INFORMED-CONSENT for BLEPHAROPLASTY SURGERY
INSTRUCTIONS
This is an informed-consent document which has been prepared to help your surgeon inform you about blepharoplasty surgery, its risks, and alternative treatments. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your surgeon.
INTRODUCTION
Blepharoplasty is a surgical procedure to remove excess skin and muscle from both the upper and lower eyelids along with underlying fatty tissue. Blepharoplasty can improve drooping skin and bagginess. It can help improve vision in older patients who have hooding of their upper eyelids. Although it can add an upper eyelid crease to the Asian eyelid, it will not erase evidence of one’s racial or ethnic heritage. Blepharoplasty will not remove “crow’s feet or other wrinkles, eliminate dark circles under the eyes, or lift sagging eyebrows.
ALTERNATIVE TREATMENTS
Alternative forms of management include not treating the skin laxness and bagginess in the eyelids by surgery. Improvement of skin laxness, fatty deposits and skin wrinkles may be accomplished by other treatments or surgery such as a brow lift when indicated. Other forms of eyelid surgery may be needed should you have disorders affecting the function of the eyelid such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eyeball (ectropion). Minor skin wrinkling may be improved through chemical skin-peels or other skin treatments. Risks and potential complications are associated with alternative forms of treatment.
RISKS OF BLEPHAROPLASTY SURGERY
Every surgical procedure involves a certain amount of risk. It is important that you understand the risks involved. An individual’s choice to undergo surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your plastic surgeon to make sure you understand the risks, potential complications and consequences of blepharoplasty surgery.
Bleeding – It is possible, though unusual, to have a bleeding episode during or after surgery.Bleeding may occur under the skin or internally around the eyeball. Should you develop postoperative bleeding, it may require emergency treatment or surgery. Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this may contribute to a greater risk of a bleeding problem. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the eyelids may delay healing and cause scarring.
Blindness – Blindness is extremely rare after blepharoplasty. However, it can be caused by internal bleeding around the eye during or after surgery. The occurrence of this is not predictable.
Infection –Infection is very rare after surgery. Should an infection occur, additional treatment including antibiotics may be necessary.
Scarring – Although good wound healing after a surgical procedure is expected, abnormal scars may occur both within the eyelid and deeper tissues. In rare cases, abnormal scars may result.
Scars may be unattractive and of a different color than surrounding skin. There is the possibility of visible marks in the eyelid or small skin cysts from sutures. Additional treatments may be needed to treat scarring.
Damage to deeper structures – Deeper structures such as nerves, blood vessels, and eye muscles may be damaged during the course of surgery. The potential for this to occur varies with the type of blepharoplasty procedure performed. Injury to deeper structures may be temporary or
permanent.
Dry eve problems – Permanent disorders involving decreased tear production can occur after blepharoplasty. The occurrence of this is rare and not entirely predictable. Individuals who normally have dry eyes may be advised to use special caution in considering blepharoplasty
surgery.
Asymmetry – The human face and eyelid region is normally asymmetrical. There can be a variation from one side to the other following a blepharoplasty surgery.
Chronic pain – Chronic painmay occur very infrequently after blepharoplasty.
Skin disorders/skin cancer – A blepharoplasty is a surgical procedure to tighten the loose skin and deeper structures of the eyelid. Skin disorders and skin cancer may occur independently of eyelid surgery.
Ectropion – Displacement of the lower eyelid away from the eyeball is a rare complication. Further surgery may be required to correct this condition.
Corneal exposure problem – Some patients experience difficulties closing their eyelids after surgery and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments or surgery and treatment may be necessary.
Unsatisfactory result – There is the possibility of a poor result from eyelid surgery. Surgery may result in unacceptable visible deformities, loss of function, wound disruption, and loss of sensation.You may be disappointed with the results of surgery. Infrequently, it is necessary to perform additional surgery to improve your results. Additional surgical procedures such as brow-lift may be needed to correct eyebrow sagging which contributes to upper eyelid problems.
Allergic reactions – In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions which are more serious may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment. Eyelash hair loss – Hair loss may occur in the lower eyelash area where the skin was elevated during surgery. The occurrence is not predictable. Hair loss may be temporary or permanent.
Delayed healing – Wound disruption or delayed wound healing is possible.
Long term effects – Subsequent alterations in eyelid appearance may occur as the result of aging, weight loss or gain, sun exposure, or other circumstances not related to eyelid surgery.
Blepharoplasty surgery does not arrest the aging process or produce permanent tightening of the eyelid region. Future surgery or other treatments may be necessary to maintain the results of a blepharoplasty.
Surgical anesthesia – Both local and general anesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation.
HEALTH INSURANCE
If Hooding of the upper eyelids interfere with your vision, your health insurance company may cover blepharoplasty surgery for the upper-eyelids only. Most health insurance companies exclude coverage of cosmetic surgical operations such as the lower-eyelid blepharoplasty or any complications that might occur from surgery. Please carefully review your health insurance subscriber information pamphlet.
ADDITIONAL SURGERY NECESSARY
There are many variable conditions in addition to risk and potential surgical complications that may influence the long term result of eyelid surgery. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with blepharoplasty surgery. Other complications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed implied, on the results that may be obtained.
FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles and charges not covered. Additional costs may occur should complications develop form the surgery. Secondary surgery or hospital day-surgery charges involved with revisionary surgery would also be your responsibility.
DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most circumstances.
However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your plastic surgeon may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page.
CONSENT FOR SURGERY/ PROCEDURE OR TREATMENT
1.I hereby authorize_________________________ to perform the following procedure or treatment and such assistants as may be selected.
2.I have received the following information sheet:
INFORMED-CONSENT for BLEPHARO PLASTY SURGERY
I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those
above.
I therefore authorize the above physician assistants or designs to perform such other procedures that are in the exercise of his or her professional judgment necessary
and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician all the time the procedure is
begun.
I consent to the administration of such anesthetics considered necessary or advisable. 1
understand that all forms of anesthesia involves risk and the possibility of complications, injury, and sometimes death.
I acknowledge that no guarantee has been given by anyone as to the results that may
be obtained.
I consent to the photographing or televising of the operation(s) or procedure(s) to be
performed,including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.
For purposes of advancing medical education, I consent to the admittance of observers to
the operating room.
I consent to the disposal of any tissue, medical devices or body parts which may be
removed.
I authorize the release of my Social Security number to appropriate agencies for legal
reporting and medical-device registration, if applicable.
IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
A. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
B THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF
TREATMENT
C. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1 – 9).
I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patent
Date____________________
Witness__________________________________________________
Patient:___________________________________________________
David I.Malitz, M.D.
TO PATIENTS INSURANCE COVERAGE, FEES, AND POLICIES:
The information you are provided with applies to Eye Institute ONLY. We are not providing you with any of the policies and procedures that are in effect at the Surgery Center (which is a separate facility).The Surgery Center’s staff will be able to answer all of your questions in reference to insurance coverage, surgical facilities, and policies.
Print Patients Name: __________________________________________
Signed:____________________________ Date:______________
Witness: ____________________________ Date: _____________