Blepharoplasty Consent Form
This is a plain-language consent form for Blepharoplasty. Please review it and revise as needed for your practice and patient population.
Blepharoplasty Consent Form
As you age, the skin and muscles of your eyelids and eyebrows may sag and droop. You may get a lump in the eyelid due to normal fat around your eye that begins to show under the skin. These changes can lead to other problems. For example:
- Excess skin on your upper eyelid can block your central vision (what you see in the middle when you look straight ahead) and your peripheral vision (what you see on the sides when you look straight ahead). Your forehead might get tired from trying to keep your eyelids open. The skin on your upper eyelid may get irritated.
- Loose skin and fat in the lower lid can create “bags” under the eyes that are accentuated by drooping of your cheeks with age. Many people think these bags look unattractive and make them seem older or chronically tired.
Upper or Lower Blepharoplasty (eyelid surgery) can help correct these problems. Patients often refer to this surgery as an “eyelid tuck” or “eyelid lift.” Please know that the eyelid itself may not be lifted during this type of surgery, but instead the heaviness of the upper eyelids and/or puffiness of the lower eyelids are usually improved.
Ophthalmologists (eye surgeons) call this surgery “blepharoplasty.” The ophthalmologist may remove or change the position of skin, muscle, and fat. Surgery may be on your upper eyelid, lower eyelid, or both eyelids. The ophthalmologist will put sutures (stitches) in your eyelid to close the incision (cut).
- For the upper lid, the doctor makes an incision in your eyelid’s natural crease.
- For the lower lid, the doctor makes an incision either through the skin just below your lashes, or in the conjunctiva (moist inside surface of your lid) where you can’t see it.
There are several options for anesthesia to make you comfortable during surgery. Blepharoplasty is sometimes done with just local anesthesia (medicine injected around your eye to numb the area). You may also be sedated (relaxed or put to sleep) by medicine from a needle in your arm or pills taken before surgery. Less commonly, or if eyelid surgery is combined with other surgery, you may be given a deeper type of anesthesia that makes you unconscious for the surgery (general anesthesia). Your ophthalmologist will discuss which type of anesthesia seems right for you, and an anesthesia specialist may be involved.
Many people find that blepharoplasty helps correct their eyelid problems. But how much it helps depends on factors that include your symptoms, eyelid structure, appearance, goals, and ability to adapt to changes. Here are some common ways that blepharoplasty can help:
- Improved peripheral vision (to the sides) and when looking up. You may be able to relax your forehead since you will not rely as much on those muscles to keep your eyes open.
- Many people with bags under their eyes feel that blepharoplasty of the lower eyelid improves how they look and makes them feel younger or less tired. But this is cosmetic surgery and some people are disappointed. Talk with your ophthalmologist about what you can expect from blepharoplasty.
- Blepharoplasty does not correct all vision problems. For instance, you will not be able to read printed words more clearly just because you had blepharoplasty. Talk with your ophthalmologist about other ways to improve vision such as with eyeglasses, contact lenses, cataract surgery, or LASIK surgery.
It is your choice whether to have blepharoplasty. Here are some other options:
- You may decide to do nothing. Excess skin, muscle, and fat around your eye will not go away, but might not bother you enough to do something about it.
- You may be able to have a different type of surgery that will lift your eyebrows. Talk with your ophthalmologist about other surgery options.
- There are other treatments and procedures to improve the appearance of lower eyelids. For instance, you could have Botox injections, filler injections, laser treatment, or a chemical peel. Talk with your ophthalmologist about these and other choices.
As with all surgery, there are risks (problems that can happen) with blepharoplasty. Here are some of the most common or serious:
- Bleeding, infection, or numbness. Temporary numbness of the eyelashes is common for the first month or two.
- Changes in how you look such as bruising, scarring, or asymmetric appearance (one side of your face not matching the other).
- Eye problems. These can include trouble closing your eyes (which can damage the cornea–the part of your eye where a contact lens sits), inability to wear contact lenses, tearing, or dry eye. Temporary dryness is common for the first few weeks.
- Vision changes such as double vision, vision loss, or in very rare cases, blindness.
- Anesthesia problems. Local anesthesia injections can damage the eye, area around the eye, or cause vision loss. General anesthesia has its own risks that you would discuss with an anesthesiology specialist.
- Your eyelids may not look or feel as perfect after surgery as you had hoped. There are no guarantees about how your eyes will look, how good your peripheral vision will be, or how you will feel after blepharoplasty surgery. This is because people differ in eyelid structure, response to surgery, how well they heal, and expectations about how surgery will help. Gradual improvement in minor issues usually occurs with continued healing over the first six months after blepharoplasty.
- You may need more treatment or surgery to take care of problems that happen after blepharoplasty. You may have to pay more since this extra treatment or surgery might not be included in the fee for blepharoplasty.
Consent. By signing below, you consent (agree) that:
- You read this informed consent form, or someone read it to you.
- You understand the information in this informed consent form.
- The ophthalmologist or staff answered your questions about blepharoplasty
- The ophthalmologist or staff offered you a copy of this informed consent form.
- You accept that blepharoplasty can change how your eyes or eyelids look.
- You understand that there may be additional costs if you need more surgery or other treatment.
I consent to have blepharoplasty surgery on (circle your choices):
Upper lid: Right Left Both
Lower lid: Right Left Both
Patient (or person authorized to sign for patient) Date
NEW – Oculofacial Informed Consent Forms
OMIC is pleased to offer 10 new procedure-specific consent forms for oculofacial plastic surgeons. These forms were prepared by OMIC Board Member, Ronald W. Pelton, MD, PhD, an oculofacial plastic surgery sub-specialist practicing in Colorado Springs, Colorado. They are intended as sample forms and contain information OMIC recommends you as the surgeon personally discuss with the patient. Please review and modify to fit your practice.
- Anterior orbitotomy: http://www.omic.com/anterior-orbiotomy-consent-form/
- Ectropion: http://www.omic.com/ectropion-consent-form/
- Entropion: http://www.omic.com/entropion-consent-form/
- Evisceration/Enucleation: http://www.omic.com/eviscerationenucleation-consent-form/
- Facial Bone Repair: http://www.omic.com/facial-bone-repair-consent-form/
- Lagophthalmos Surgery with Gold Weight: http://www.omic.com/lagophthalmos-surgery-with-a-gold-weight-consent-form/
- Optic Nerve Sheath Fenestration (ONSF) http://www.omic.com/optic-nerve-sheath-fenestration-consent-form/
- Orbital Decompression Surgery: http://www.omic.com/orbital-decompression-surgery-consent-form/
- Orbital Fracture Repair: http://www.omic.com/orbital-fracture-repair-consent-form/
- Repair of Defect After Skin Cancer Removal: http://www.omic.com/repair-of-defect-after-skin-cancer-removal-consent-form/
OMIC is also pleased to announce a new plain-language version of the blepharoplasty consent form. This form was developed by our Board and Committee members Drs. Ron Pelton and Rob Fante and OMIC Risk Manager Anne Menke.
Oculofacial page: http://www.omic.com/risk-management/ophthalmology/oculoplastics/
The importance of a procedure-specific consent form in relation to defense of a claim for malpractice
Without a document signed by the patient listing the risks specific to the procedure, the jury will be confronted with two entirely different versions of what was discussed. Unfortunately, it is quite rare that handwritten chart notes are as comprehensive as a procedure-specific informed consent document. However, such a note in the patient’s chart, coupled with a procedure-specific informed consent document, presents a formidable defense. If you spend a significant amount of time with a patient discussing a procedure, be sure to document the discussion, including how much time was spent. This helps refute claims that the physician was “in and out” of the room and did not seriously address the patient’s concerns. Lastly, we encourage you to send the patient home with a copy of the consent form. This gives the patient more time to review the form and potentially invalidates the claim that the patient couldn’t remember the issues discussed.
OMIC policyholders may contact our confidential Risk Management Hotline with questions about these consent forms and other risk management resources. Call 800-562-6642 option 4 or email riskmanagement@omic.com.
Repair of defect after skin cancer removal consent form
Please click on this link to download a copy of the repair of defect after skin cancer removal consent form.
INFORMED CONSENT FOR SKIN CANCER SURGERY REPAIR
(Repair of defect after skin cancer removal)
WHY MIGHT I NEED SURGERY AFTER SKIN CANCER REMOVAL?
Skin cancer in light-skinned people is relatively common. In order to remove the cancer, a dermatology surgeon (MOHS surgeon) may remove the cancer and ask your doctor to repair the defect (missing tissue).
HOW IS THE SKIN REPAIR DONE?
Repair of the missing skin tissue is usually done in an operating room. If the defect is small, it may be done under simple local anesthesia. However, if the defect is large, it may require general anesthesia. Two basic techniques are used: Flaps and Grafts. A skin graft is done by removing skin in a normal spot and stitching it to fill in the missing tissue from the skin cancer removal surgery. A flap is done by incising (cutting) and stretching the skin around the defect to fill in the hole. Your doctor will choose the type of closure that he feels is best for your skin defect.
HOW WILL THIS SURGERY AFFECT MY APPEARANCE?
The cosmetic results of the skin cancer repair surgery depend upon the patient’s severity (size) and location of the defect, the patient’s unique anatomy and appearance goals. Skin cancer defect surgery is not considered cosmetic surgery but most patients feel that they look better after the cancer is removed and they have healed. The goal of this surgery is to rid the patient of the cancer and give them the very best cosmetic (normal) appearance as possible.
It is important to note that some patients have unrealistic expectations about how skin cancer surgery will impact their lives. Carefully evaluate your goals and your ability to deal with changes to your appearance before agreeing to this surgery. Understand the risks and ask questions of your doctor.
WHAT ARE THE MAJOR RISKS?
Risks of skin cancer surgery include but are not limited to: bleeding, infection, an asymmetric or unbalanced appearance, scarring, numbness and/or tingling on the face and damage to nerves that move the face or give feeling to the face. You may need additional treatment or surgery to treat these complications; the cost of the 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 reaction.
WHAT ARE THE ALTERNATIVES?
In some patients (bed-ridden patients that are unable to undergo surgery or patients that refuse surgery) the skin cancer can be treated with topical medicine and treatments (freezing therapy) or even radiation. The downside of this type of treatment is that it is impossible to tell if all the cancer cells are dead. The skin cancer may look as if it is gone and then return months or years later. Surgery is considered to be the gold standard.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
The type of anesthesia will depend on the size and location of the tissue defect and patient preference. It may be simple local numbing with lidocaine (novocaine) or general anesthesia with the patient completely asleep. 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 understand that it is impossible for my doctor to inform me of every possible complication that may occur.
- I have been informed that results (functional or cosmetic) cannot be guaranteed, that adjustments and more surgery may be necessary, and that there may be additional costs associated with more treatment.
- By signing below, I agree that my doctor has answered all of my questions, that I understand and accept the risks, benefits, and alternatives of skin cancer surgery, and the costs associated with this surgery and future treatment. I feel that I am able to accept the risks involved.
I have been offered a copy of this document.
I consent to skin cancer surgery on:
Right Left side: _________
Other: _________________________________________________
______________________________________ _______________
Patient (or person authorized to sign for patient) Date
Orbital Fracture Repair Consent Form
Please click on this link to download the orbital fracture repair consent form.
INFORMED CONSENT FOR ORBITAL FRACTURE REPAIR
(“Eye socket bone repair”)
WHY MIGHT I NEED REPAIR OF THE BROKEN BONES IN MY EYE SOCKET?
The bones of the eye socket are some of the thinnest bones in the body – even thinner than an eggshell in places. If the bones are broken and displaced (moved from their normal position), problems can arise. Some patients will develop permanent double vision after a fracture that is not repaired. If the fracture is large enough, some will develop a sunken eye appearance with the broken eye looking smaller. Many patients will get numbness in the lower lid and cheek after a fracture but this usually gets better even without surgery.
HOW IS THE SOCKET REPAIR DONE?
Repair of broken bones in the eye socket is usually done in an operating room with the patient under general anesthesia (completely asleep). Your doctor will NOT remove the eyeball!! Small incisions (usually inside the eyelid) are used to get to the fractures and delicate instruments are used to move the eye to one side and allow your doctor to see and repair the fracture. Often, a thin flat implant is placed over the fracture in the bone to cover the hole. This may be permanent or it may be dissolvable. Some implants have titanium in them, some are plastic and some are made of other material. Your doctor will choose the type that he feels is best for your type of fracture.
HOW WILL EYE SOCKET SURGERY AFFECT MY VISION OR APPEARANCE?
The results of orbital (eye socket) surgery depend upon each patient’s severity and location of trauma, symptoms, unique anatomy and appearance goals. Eye socket surgery is not considered cosmetic surgery but most patients feel that they look better after they have healed. Orbital surgery does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological trauma behind the eye. This surgery cannot repair all problems associated with trauma to the face.
It is important to note that some patients have unrealistic expectations about how orbital surgery will impact their lives. Carefully evaluate your goals and your ability to deal with changes to your appearance before agreeing to this surgery. Understand the risks and ask questions of your doctor.
WHAT ARE THE MAJOR RISKS?
Risks of orbital surgery include but are not limited to: bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), double vision, 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 the 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 double vision or sunken eye and decide not to have surgery on your eye socket at this time. In some cases the double vision may be improved with glasses or eye muscle surgery.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Most orbital surgeries are done with general anesthesia with the patient completely asleep. 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 understand that it is impossible for my doctor to inform me of every possible complication that may occur.
- I have been informed that results cannot be guaranteed, that adjustments and more surgery may be necessary, and that there may be additional costs associated with more treatment.
- By signing below, I agree that my doctor has answered all of my questions, that I understand and accept the risks, benefits, and alternatives of eye socket bone repair, 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 have been offered a copy of this document.
I consent to orbital fracture repair surgery on:
Right Left side: _________
Other: _________________________________________________
_______________________________________ _______________
Patient (or person authorized to sign for patient) Date
Orbital Decompression Surgery Consent Form
Please click on this link to download the orbital decompression consent form.
INFORMED CONSENT FOR ORBITAL DECOMPRESSION SURGERY
(Removing fat and/or bone from the eye socket)
WHY MIGHT I NEED ORBITAL DECOMPRESSION SURGERY?
Certain conditions such as Graves’s disease can cause the pressure in the orbit (eye socket) to rise to dangerous levels as the muscles that move the eye enlarge. This can put the optic nerve at risk and in some instances can cause blindness. In addition, the increased pressure can cause the eyes to bulge forward giving the patient a “bug-eyed” appearance. By removing fat and/or bone from the eye socket, the soft tissues of the eye socket can relax back into the now enlarged orbit. So, this surgery can help to relieve the pressure in the eye socket and allow the eye tissues to revert to a more normal position.
WHAT ARE THE RISKS OF GRAVES DISEASE AND BULGING EYES TO MY OCULAR HEALTH?
The most serious risks of Graves’s disease to the eye is usually the damage to the optic nerve and loss of vision which can be extensive and permanent. In addition, bulging eyes may not close all the way giving the patient dry eyes and potentially corneal exposure and damage which can cause permanent visual loss. The swollen muscles of Graves’s disease can also result in double vision.
HOW WILL THIS SURGERY AFFECT ME AND MY APPEARANCE?
Orbital decompression surgery is NOT cosmetic surgery. It is being done to save your vision from deteriorating. The cosmetic results of this surgery may be minimal or they may be dramatic. Because of the nature of this disease and the fact that it affects each patient differently, it is impossible to tell prior to surgery if the cosmetic outcome will be pleasing to the patient. Nonetheless, many patients find that they look and feel better after the surgery.
It is important to note that some patients have unrealistic expectations about how orbital decompression surgery will impact their lives. Carefully evaluate your goals and your ability to deal with the outcome before agreeing to this surgery. Understand the risks and ask questions of your doctor.
WHAT ARE THE MAJOR RISKS OF ORBITAL DECOMPRESSION SURGERY?
Risks of orbital decompression surgery include but are not limited to: bleeding, infection, scarring, need for more surgery, loss of vision, loss of visual field or even blindness. Some patients may develop double vision after this surgery that may never go away. You may need additional treatment or surgery to treat these or other complications. The cost of the 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.
WHAT ARE THE ALTERNATIVES TO ORBITAL DECOMPRESSION SURGERY?
You may be willing to live with the symptoms of Graves disease (headache, double vision, visual loss) and decide not to have any surgery at this time. Other options include eyelid surgery, oral steroids or radiation to the orbits. Your doctor is happy to discuss these with you and refer you to the appropriate physicians if you wish.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Orbital decompression surgery is done under general anesthesia with the patient completely asleep. 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 understand that it is impossible for my doctor to inform me of every possible complication that may occur.
- My doctor has told me that results cannot be guaranteed, that adjustments and more surgery may be necessary (and that there may be additional costs associated with more treatment).
- By signing below, I agree that my doctor has answered all of my questions and has encouraged me to ask more questions as they arise. I understand the risks, benefits, and alternatives of orbital decompression surgery, and the costs associated with this surgery and future treatment. I feel that I am able to accept the risks involved.
I have been offered a copy of this document.
I consent to orbital decompression surgery on:
Right_____ Left _____ Both sides_________
Other: _________________________________________________
_______________________________________ _______________
Patient (or person authorized to sign for patient) Date
