Sculptra Information and Consent Form

Diagnosis — A natural, youthful face is full and not tight. Age related changes of the lips and mouth include atrophy of the lips and atrophy of the corners of the mouth resulting in downturn. Another eary sign of aging is the development of nasolabial lines. Although the upper face can easily be rejuvenated with Botox , the lower face is less amenable to this treatment. In order to treat the entire aging face, a combination of Botox and injectable fillers is often needed for optimal results.

Sculptra — Sculptra is a safe, synthetic, and biocompatible material that is injected below the surface of the skin. It's made up of micro spheres (a spherical shell that is usually made of a biodegradable or reabsorbable 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, patients don't require a test for allergic reactions.

Sculptra is approved to treat lipoatrophy, the progressive facial decomposing seen on most HIV patients. but it is used "off-label" for cosmetic purposes.

Side Effects — Side effects of Sculptra may include: delayed appearance of small bumps under the skin in the treated area, bleeding, tenderness or discomfort, redness, bruising, or swelling may occur at the site of injection.

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 East for as long or as well as expected. There are no promises or guarantees regarding the degree of improvement when using Sculptra.

Postoperative Care —

• Ice packs may be used during the first 24 hours- 10 minutes on, 10 minutes off.
• Massage the injected site as directed before bedtime after treatment.
• Aspirin, NSAlDs, and alcohol should be avoided for the first few days after treatment.
• Tylenol may be used for pain control.
• Exaggerated movements of the areas augmented should be avoided for the first several days.
• Avoid hot foods or gum chewing for the first several hours as mouth trauma may occur in the anesthetized areas.

Notify the physician 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, 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 notify your physician if you have a history of oral herpes simplex (cold sores).

Alternatives — As explained, not all wrinkles will respond to sculptra. Other alternatives are dermabrasion; chemical peeling; laser resurfacing; thermage, face lifting, brow lifting, neck lifting, and other surgical resection of the frown muscles of the frown muscles of the brow; treatments with Rein-A or Renova or alpha hydroxy acids may also produce some benefits.

Photography — I hereby give my permission to take photographs of alt treated sites for diagnostic purposes and to accurately document the medical record in the usual and customary manner. I agree that these photographs are the property of Koger Dermatology and my photographs can be used for teaching purposes, to illustrate scientific papers, books or for use in general lectures. It is specifically understood that in any such publication or use, I shall not be identified by name.

Consent — I voluntarily request treatment by Dr. O'Neal Koger, M.D. or Cheryl Jones MS, PA-C using Sculptra, which has been explained to me, and my questions regarding such treatment, its alternative, its complications and risk have been answered by the doctor, his staff, and' or written information. The Information provided Is clear to me and I understand the risks and complications of the treatments. My questions have been fully and completely answered and I have read this document and understand its contents. I hereby give my unrestricted informed consent for the procedure.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.