Lower Blepharoplasty Consent Form

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Raleigh Eye and Face Plastic Surgery 4201 Lake Boone Trail. Ste 103 Raleigh, NC 27607 Cosmetic Lower Blepharoplasty Consent Form As we age, fat in the eye socket shifts forward creating puffy eyelids. In some patients, the skin and structures in the eyelid may also loose elasticity which can lead to the appearance of extra skin and possibly sagging of the eyelid. These changes can create “bags” under the eyes. Many people think these bags look unattractive and make them seem older or frequently tired. Lower Blepharoplasty can help correct these problems. Dr. Mettu may remove or change the position of fat. In some cases, a small amount of skin is removed. Additionally, the eyelid may also be tightened in some patients. After the consultation, Dr. Mettu outlines the specific surgical plan to give you the best possible results. While there are several options for anesthesia generally speaking, Dr. Mettu performs lower blepharoplasty under general anesthesia. This helps ensure that you are comfortable throughout the procedure so Dr. Mettu can focus on helping you obtain the best possible results. Many people with bags under their eyes feel that lower blepharoplasty improves how they look and makes them feel younger and less tired. It is your choice whether to have blepharoplasty. Here are some other options: • You may decide to do nothing. • There are other treatments and procedures that may help improve the appearance of lower eyelids in some patients. For example, a small number of patients are candidates for tear trough filler injections. As with all surgery, there are risks with blepharoplasty. Here are some of the risks: • Bleeding. • Infection. • Numbness. • Suboptimal results. • Eye problems: these can include trouble closing your eyes (which can damage the cornea--the part of your eye where a contact lens sits), inability to wear contact lenses, tearing, or dry eye. • Vision changes such as double vision and vision loss. • Anesthesia problems: general anesthesia has its own risks that you may further discuss with the anesthesiology team. However, general anesthesia is generally well tolerated. Problems from local anesthetic injections that are given by Dr. Mettu during the surgery are possible but are also rare. • Your eyelids may not look or feel as perfect after surgery as you had hoped. This is because people differ in eyelid structure, response to surgery, how well they heal, and expectations about how surgery will help. Gradual improvement in minor issues usually occurs with continued healing over the first six months after blepharoplasty. • You may need more treatment or surgery to take care of problems that happen after blepharoplasty that don’t resolve over time. Consent. By signing below, I consent (agree) that: • I read this informed consent form. • I understand the information within including the benefits, alternatives, and risks outlined in this informed consent form. • Dr. Mettu has answered my questions about blepharoplasty surgery to my satisfaction. I consent to have Pradeep Mettu, MD perform lower blepharoplasty surgery on the following lower lids (circle your choice): Right Left Bilateral Patient (or person authorized to sign for patient) Date Rev. 03/20 Page | 1 .

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Blepharoplasty Consent Form
Patient Name (ID): D.O.B.: Date: BLEPHAROPLASTY CONSENT FORM As you age, the skin and muscles of your eyelids and eyebrows may sag and droop. You may get a lump in the eyelid due to normal fat around your eye that begins to show under the skin. These changes can lead to other problems. For example: • Excess skin on your upper eyelid can block your central vision (what you see in the middle when you look straight ahead) and your peripheral vision (what you see on the sides when you look straight ahead). Your forehead might get tired from trying to keep your eyelids open. The skin on your upper eyelid may get irritated. • Loose skin and fat in the lower lid can create "bags" under the eyes that are accentuated by drooping of your cheeks with age. Many people think these bags look unattractive and make them seem older or chronically tired. Upper or Lower Blepharoplasty (eyelid surgery) can help correct these problems. Patients often refer to this surgery as an "eyelid tuck" or "eyelid lift." Please know that the eyelid itself may not be lifted during this type of surgery, but instead the heaviness of the upper eyelids and/or puffiness of the lower eyelids are usually improved. Ophthalmologists (eye surgeons) call this surgery "blepharoplasty." The ophthalmologist may remove or change the position of skin, muscle, and fat. Surgery may be on your upper eyelid, lower eyelid, or both eyelids. The ophthalmologist will put sutures (stitches) in your eyelid to close the incision (cut). • For the upper lid, the doctor makes an incision in your eyelid's natural crease.
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Lower Eyelid Blepharoplasty 23 Roger L
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The Naderi Center Upper Blepharoplasty Instructions
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