using Sculptra Aesthetic.
- Ice packs may be used during the first 24 hours- 10 minutes on, 10 minutes off.
- Massage the injected site as instructed for 5 minutes, 5 times/day for 5 days.
- Elevate the head with two pillows while sleeping during the first few days to minimize swelling.
- Aspirin, NSAIDs, and alcohol should be avoided for the first few days after treatment.
- Tylenol may be used for pain control.
- Avoid hot foods or gum chewing for the first several hours as mouth trauma may occur in the
anesthetized areas. Notify Dr. Bridges for significant swelling, bleeding, eye pain, vision loss,
dusky discoloration, excessive pain, or fever.
Drugs, Pregnancy and Allergies – You should not be pregnant, nursing an infant, have a
history of a bleeding disorder, abnormal scarring or autoimmune disease. You should not be
taking any of the following medications: immunosuppressants or blood thinners. Also, you should
have told your physician if you have a history of oral herpes simplex (cold sores).
Alternatives – As explained, not all wrinkles will respond to Sculptra Aesthetic. Other alternatives
are dermabrasion; chemical peeling; laser resurfacing; face-lifting, browlifting, necklifting, and
other surgical resection of the frown muscles of the brow; topical skin care treatments also
produce some benefits.
Follow-Up Suggested by the Doctor – I agree to follow up with my doctor as scheduled and as
recommended by Dr. Bridges. I agree to inform Dr. Bridges of any problem that I am having and
to allow him to see me at that time
I voluntarily request treatment by West Ave Plastic Surgery using Sculptra Aesthetic. My
questions regarding such treatment, alternatives, complications, and risk have been answered by
the doctor, his staff, and/ or though written information. The information which I have been given
has been in terms clear to me and I understand the risks and complications of the treatments. My
questions have been fully and completely answered for me and I have read this document and
understand its contents. I hereby give my unrestricted informed consent for the procedure.
DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU
UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM.
DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR
MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have provided and explained the information set forth herein and answered all questions of the
patient or the patient's representative concerning treatment/surgery. I have informed the patient
of the available alternatives to soft tissue augmentation, and of the potential risks and
complications that may occur as a result of this treatment.