With eyelid surgeries, as with any surgery, there are some unlikely problems that may arise, and I understand that they can happen even with the best medical care.  I understand and accept the possibility of the following complications or problems after my eyelid surgery. 

WHAT IS BLEPHAROPLASTY?
A blepharoplasty is the removal or repositioning of skin, muscle, and fat of the upper and/or lower lids. In the upper lid, the incision is made and hidden in the natural lid crease.  For the lower lid, an incision can be made through the skin just beneath the lashes, or through the moist inside surface if the lid called the conjunctiva.  Fat injections, laser resurfacing, or other procedures may be performed at the same time.

HOW WILL EYELID SURGERY AFFECT MY VISION OR APPEARANCE?
The results of blepharoplasty depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Blepharoplasty only corrects vision loss due to excess skin, muscle and fat that blocks the eye. By removing this excess skin, muscle, and fat that blocks the eye, blepharoplasty of the upper lids may allow more light in and improve your peripheral vision.  Blepharoplasty does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye.

Because excess skin, muscle, and fat are consequences of aging, most patients feel that blepharoplasty improves their appearance and makes them feel more youthful. Some patients, however, have unrealistic expectations about how changes in appearance will impact their lives. Others may have difficulty adjusting to changes to their appearance. Carefully evaluate your goals and your ability to deal with changes to your appearance before agreeing to this surgery.

WHAT ARE THE MAJOR RISKS?

Risks of blepharoplasty include but are not limited to the following: 

Bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), drooping of the upper eyelids, pulling down of the lower eyelids, eyelid cysts, residual fat pockets, double vision, tearing or dry eye problems, inability to wear contact lenses, 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 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 aging, extra skin, lax muscle, and bulging fat around your eyes and decide not to have surgery on your lids at this time.  In some cases using lasers, chemical peels, botulinum toxin, and/or injectable fillers can improve your appearance without surgery.

WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Most blepharoplasties are done with “local” anesthesia, that is, injections around the eye to numb the area.  You may also receive sedation from a needle placed into a vein in your arm or pills taken before surgery.  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 have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur.

I will allow my physician to perform any additional procedures or interventions deemed necessary during surgery to maximize safety or outcome, including those that were not discussed prior.  

My physician has told me that results cannot be guaranteed, that adjustments and more surgery may be necessary, and that there are additional costs associated with more treatment.

By signing below, I agree that my physician has answered all of my questions, that I understand and accept the risks, benefits, and alternatives of blepharoplasty, and the costs associated with this surgery and future treatment, and that I feel I will be able to accept changes in my appearance.

I understand that I must tell Dr. Kotlus and associates if I have had any previous eye or eyelid surgery or problems.

I will report a change in my vision to Dr. Kotlus and associates immediately. 

I am responsible for my follow-up appointment. 

I have received, read, and reviewed the “Blepharoplasty Instructions and Care Sheet”.

The goal of fat grafting in every case is to either aesthetically add or restore lost or deficient soft tissue volume in the face or body. In some reconstructive procedures, the additional goal of fat grafting is to improve tissue quality and help prevent future wound healing problems.

There are alternatives to fat grafting and they change based on the reason and the face or body site that needs more volume or contour. They could include synthetic injectable fillers, biologic injectable fillers and synthetic implants.

The limitations of fat grafting are based on several factors including the size and availability of fat from the donor site, how much volume the recipient site can take and, most importantly, how much fat survives after transplantation.

Expected outcomes include the following: temporary swelling and bruising from the donor and recipient sites, temporary skin numbness from the donor and recipient sites, and months of healing and fat graft settling until the final result is seen in terms of permanent volume and contour. Healing of any fat grafting procedure is a process and the minimal amount of time to judge the result is three months and may take as long as six months to see the final retained volume and shape of the grafted face or body site(s).

RISKS

Significant complications from fat grafting are very rare but could include infection. More likely occurrences could include small nick-type scars from the harvest and injection of concentrated fat aspirates and a longer scar for the harvest and insertion of solid dermal-fat grafts. Additional risks include partial or complete loss of the fat graft, irregularities and asymmetries of the harvested and grafted areas, overcorrection vs. undercorrection of the treated areas and the unpredictability of fat grafting volume retention. While estimates are provided for percent of fat grafting survival based on Dr. Kotlus’ experience, no guarantee can ever be made on how much fat will survive in any one patient. Any of these risks may require revisional surgery for improvement.

Should additional surgery be required to do additional fat grafting, perform contour adjustments or revise any harvest or graft insertion scars, these may generate additional costs.

I have had sufficient opportunity to discuss this condition, my past medical and social history, and treatment with the doctor and/or his associates, and all my questions have been answered to my satisfaction. I believe that I have adequate knowledge upon which to give an informed consent to the proposed treatment.

NOTE: Since smokers have a higher rate of respiratory complications and problematic wound healing, smoking is not permitted for 3 weeks before and 3 weeks after surgery. If I continue to smoke, I know it will increase the likelihood of a complication.

I ACKNOWLEDGE THAT NO GUARANTEES, EXPRESSED OR WRITTEN, HAVE BEEN MADE TO ME AS TO THE RESULTS OF THIS PROCEDURE. I ALSO ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY FULLEST SATISFACTION. I UNDERSTAND AND ACCEPT THE RISKS OF THESE AND OTHER POSSIBLE COMPLICATIONS AND CONSEQUENCES ASSOCIATED WITH THIS PROCEDURE. I HEREBY GIVE MY CONSENT TO PERFORM THIS PROCEDURE.     

In case of an accidental exposure to my blood, I consent to have blood drawn and tested for infectious diseases such as Hepatitis and HIV. Confidential test results will not be disclosed without my written consent except as required by law.

The goal of laser/chemical skin rejuvenation is to reduce or partially eliminate facial wrinkles, discoloration or reduce scarring from skin conditions such as acne. Generally, the results of laser/chemical skin rejuvenation demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.  As with all cosmetic procedures, there are benefits, limitations, and downsides.

Alternatives to Skin Resurfacing:

The alternatives to skin rejuvenation include non-ablative laser skin resurfacing, dermabrasion, deeper chemical peels, radiofrequency, plasma, and topical medications. The advantages and disadvantages (risks and benefits) of each of these alternatives to skin rejuvenation have been explained to me as well as the alternative of having no procedure, accepting my present skin condition, using cosmetics and considering other methods of skin rejuvenation.  Another thing I can do is leave everything alone, and take no risk, no downtime, no discomfort, and no change of my skin.

Possible Intra-operative Complications of Chemical/Laser Skin Resurfacing Surgery:

Blindness/Corneal Burns  - There is a risk of accidental eye injury which could cause blindness or burns of the eyeball. This is unlikely.

Flash Fires  - Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.

Possible Effects of Chemical/Laser Skin Resurfacing Surgery:

Pain - Discomfort, burning sensation or pain the first few days after surgery. A local anesthetic is usually used to block pain during the treatment, but some degree of discomfort will occur after the anesthetic effects have worn off and this pain may persist for several days.

Redness of Skin  - Erythema or redness of the skin for a two- to six-month period or possibly longer.

Swelling - Temporary edema (swelling) or ecchymosis (bruising) of the tissue of the face and neck, usually subsiding in three to seven days.

Wound Healing - Oozing, weeping, crusting and flakiness of the treated area, usually persisting for one to four weeks.

Skin Thickening - Textural changes of the treated skin, such as skin thickening, which may persist for a variable time following the skin resurfacing treatment.

Cysts - Milia or cysts, especially in the eyelid skin region (if the eyelid skin is included in the area of treatment), particularly if ointments were used in the postoperative phase for a protracted period.

Skin Tightness - Sensation of skin tightness (peaks at 3-8 weeks postoperatively).

Contact Dermatitis - Contact dermatitis due secondarily to topical preparations (ointments) used post- operatively.

Herpes Simplex Dermatitis (Fever Blisters) - Occurrence or recurrence of herpes simplex dermatitis, particularly if not pre-, intra- and post-operatively treated with a systemic antiviral medication such as Acyclovir/Valtrex.  Even with pre-treatment, infections can still occur, and can cause scarring.

Skin Itchiness - Pruritis or itching in the early healing phase.

Skin Hyperpigmentation - Transient (or rarely permanent) hyperpigmentation (darkening of the skin), especially in darker- skinned people, occurring three to eight weeks after laser therapy.

Cellulitis or Skin Infections  - Cellulitis or infection of the skin and soft tissues, especially if careful post-operative hygiene is not practiced.  This can occur from bacteria, fungus, or as mentioned above, virus.  These can lead to delayed healing, or poor healing.

Skin Hypopigmentation  - Hypopigmentation (lightening of the skin), which occurs because of injury to the melanocytes (pigment containing cells in the skin) and which can be permanent.  If a local area is treated, it is more apparent, as the resurfaced skin will appear clearer than the sun damaged skin

Increased susceptibility to sun - Because of the permanent thinning of the epidermis and dermis and reduction in the number of melanocytes (pigment cells in the skin), there is probably a lifelong risk of greater susceptibility skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.

The risk of scarring exists in all cases. It is variable and is often related to an individual's genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.

Skin Pigment Changes - Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.

Ectropion - Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.

 

I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.

I understand this is an elective procedure and that chemical/laser skin resurfacing surgery is not reversible.

I also understand that more than one resurfacing procedure may be required to achieve the optimal obtain- able results.

I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of chemical/laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after skin resurfacing surgery.

My surgeon has explained chemical and laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the skin resurfacing surgical procedure. I therefore consent to having skin resurfacing surgery.

Cosmetic Surgery - A $1000.00 scheduling deposit is required to secure a surgery date. This deposit will be applied to your surgical fees unless the surgery is cancelled or rescheduled within 10 business days of the scheduled surgery date. The remaining balance is due prior to your surgery.  You are responsible for x-ray, laboratory, pathology, and medication fees if necessary.  Cosmetic surgery procedures are not covered under health insurance.

Revisions are occasionally necessary in cosmetic surgery and will be performed within one year of surgery with no separate surgeon fee at the doctor’s discretion. However, facility and anesthesia fees will apply for revision procedures.

I have read and understand the above Financial Policy. I have had the opportunity to address questions about this Policy, and all my questions have been answered to my satisfaction. I agree to be bound by the terms of this Policy.

 

I authorize Dr. Brett Kotlus, and/or his representative(s), to take photographs or film/video of me or parts of my body for the for medical purposes and to be used for my care, medical presentations and/or articles.

In addition, I authorize the use of these images, without compensation to me, for the following specific purposes: (Please check the boxes marked Yes or No for each item)

I have been informed by Brett Kotlus, M.D. and his staff, that the risks of all aspects of surgery are significantly increased in patients who smoke or have been a smoker. I understand that it is recommended to discontinue smoking for a minimum of three weeks prior and three weeks following surgery. Despite such precautions, there are still additional risks such as infection, scarring, bleeding and tissue loss in patients with a smoking history. I recognize and accept these additional risks as well as any other treatment or procedures that may be required.

I have read this informed consent and certify that I understand its contents in full.  I have had enough time to consider the information from my physician and feel that I have had enough time to consider the information from my physician and feel that I am sufficiently advised to consent to this procedure.  I hereby give my consent to this procedure and I have been asked to sign this form after my discussion with the physician.  I agree to have my photos taken for record keeping, comparison and research purposes.