Microsoft word - blepharoplasty handouts.doc

SKIN & LASER SURGERY CENTER, P.C.
AMIR A. BAJOGHLI, M.D.
Fellow, American Academy of Dermatology Diplomate, American Board of Dermatology and Internal Medicine MOHS Micrographic Surgery • Laser Cutaneous Surgery Patient Name: _____________________________DOB: ______ _____ Date: ____________ BLEPHAROPLASTY CONSENT FORM
INSTRUCTIONS
The following consent form contains information to inform you regarding blepharosplasty surgery, as well as its
risks and alternative treatment.
Please carefully read each page and sign the consent for surgery, as proposed by your surgeon.
WHAT IS “BLEPHAROPLASTY”?
Blepharoplasty is a cosmetic surgical procedure performed to remove excess skin and muscle from both the
upper and lower eyelids, along with underlying fatty tissue. Blepharoplasty can help improve vision in older
patients who have hooding of their upper eyelids, thus improving drooping skin and sagging. For many Asian
patients lacking a crease in the eyelids; it can add an upper eyelid crease, however it will not erase evidence of
one’s racial or ethnic heritage. Blepharoplasty should not be used as a method to remove wrinkles as it will not
eliminate “crow’s feet” or other wrinkles surrounding the eyes, nor will it erase dark circles or lift drooping
eyebrows.
Blepharoplasty surgery is customized to fit every patient’s needs. This procedure can be performed alone,
involving the upper, lower, or both eyelid regions, or in conjunction with other surgical procedures of the eye, face,
brow, or nose. Although eyelid surgery cannot stop the aging process it can however, diminish the look of loose
and sagging skin in the eyelid region.
ALTERNATIVE TREAMENTS
Alternative approaches to surgery can help to manage the appearance of loose and/or sagging skin within the eye
region. Patients considering about to undergo Blepharoplasty should be aware that they will have a scar where
the incision is made. Other options such as a brow lift may help to treat the problem. Minor skin wrinkling may be
improved through chemical skin-peels or other skin treatments. However, there are risks and potential
complications associated with alternative treatments.
RISKS OF BLEPHAROPLASTY SURGERY
There are several risks involved when undergoing any type of surgery. Although the majority of patients do not
experience the following complications, you should discuss each of them with your surgeon, to make sure you
understand the risks, potential complications, and consequences of blepharoplasty surgery.
Bleeding- It is possible, though unusual, that you may have problems with bleeding during or after surgery.
Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or blood
transfusion. Hospitalization may be required, and hospital fees will be the patient’s responsibility. Do not take any
aspirin or anti-inflammatory medications for one week before surgery, as this contributes to a greater risk of
bleeding. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or
after surgery. Accumulations of blood under the skin may delay healing and cause scarring. Following making
your appointment for surgery, you will be mailed a list of medications to avoid at least one week before the
blepharoplasty procedure is performed.

Blindness- Blindness is extremely rare after this surgery. 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 unusual after this surgery. Should an infection occur, additional treatment, including
antibiotics or surgery, may be necessary. This risk is increased in smokers.
*Confidential Page
Initial ________
SKIN & LASER SURGERY CENTER, P.C.
AMIR A. BAJOGHLI, M.D.
Fellow, American Academy of Dermatology Diplomate, American Board of Dermatology and Internal Medicine MOHS Micrographic Surgery • Laser Cutaneous Surgery Patient Name: _____________________________DOB: ______ _____ Date: ____________
Scarring- You will have a scar. 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 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 asymmetrical. There can be a variation from one side
to the other following a blepharoplasty surgery.
Chronic Pain- Chronic pain may 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 eyelid surgery.
Ectrpion- Displacement of the lower eyelid away from the eyeball is a rare complication. Further surgery may be
required to correct this condition.
Corneal Exposure Problems- 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 treatments 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 a 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 of this is not predictable. Hair loss may be temporary or permanent.
Delayed Healing- Wound disruption or delayed wound healing is possible.
Smokers- Smokers have a greater risk of complications and wound-healing complications.
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 blepharoplasty.
*Confidential Page
Initial ________
SKIN & LASER SURGERY CENTER, P.C.
AMIR A. BAJOGHLI, M.D.
Fellow, American Academy of Dermatology Diplomate, American Board of Dermatology and Internal Medicine MOHS Micrographic Surgery • Laser Cutaneous Surgery Patient Name: _____________________________DOB: ______ _____ Date: ____________

Surgical Anesthesia- Both local and general anesthesia involves risk. There is the possibility of complications,
injury, and even death from all forms of surgical anesthesia or sedation.
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. If 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 or implied on the results that may be obtained.
Revision surgery or a touch-up procedure is occasionally required.
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 from the surgery. Secondary
surgery or hospital day-surgery charges involved with reversionary surgery would also be your responsibility.
MEDICATIONS TO AVOID PRIOR TO DERMATOLOGIC SURGERY

DO NOT TAKE ASPIRIN, “BABY ASPRIN” OR BLOOD-THINNING PRODUCTS FOR TWO (2)
WEEKS PRIOR TO YOUR SURGERY. THIS MUST BE DISCUSSED WITH YOUR DOCTOR
(INTERNIST OR PRIMARY CARE, OR CARDIOLOGIST, ETC) Some of these products include:
ASPRIN DARVON
“Baby” Aspirin
MULTIVITAMINS
VITAMIN E
VITAMIN C
MOTRIN SYNALGOS
DC GINKO BILOBA
*PLEASE DO NOT CONSUME ANY ALCOHOL BEVERAGES 3 DAYS PRIOR AND POST-SURGERY.
¾ You may take Tylenol, Acetaminophen, Datril, Darvocet or Darvon, Percocet if
needed for pain relief. If you have any questions regarding whether any medications you *Confidential Page
Initial ________
SKIN & LASER SURGERY CENTER, P.C.
AMIR A. BAJOGHLI, M.D.
Fellow, American Academy of Dermatology Diplomate, American Board of Dermatology and Internal Medicine MOHS Micrographic Surgery • Laser Cutaneous Surgery Patient Name: _____________________________DOB: ______ _____ Date: ____________ are taking are considered blood thinners or not, please call our office at (703) 492-4140 ext 23 Woodbridge or (703) 893-1114 Tyson’s Corner. ¾ If you are taking Coumadin (Warfarin), please check with you prescribing doctor to see if it is safe for you to stop Coumadin for your surgery. If so, please have your doctor give you instructions for when to stop and restart Coumadin. cannot stop Coumadin, please have your prescribing doctor’s office draw your
blood to check that your Coumadin level is in the correct range, and notify our office with your results. ¾ If you are on Lovenox or Fragmin (low Molecular Weight Heparin), please check with your doctor’s office to know if it is safe for you to discontinue the medication for your surgery. If so, please have your doctor give you instructions for when to stop and restart the medication. ¾ If you need to take antibiotics prior to dental or surgical procedures, please call our office at (703) 492-4140 Woodbridge or (703) 893-1114 Tyson’s Corner for a prescription and further instructions. Patient Instructions:
Two weeks prior to surgery, the patient should use either Sterilid Eyelid Cleanser (Thera Tears) or Ocu
Soft Lid Scrub. Use twice a day for two weeks prior to and after surgery.
The patient also needs to apply Erythromycin Opthalmic ointment twice a day to the upper eyelid (suture
area) one week prior to and after surgery.
In addition, the patient will also need to use Artificial Tears; two drops, three times a day for two weeks prior
to and after surgery. Natural Tears can also be used as a substitute.
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 patients in most circumstances.
However, informed consent documents should not be considered all-inclusive in defining other methods of care
and risks encountered. Your surgeon may provide you with additional 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 the facts involved in individual cases and are subject to change,
as science knowledge and technology advance, and as practice patterns evolve.
1.) For purposes of advancing medical education, I consent to the admittance of observers to the 2.) I consent to the disposal of any tissue, medical devise, or body parts which may be removed. 3.) I authorize the release of my social security number to appropriate agencies for legal reporting and medical device registration, if applicable. 4.) IT HAS BEEN EXPLAINE 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. *Confidential Page
Initial ________
SKIN & LASER SURGERY CENTER, P.C.
AMIR A. BAJOGHLI, M.D.
Fellow, American Academy of Dermatology Diplomate, American Board of Dermatology and Internal Medicine MOHS Micrographic Surgery • Laser Cutaneous Surgery Patient Name: _____________________________DOB: ______ _____ Date: ____________ I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-4). I AM SATISFIED WITH THE EXPLANATION. I understand that the success of the procedure is to a great extent dependant upon my closely following instructions. Post-operative care, activities, and precautions have been explained to me, and I understand them. I also consent to the administration of such anesthetics as may be considered necessary and advisable by the attending physicians and/or anesthetist. I am aware that risks are involved with anesthesia, such as allergic or toxic reactions and even cardiac or respiratory arrest. I also consent to have my photographs used for medical, educational, and scientific purposes. I have had sufficient opportunity to discuss this condition 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 delayed wound healing, smoking is not recommended for 1-3 weeks before and after surgery. Any contemplated weight loss is strongly recommended before surgery. I AM AWARE THAT THE PRACTICE OF MEDICINE IS NOT AN EXACT SCIENCE, AND I
ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME AS TO THE RESULTS OF THE
PROCEDURE.
I ACKNOWLEGE THAT I HAVE READ THE ABOVE AND ALL MY QUESTIONS HAVE BEEN ANSWERED
TO MY FULL SATISFACTION. I UNDERSTAND AND ACCEPT THE RISKS OF THESE AND OTHER
POSSIBLE COMPLICATIONS AND CONSEQUENCES ASSOCIATED WITH THIS OPERATION.
It is important that you read the above information carefully and have all of your questions answered
before signing the consent.
I, ___________________________, have read and understand the information above. My signature below indicates I have had the opportunity to ask questions and give informed consent to proceed with treatment. I agree to comply with the requirements placed on me by this consent form. I am aware of potential risks associated with treatment and wish to proceed. The following procedure __________________________ is quoted a fee of $________. This quote is valid for 30 days from the date of the provider’s agreement. I hereby give permission to Skin & Laser Surgery Center, P.C. to perform the procedure and agree to the quoted fee associated for this procedure. My form of payment will be _______________________ and I agree to make this payment after the services are rendered. ________________________________________ ________________________________________ *Confidential Page
Initial ________

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