Upon your arrival (or sometimes a few days ahead of time) at the office, surgicenter, or hospital, you will asked to read and sign a form granting permission for the surgeon and staff to perform your blepharoplasty. Such "informed consent" is an important legal document, which should not be treated as a mere "formality".
SAMPLE CONSENT FOR
BLEPHAROPLASTY SURGERY
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Note: This sample consent form is not the actual form used in Dr. Meronk's practice and is offered for general informational purposes only. Your own doctor's form will differ.
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1. I, _______________________, authorize Dr. _________ to perform on me an operation known as blepharoplasty, also known as eyelid lift. This procedure is undertaken for the sole purpose of attempting to remove or reposition excess skin, fat and/or muscle from the eyelids to improve my appearance and/or improve my peripheral vision.
Blepharoplasty surgery will be performed on:
(Circle one)
Both upper eyelids
Both lower eyelids
All four eyelids
One eyelid ______
Treatment will be delivered in the:
(Circle one)
Office operating room
Hospital
Surgicenter
2. The nature and purpose of blepharoplasty surgery have been explained to me as well as any feasible alternatives, including having no surgery at all. I understand that my doctor will attempt to improve my appearance and/or peripheral vision by removing skin and/or fat and/or muscle tissue from my eyelids. Droopiness caused by forehead or brow relaxation or defective support within the deeper eyelid tissue will not be improved by this operation. I understand that blepharoplasty surgery gives a relatively long lasting result, but I have not been promised any permanent correction from the progressive changes of aging.
3. I consent to the administration of anesthetics or sedative medications, which will be given orally, by injection into the tissue, by injection into a vein, or by inhalation.
4. I consent to the performance of any other additional medical or surgical procedures that my doctor feels are medically necessary during the course of my operation if arising due to unforeseen circumstances or complications during the operation.
5. I know that the practice of medicine and surgery is not an exact science and that reputable practitioners cannot guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained.
6. All medical and surgical treatment carries with it the possibility of adverse reactions and complications. The following list of potential complications is not intended to scare you but rather inform you of the major possible adverse reactions that could occur from surgery on the eyelids.
I understand the major risks and complications of blepharoplasty surgery to include the following:
From anesthesia: Serious heart or breathing problems, drug reactions, allergy
From surgery: Infection, excessive bleeding, loss of vision, double vision, inability to close the eyelids fully, droopy upper eyelids, retracted lower eyelids, poor cosmetic result, over-correction, under-correction, scarring, tearing, the need for additional surgery.
7. I consent to the photographing of my appearance before, during, and after the surgery for medical documentation and/or insurance-related purposes.
8. I consent to the disposal of any tissues removed surgically.
9. I have been advised of the nature of the proposed surgery and anesthesia to my satisfaction. If I desire any additional explanation of the foregoing or further information about the operation and its risks and possible complications, this has been given to me prior to the signing of this surgical consent.
Signed _____________________________
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Following signing of the surgical consent, you will be escorted to a "holding area", where you will be prepared for surgery. You may be asked to change into a gown, put on a special bonnet to keep your hair off your face, and wear a pair of paper booties over your shoes.
While the nursing staff should already have a copy of your medical history and physical examination from your surgeon, be sure to discuss any special or unusual medical requirements with the staff, including any allergies to medications, problems with abnormal bleeding, or serious cardiopulmonary limitations.
Once your blood pressure and pulse have been recorded, you will receive any oral sedation or, if intravenous sedation is to be used, an intravenous line will be inserted.
In the operating room, your surgeon will usually be accompanied by two staff members (a surgical assistant and a general medical assistant) and, if intravenous medications are to be used, an anesthesiologist or nurse anesthetist.
You will be positioned lying down on an operating table and cushioned to make you comfortable. Your face will be cleansed with a disinfectant, and sterile surgical drapes will cover all but your brows, eyes, and nose. The operating room lights will seem overly bright at first. Depending on your depth of sedation, you may hear your surgeon and staff talking to each other and to you. A blood pressure cuff wrapped around your arm will inflate periodically.
If you remain awake during your surgery, you will be instructed to keep your eyes closed except at certain times when your surgeon will want to inspect the effects of his or her work in progress. Do not worry about seeing much of what's going on; between your sedation and the bright lights, it's hard to make out any details.
If your surgery is performed under local anesthesia with sedation (the method used most commonly), you will feel some pressure throughout the operation but very little or almost no discomfort. If you do feel noticeable discomfort, tell your surgeon, who will be able to inject additional local anesthetic.
Once your surgery is finished, your surgeon will remove the drapes, clean off your face, and raise you up into a semi-reclining position. Your eyelids will be covered with moist, cool gauze pads, which feel very soothing. Generally, most patients remain this way for five to ten minutes. If there is no evidence of excessive bleeding, no undue pain, and stable vital signs, your surgeon may elect to either move you back to a holding area for further observation or, most commonly, put you in a wheelchair to escort you out to your car.
Bandages are not applied after blepharoplasty. Instead, a pair of dark wrap-around protective sunglasses serves as your "dressing". As you are escorted back to your car, a staff member will review all instructions with your driver. Because of your sedation, you will likely remember little of what happened or about what you are told, so all instructions are also given to you in writing.
Most surgeons will provide you with a courtesy "goody bag", containing such items as your sunglasses, an antibiotic ointment, a small supply of strong pain medication, a gel ice-pack, a bottle of artificial tears, an extra supply of sterile gauze, printed instructions, and your follow-up appointment card.
On the drive home, it is preferable to recline your seat back slightly and keep your eyes closed. If you were given an ice pack, you may apply it over a gauze pad over your eyelids (without the gauze, the ice pack may feel too cold). It is normal for the gauze to collect a small amount of blood mixed in with tears.
If you prefer to keep your eyes open, don't be surprised if your vision is blurry or even double (side effects of the sedation, local anesthetic, antibiotic ointment, and excessive tearing). Your eyelids will feel puffy and will not blink very well. Because the power of the orbicularis muscles may be weakened from the surgery, anesthesia, and developing swelling, your eyelids may appear to "hang", look "overdone", and not close fully.
Don't worry. Now is not the time to try to evaluate the success of your operation.
Besides, if you think you look bad now, just wait until you see yourself tomorrow.
Next:
Do's and Don'ts After Surgery
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