Sclerotherapy Procedure Consent
Sclerotherapy is used to treat spider veins (purple, red) and reticular veins (blue, green) of the lower legs. The procedure may require multiple sequential treatments.
We use Polidocenol (Asclera) in a foam or liquid mixture. No anesthesia or allergy testing is needed prior to treatment.
Following your treatment, you may experience pain, swelling, and redness for the first several days. You must wear compression hose for 7-10 days after the procedure.
Risks of this procedure include, but are not limited to, the following:
Pain – Some people may feel some pain with this treatment, similar to a “bee sting”. Stinging or slight pain may be present after the procedure and throughout the healing process.
Redness – There may be surrounding redness of the area. The redness may be present for days.
Swelling – Swelling will be present after the procedure and should likely resolve after 1-2 days.
Itching – You may experience mild itching along the vein route. This itching normally lasts 1 to 2 hours but may persist for a day of so.
Transient Hyperpigmentation – Approximately 10% of patients who undergo sclerotherapy notice discoloration (light brown streaks) after) after treatment. In almost every patient the veins become darker immediately after the procedure. In rare instance this darkening of the vein persists for 4 to 12 months.
Sloughing – Sloughing occurs in less than 1% of the patients who receive sclerotherapy. Sloughing consists of a small ulceration at the injection site that heals slowly over 1 to 2 months. A blister may form, open, and become ulcerated. The scar that follows should return to a normal color. This occurrence usually represents injection into or near a small artery and is not preventable.
Allergic reactions – Very rarely a patient may an allergic reaction to the sclerosing agent used. The risk of an allergic reaction is greater in patients who have a history of allergies.
Scarring – There is a risk of scarring with this procedure at any time during the healing process. The scarring may be discolored and may be permanent.
Bleeding / Bruising – You may get some pinpoint bleeding which will probably stop within a few minutes without any lasting effect. The bleeding may result in bruising of the skin. The immediate bleeding / bruising will darken to purple and purple-yellow and will disappear in one to two weeks.
Ulceration – Sclerotherapy may result in ulceration or sore formation. A scab will form and should resolve in 1-2 weeks. Scarring or discoloration may result from any blister formation.
Scabbing – A scab may be present after a ulceration forms. The scabbing will disappear during the natural wound healing process of the skin. Scarring or discoloration may result from any scab formation.
Infection – An infection of the wound is always possible. Any blistering or bleeding must be dressed with an antibiotic ointment and covered. Any infection could last seven to ten days and could lead to scarring.
Telangiectatic matting – This refers to the development of new tiny blood vessels in the treated vessel. This temporary phenomenon occurs 2 to 4 weeks after treatment and usually resolves within 4 to 6 months. If occurs in up to 18% of women receiving estrogen therapy and in 2% to 4% of all patients.
Ankle swelling – Ankle swelling may occur after treatment of blood vessels in the foot or ankle. If usually resolves in a few days and is lessened by wearing the prescribed support stockings.
Phlebitis – Phlebitis is a rare complication, seen in approximately 1 out of every 1000 patients treated for varicose veins greater than 3 to 4 mm in diameter. The possible dangers of phlebitis include the possibility of a pulmonary embolus (a blood clot to the lungs) and post phlebitis syndrome, in which the blood clot is not carried out of the legs, resulting in permanent swelling of the legs.
Failure to Achieve Desired Results – It is very possible that this procedure may fail to achieve your desired results. Strict adherence to the pre-op and post-op instructions is essential. You may need to repeat your treatments to achieve the desired results.
I, the undersigned, have read and understand the information contained within this consent form. My signature indicates that I have read and understand the information in the consent. I hereby release the dermatology office and my physician from all liability associated with this procedure. Furthermore, my signature below indicates my consent to the treatment described and my agreement to comply with the requirements placed on me by this consent form.
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