INFORMED-CONSENT for BLEPHAROPLASTY (COSMETIC EYELID) SURGERY
This document contains information about blepharoplasty (cosmetic eyelid) surgery. Risks and alternative treatments are described. Please read each paragraph completely. If you have questions, need further explanation, or see words you don’t know, ask Dr. Laverson. Your signature below confirms your understanding of this information and your desire for cosmetic eyelid surgery.
Blepharoplasty is a surgical procedure to create more youthful appearing features. Techniques involved usually (but not always) include removal of excess skin and rearrangement of muscle and/or fat of both the upper and lower eyelids. Underlying fat that produces an aging or tired appearance may be selectively removed or repositioned. 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 may only partially correct “crow’s feet” or other wrinkles, and may only partially eliminate dark circles under the eyes. The operation does not lift sagging eyebrows.
Blepharoplasty surgery is customized for every patient, depending on his or her particular needs. It can be performed alone involving upper, lower or both eyelid regions, or in conjunction with other surgical procedures of the eye, face, brow, or nose. In some patients, who have looseness between the lower eyelid and the eyeball, consideration for tightening of the lower eyelid (canthoplasty/canthopexy) at the time of blepharoplasty may be recommended. Eyelid surgery cannot stop the process of aging. It can however, diminish the look of loose skin and bagginess in the eyelid region.
An alternative form of management is no surgery at all. Improvement of skin laxness, fat bulges, and skin wrinkles may be accomplished by other treatments or surgery such as a brow lift, Botox®, laser, and chemical peel or tretinoin. 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. Botox® and laser treatment are other common procedures to improve the appearance of adult eyelids.
RISKS of BLEPHAROPLASTY SURGERY
Every surgical procedure involves risk. It is important to understand the risks involved. Your choice of surgical procedure depends on a comparison of expected beneftit to known risks. Although most patints experience no complications, the following adverse outcomes and events have been associated with blepharoplasty (eyelid) 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 post-operative 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. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding. 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. Nerve injury can cause numbness of the forehead or inability to close the eyes. These problems usually improve with time, but may never completely resolve.
Dry eye 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 asymmetric (Right and left sides not perfectly identical). There can be a variation from one side to the other following blepharoplasty surgery.
Chronic pain– Chronic pain may occur very infrequently after blepharoplasty.
Skin disorders/skin cancer– Skin disorders and skin cancer may occur independently of eyelid surgery.
Corneal exposure problems– Some patients experience difficulties closing their eyelids after surgery and problems may occur in the cornea due to dryness. This problem is most often temporary, but may be permanent. Should this complication occur, additional treatments or surgery and treatment may be necessary.
Unsatisfactory result– You may be disappointed with the results of eyelid surgery. Surgery may result in unacceptable visible deformities, loss of function, wound disruption, and loss of sensation. You may have dry eyes, irritated eyes, difficulty closing or opening the eyes, change in shape of the eyes, asymmetry between right and left sides, and/or other problems. Sometimes, it is necessary to perform a secondary (revision) surgery to correct problems and/or improve your results. Additional plastic surgery procedures such as a browlift may be needed to correct eyebrow sagging which contributes to upper eyelid problems.
Ectropion/Eyelid malposition– Displacement of the lower eyelid away from the eyeball is a rare complication. Further surgery may be required to correct this condition.
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 of this 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.
If skin covering the upper eyelids impairs your vision, health insurance sometimes covers blepharoplasty surgery for the upper eyelids only. Health insurance excludes cosmetic surgery such as lower eyelid blepharoplasty, and complications that may result from surgery. For further information, review your health insurance subscriber contract.
ADDITIONAL SURGERY NECESSARY
Many conditions and possible surgical complications influence the long term result of eyelid surgery. Although complications occur infrequently, the above risks are particularly associated with blepharoplasty surgery. Other problems may occur but are less common. If complications develop, additional surgery or other treatments may be indicated. Medicine and surgery are not exact sciences. Good results are expected, but there is no guarantee or warranty of any particular result.
The cost of surgery involves charges for several services provided. The total includes federal, state, and local taxes, licensing, regulatory mandates, fees charged by Dr. Laverson, the anesthesiologist, the surgery center, and any devices, implants, or specialized equipment needed for the procedure. You are responsible for the total cost. If complications develop, additional unforeseen expenses may be incurred. You may be responsible for these as well. In the unfortunate (and unlikely) event this happens, Dr. Laverson tries to minimize additional expenses, but this cannot be predicted in advance.
Please understand the above information before signing the consent below.
CONSENT FOR BLEPHAROPLASTY (COSMETIC EYELID SURGERY)
1. Dr. Steve Laverson and assistant(s) are requested and authorized to perform EYELID SURGERY / BLEPHAROPLASTY upon me. I have read and understand the above information about blepharoplasty (cosmetic eyelid surgery), and my questions have been answered.
2. Although truly rare, during the course of the operation, unforeseen conditions may necessitate different and/or additional procedures. Dr. Laverson is authorized to perform such procedures that are in his professional judgment necessary, desirable, and in my own best interest. The authority granted under this paragraph shall include conditions that require treatment and are not known to Dr. Laverson at the commencement of surgery.
3. I consent to the administration of anesthetics considered necessary or advisable. Anesthesia involves a small risk and the possibility of complications, injury, and rarely death.
4. NO GUARANTEE has been expressed or implied by anyone about the results of surgery.
5. I consent to the disposal of any tissue, medical devices or body parts which may be removed.
6. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. COSMETIC EYELID SURGERY (BLEPHAROPLASTY)
b. THERE ARE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. THERE ARE RISKS ASSOCIATED WITH BLEPHAROPLASTY
I CONSENT TO COSMETIC EYELID SURGERY AND THE ABOVE LISTED ITEMS (1-6).
I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient