I recognize that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures. I further authorize and request that Dr.Kotlus and their assistants perform such as are in his professional judgment necessary and desirable. The authority granted under this consent shall extend to procedures necessary to treat and correct conditions not known at the time of consultation.

The Forehead lift procedure will involve incisions (cuts) in the temples and forehead hairline areas.  

No guarantees, expressed or written, have been made to me as to the amount or percentage of improvement in terms of either age or permanency of results.

Alternatives include nonsurgical treatments including botulinum injections or simply doing nothing.

I understand that deep wrinkles and lines may persist after the procedure and the aging process will not cease after the procedure.  Surgery results may not match expectations in every patient.

Brow surgery does not correct abnormal eyelid position (ptosis)

My physician has discussed with me the surgical alternatives and some of the possible complications encountered by all cosmetic surgeons. Most of these complications are infrequent and not anticipated. Some of them are:

There will be swelling and discoloration (bruising). This may remain for several weeks, but can last longer.

Red marks and tiny blood vessels may occur. Grooves or dimpling of the skin is possible.

Permanent scars will be present. However, they are usually well hidden and thus are inconspicuous. The amount of scarring depends upon how well healing occurs. Scars can possibly become raised, stretched and/or red necessitating revision.

Infection and/or inadequate blood supply could cause skin loss on the face with a subsequent scar formation. This may necessitate secondary surgery. A skin graft may be necessary. A scar is present in the area from which the skin is taken for the graft (donor site).

Hematomas due to accumulation of blood within the tissue may occur and delay healing or cause skin loss. Expanding hematomas must be drained.

Hair loss could occur in the areas where the incisions are made. This is usually temporary.

Numbness could occur around the operative areas. This numbness is usually temporary but could persist. Localized areas of discomfort could develop, although rare.

Nerve Injury could cause inability to raise eyebrows or asymmetry.

Eye irritation or difficulty closing the eyes can occur and may require further treatment.

Surgical screws or deep permanent sutures may poke through the skin or produce irritation that requires removal.

I understand that if the doctor or I feel that a secondary procedure is necessary, there will be an additional surgical fee.

I understand that the success of the procedure is to a certain extent dependent upon my closely following pre and postoperative instructions. Postoperative cares, including my skincare regime, activities, and precautions, have been explained to me and I understand them.

I have had sufficient opportunity to discuss this condition, my past medical and social history, 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 problematic wound healing, smoking is not permitted for 6 weeks before and 3 weeks after surgery. If I continue to smoke, I know it will increase the likelihood of a complication.

I ACKNOWLEDGE THAT NO GUARANTEES, EXPRESSED OR WRITTEN, HAVE BEEN MADE TO ME AS TO THE RESULTS OF THIS PROCEDURE. I ALSO ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY FULLEST SATISFACTION. I UNDERSTAND AND ACCEPT THE RISKS OF THESE AND OTHER POSSIBLE COMPLICATIONS AND CONSEQUENCES ASSOCIATED WITH THIS PROCEDURE. I HEREBY GIVE MY CONSENT TO PERFORM THIS PROCEDURE.     

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)