Skin Revision Treatment Consent Form Printable version(click here)
Electrocautery (Electrocoagulation), also known as Radio Frequency Diathermy, is a procedure where a fine wire probe is used to transmit radio waves to tissues near the probe. Molecules within the tissue are caused to vibrate, which leads to a rapid increase in temperature, leading to coagulation of proteins, vessels, and broken capillaries within the tissue. This process results in disappearance of unwanted skin growths. Same as for moles and skin tags, the current causes cauterization to the root by cutting off blood supply, effectively killing and destroying the abnormal growth without damaging the surrounding tissues.
Although rare, the following may occur with treatment:
1. Microscarring: The RF system can create a bruise and/or a moderate burn or blister to the skin. For an effective treatment, the RF energy needs to be just below the blistering point which means skin will be red.
2. Hyperpigmentation (browning) and Hypo‐pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 1 to 3 months in some rare cases. Permanent color change is also a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial in reducing the risk of color change.
3. Infection: Although infection following RF treatment is unusual, bacterial, fungal, and viral infections can occur if the area is picked or not kept clean. Herpes simplex virus infections around the mouth can occur following a RF treatment. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. If you have
a history of herpes simplex virus in the treated area we recommend preventative therapy.
4. Bleeding: Pinpoint bleeding is rare but can occur following RF treatment procedures. Should bleeding occur, additional treatment might be necessary.
5. Skin tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Only clearly benign pigmented lesions can be treated. Check with your dermatologist for clearance for the treatment if the lesion has changed in color, size, extremely elevated or is painful to the touch.
6. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported.
Until the thin scabs fall off:
• keep scab as dry as possible, to keep it clean use rubber alcohol twice a day , use Polysporin if there is a redness around treated areas, do not try to remove scab before it will come off naturally .
• do not apply heavy makeup for at least 24 hours as it will disturb the treatment sites.
• no tanning one week AFTER treatment, no sauna , swimming pool or hot tub for 2 weeks.
Wear sunscreen of at least SPF 25 before and after treatment to protect your skin. After the scab falls off you can use “Mederma”cream to help skin to recover faster.
To speed up the cells turn over process Microdermabrasion is recommended one month later. It should be performed once a week at low intensity and go over the spot a few passes.
Compliance with the aftercare guidelines is crucial for healing, prevention of scaring, hyper‐pigmentation and hypo‐pigmentation. Patient may need to return to the office in 10 days for the RF operator to observe the treatment.
Informed Consent and Waiver of Liability
I,______________________________________ hereby authorize and direct Irina Kouzmina of Iris Beauty Solution to perform the procedure of Electrocautery (Electrocoagulation ) treatment (skin irregularity removal) of the following areas: ______________________________________________________________________________
I understand that the skin treated may be red and swollen with fine, thin scabs forming and I have to keep the treated areas covered with Polysporin until the thin scabs fall off. This process should 1 to 3 weeks, but can take as long as 1 to 3 months in some rare cases. I must not scratch the scabs, as this can cause scarring and prolong the healing time. I am not taking Accutane and did not take Accutane for at least 6 months prior to resuming treatment. I understand that I may need multiple treatments for the desired outcome and full healing process and recovery of skin color can take from 4 month to 1 year in some cases.
_______I understand that this treatment is not recommended for diabetics or for people with high blood pressure. I am not diabetic nor do I have high blood pressure.
_______If you have a pacemaker, are pregnant or have a baby within 6 month you are not a candidate for this treatment.
_______I certify that I have no history of shingles or cold sores (herpes virus infections). If Yes, I shall see my physician for preventative treatment before receiving Electrocoagulation treatment.
_______I was explained all aspects of treatment, complications, post care and understand them.
_______I certify that my skin lesion (mole, skin tag, pigmented spot, ect) had been evaluated by a physician or dermatologist and it is benign and I accept all responsibility for the decision to have cosmetic removal done.
_______I understand that taking Before and After pictures is a condition of such procedures. I hereby forever release and discharge Iris Beauty Solution from any and all claims, action and demands arising out of use of said photographs for website.
I shall not hold Iris Beauty Solution, its employees, or owners liable, nor shall place responsibility on Iris Beauty Solution should Electrocautery treatment cause me any unexpected problems. I am aware that I am accepting this treatment at my own risk and that Iris Beauty Solution shall be released of all responsibilities and liabilities should Electrocautery treatment cause any adverse effect.