I DECLARE THAT I UNDERSTAND THE FOLLOWING INFORMATION:

The goal of laser/chemical skin rejuvenation is to reduce or partially eliminate facial wrinkles, discoloration or reduce scarring from skin conditions such as acne. Generally, the results of laser/chemical skin rejuvenation demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.  As with all cosmetic procedures, there are benefits, limitations, and downsides.

 Alternatives to Skin Resurfacing:

The alternatives to skin rejuvenation include non-ablative laser skin resurfacing, dermabrasion, deeper chemical peels, radiofrequency, plasma, and topical medications. The advantages and disadvantages (risks and benefits) of each of these alternatives to skin rejuvenation have been explained to me as well as the alternative of having no procedure, accepting my present skin condition, using cosmetics and considering other methods of skin rejuvenation.  Another thing I can do is leave everything alone, and take no risk, no downtime, no discomfort, and no change of my skin.

 

Possible Intra-operative Complications of Chemical/Laser Skin Resurfacing Surgery:

Blindness/Corneal Burns  - There is a risk of accidental eye injury which could cause blindness or burns of the eyeball. This is unlikely.

Flash Fires  - Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.

 

Possible Effects of Chemical/Laser Skin Resurfacing Surgery:

Pain - Discomfort, burning sensation or pain the first few days after surgery. A local anesthetic is usually used to block pain during the treatment, but some degree of discomfort will occur after the anesthetic effects have worn off and this pain may persist for several days.

Redness of Skin  - Erythema or redness of the skin for a two- to six-month period or possibly longer.

Swelling - Temporary edema (swelling) or ecchymosis (bruising) of the tissue of the face and neck, usually subsiding in three to seven days.

Wound Healing - Oozing, weeping, crusting and flakiness of the treated area, usually persisting for one to four weeks.

Skin Thickening - Textural changes of the treated skin, such as skin thickening, which may persist for a variable time following the skin resurfacing treatment.

Cysts - Milia or cysts, especially in the eyelid skin region (if the eyelid skin is included in the area of treatment), particularly if ointments were used in the postoperative phase for a protracted period.

Skin Tightness - Sensation of skin tightness (peaks at 3-8 weeks postoperatively).

Contact Dermatitis - Contact dermatitis due secondarily to topical preparations (ointments) used post- operatively.

Herpes Simplex Dermatitis (Fever Blisters) - Occurrence or recurrence of herpes simplex dermatitis, particularly if not pre-, intra- and post-operatively treated with a systemic antiviral medication such as Acyclovir/Valtrex.  Even with pre-treatment, infections can still occur, and can cause scarring.

Skin Itchiness - Pruritis or itching in the early healing phase.

Skin Hyperpigmentation - Transient (or rarely permanent) hyperpigmentation (darkening of the skin), especially in darker- skinned people, occurring three to eight weeks after laser therapy.

Cellulitis or Skin Infections  - Cellulitis or infection of the skin and soft tissues, especially if careful post-operative hygiene is not practiced.  This can occur from bacteria, fungus, or as mentioned above, virus.  These can lead to delayed healing, or poor healing.

Skin Hypopigmentation  - Hypopigmentation (lightening of the skin), which occurs because of injury to the melanocytes (pigment containing cells in the skin) and which can be permanent.  If a local area is treated, it is more apparent, as the resurfaced skin will appear clearer than the sun damaged skin

Increased susceptibility to sun - Because of the permanent thinning of the epidermis and dermis and reduction in the number of melanocytes (pigment cells in the skin), there is probably a lifelong risk of greater susceptibility skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.

The risk of scarring exists in all cases. It is variable and is often related to an individual's genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.

Skin Pigment Changes - Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.

Ectropion - Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.

 

I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.

I understand this is an elective procedure and that chemical/laser skin resurfacing surgery is not reversible.

I also understand that more than one resurfacing procedure may be required to achieve the optimal obtain- able results.

 

I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of chemical/laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after skin resurfacing surgery.

My doctor has explained chemical and laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the skin resurfacing surgical procedure. I therefore consent to having skin resurfacing surgery.

 

 

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 ptosis correction.