This is an informed consent document that has been prepared to help inform you of malar (cheek) and chin implant surgery, its risks, as well as alternative treatments. It is important that you read this information carefully and completely.

I voluntarily request that Dr. Kotlus and such associates, technical assistants and other health care providers as he may deem appropriate, treat my condition which has been explained to me as deficiency of the cheek area or deficiency of the chin protrusion.

I understand that the following surgical procedure is planned for me, and I voluntarily consent, request, and authorize this procedure: cheek implant‐ via transoral incision, or chin implant‐via submental (underneath chin) incision with silicone implant(s).

I understand that my physician may discover other or different conditions which may require additional or different procedures than those planned.

I have been advised that the object of the procedure I have requested is an elective change in appearance, not perfection. It is possible for imperfections to ensue, and that the result may not live up to my expectations or goals.

I fully understand that the practice of medicine and surgery is not an exact science, and that any reputable physician cannot guarantee results.

I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made to me by my physician or anyone regarding the outcome of the procedure which I have requested and authorized. I also understand the limitations of this procedure.

I have been advised that the chin implant is done through an external incision, which would leave a permanent scar. Cheek implants are done through an intra‐oral incision, which would leave a mucosal scar.

I have also been advised that scars take longer than one year to mature, and the changes that normally occur in their appearance during the healing period have also been indicated to me. The intended locations and extent of the chin and cheekimplants have also been indicated to me.

I understand there are risks inherent in any treatment, procedure or surgery. The potential always exists for infection, hemorrhage, blood clots in veins or lungs,
allergic reaction, medication reaction and even death. I also realize that the following risks and hazards may occur in connection with this particular procedure: bleeding, hematoma, seroma, infection, rejection, deformity of the cheek area or chin area, pain or numbness, sensory nerve injury, motor nerve injury causing paralysis of the affected muscle group, speech changes, movement of the implant, asymmetry, and malposition or displacement of the implant. These problems could also necessitate further procedures which may or may not correct them.

My physician has fully explained in terms clear to me the nature of the procedure to be performed, the foreseeable or common risks and complications, alternative methods of treatment, as well as what I may experience if recovery is uneventful.

I acknowledge that I have been given an opportunity to ask any questions I desire regarding the diagnosis and surgical procedure and that these questions have been fully explained to me in layman’s terms.

I have read this document (or have had it read to me) and I understand its
contents. I hereby give my unrestricted informed consent for the surgical procedure.