Facial Bone Repair Consent Form

Please click on this link to download a copy of the facial bone repair consent form.

INFORMED CONSENT FOR FACIAL FRACTURE REPAIR

(“Facial bone repair”)

WHY MIGHT I NEED REPAIR OF THE BROKEN BONES IN MY FACE?

The bones of the face are the framework that all of the skin, muscles and other soft tissue rest on. If the bones are broken and displaced (moved from their normal position), problems can arise. Some patients will develop permanent double vision after a fracture that is not repaired. If the fracture is large enough, some will develop a sunken eye appearance with the broken eye looking smaller. Many patients will get numbness in the lower lid and cheek after a fracture but this usually gets better even without surgery. A flattened facial appearance and chewing problems can also result from facial bone fractures

HOW IS THE FACIAL BONE REPAIR DONE?

Repair of broken bones in the face is usually done in an operating room with the patient under general anesthesia (completely asleep). Your doctor will NOT remove the eyeball or peel your face off!! Small incisions are used to get to the fractures – often inside the mouth or inside the eyelid. Delicate instruments are used to move the eye and soft tissues to one side and allow your doctor to see and repair the fracture. Usually, thin flat implants are placed over the fracture and screwed into position to repair the break. These may be permanent or they may be dissolvable. Some implants have titanium in them, some are plastic and some are made of other material. Your doctor will choose the type that he feels is best for your type of fracture.

HOW WILL FACIAL FRACTURE SURGERY AFFECT MY VISION OR APPEARANCE?

The results of facial fracture repair surgery depend upon each patient’s severity and location of trauma (which bones are broken), symptoms, unique anatomy and appearance goals. Facial fracture surgery is not considered cosmetic surgery but most patients feel that they look better after they have healed. Facial fracture surgery does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological trauma behind the eye and does not repair paralyzed nerves. This surgery cannot repair all problems associated with trauma to the face.

It is important to note that some patients have unrealistic expectations about how facial fracture surgery will impact their lives. Carefully evaluate your goals and your ability to deal with changes to your appearance before agreeing to this surgery. Understand the risks and ask questions of your doctor.

WHAT ARE THE MAJOR RISKS?

Risks of facial fracture surgery include but are not limited to: bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), double vision, numbness and/or tingling near the eye or on the face, and, in rare cases, loss of vision. You may need additional treatment or surgery to treat these complications; the cost of the additional treatment or surgery is NOT included in the fee for this surgery. Due to individual differences in anatomy, response to surgery, and wound healing, no guarantees can be made as to your final result. For some patients, changes in appearance may lead to anger, anxiety, depression, or other emotional reactions.

WHAT ARE THE ALTERNATIVES?

You may be willing to live with the symptoms and appearance of flattened face, double vision or sunken eye and decide not to have surgery on your facial fractures at this time. In some cases the double vision may be improved with glasses or eye muscle surgery. Cosmetic work with implants and fillers may help the appearance at a later date.

WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?

Most facial fracture surgeries are done with general anesthesia with the patient completely asleep. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.

PATIENT’S ACCEPTANCE OF RISKS

I understand that it is impossible for my doctor to inform me of every possible complication that may occur with facial fracture repair.
My doctor has told me that results cannot be guaranteed, that adjustments and more surgery may be necessary, and that there may be additional costs associated with more treatment.
By signing below, I agree that my doctor has answered all of my questions. I understand the risks, benefits, and alternatives of facial fracture repair, and the costs associated with this surgery and future treatment, and that I feel I will be able to accept the risks involved.

I have been offered a copy of this document.

I consent to facial fracture repair surgery on:

Right ___________Left___________ side(s)

Other: _________________________________________________

_______________________________________ _______________

Patient (or person authorized to sign for patient) Date

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