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 ASIAN DOUBLE EYELID SURGERY?
Asian double eyelid surgery is the removal or repositioning of skin, muscle, and fat of the lids.  It is often performed to create an eyelid crease, to enhance an existing crease, to improve the symmetry of the eyelids, or to improve on a previous procedure.  Surgery to correct a droopy eyelid or to remove excess skin resulting from aging may be performed at the same time.

HOW WILL EYELID SURGERY AFFECT MY APPEARANCE?
The results of eyelid surgery depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes.

Some patients 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 Asian eyelid surgery include but are not limited to the following: 

Bleeding, infection, an asymmetric or unbalanced appearance, thickened scars, red scars, darkening of the skin, difficulty closing the eyes (which may cause damage to the underlying corneal surface), drooping of the upper eyelids, eyelid cysts, 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. Eyelid creases may diminish over time or could be positioned at different heights.  Some of these issues can result from unpredictable healing patterns or from pre-existing asymmetry that may not be correctable with surgery.  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, monolids, asymmetric eyelids, extra skin, lax muscle, droopy eyelids and bulging fat around your eyes and decide not to have surgery on your lids at this time.  Suture methods and incisional methods are options for double eyelid creation.

WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Most eyelid surgeries 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.

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 Asian 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 probl

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 “Asian Eyelid Surgery Instructions and Care Sheet”.

Cosmetic Surgery - A $500.00 non-refundable 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 10 business days 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 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. My physician has told me that results cannot be guaranteed and that adjustments and more surgery may be necessary. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of double eyelid surgery.