ELMHURST HOSPITAL CENTER



Informed Consent: Blepharoplasty

No medications have been given to me prior to signing this consent form:

Name___________________ Date____________________Time_______

Instructions:

This is an informed consent document that Dr. Ende prepared to inform you about blepharoplasty surgery, its risks and alternative treatments. It is important for you to read this information carefully and completely. Read each page and sign the consent for surgery as proposed by your surgeon.

Introduction:

Blepharoplasty is a surgical procedure to remove excess skin, muscle, and underlying fatty tissue from both the upper and lower eyelids. Blepharoplasty can improve drooping skin and bagginess. It may improve vision in older patients who have hooding of their upper eyelids. Although it can add an upper eyelid crease to the Asian eyelid, it will not erase evidence of one’s racial or ethnic heritage. Blepharoplasty will not remove “crow’s feet” or other wrinkles, eliminate dark circles under the eyes, or lift sagging eyebrows.

Blepharoplasty surgery is customized for every patient, depending on his or her particular needs. It can be performed alone, involving upper, lower or both eyelid regions, or in conjunction with other surgical procedures of the eye, face, brow, or nose. Eyelid surgery cannot stop the process of aging. Whenever the skin is cut, it heals with a scar. You will have a permanent scar.

Alternative Treatment:

Alternative forms of management include not treating the skin laxity and bagginess in the eyelids by surgery. Improvement of skin laxity, fatty deposits, and skin wrinkles may be accomplished by other treatments or surgery, such as brow lift, when indicated. Other forms of eyelid surgery may be needed should you have disorders affecting the function of the eyelid, such as drooping eyelids from muscle problems (eyelid ptosis) or looseness between the eyelid and eyeball (ectropion). Minor skin wrinkling may be improved through chemical peels or other skin treatments. Risks and potential complications are associated with alternative forms of treatment.

Patient signature

Risks of Blepharoplasty Surgery

Every surgical procedure entails a certain amount of risk and it is important that you understand the risks involved with blepharoplasty surgery. An individual’s choice to undergo a surgical procedure is based on the comparison of risk to potential benefit. Although the majority of patients do not experience the following complications and consequences of blepharoplasty surgery, you should discuss each of them with Dr. Ende to make sure you understand the risks, potential complications and consequences of blepharoplasty surgery. A certain amount of bruising is to be expected after eyelid surgery. You will need to take time off of work in order to recover from the bruising.

Bleeding

It is possible, though unusual, that you may have problems with bleeding during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood, or a blood transfusion. Hospitalization may be required and hospital fees will be the responsibility of the patient. Do not take any aspirin or anti-inflammatory medications for two weeks prior to surgery, as this increases the risk of bleeding. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the skin may delay healing and cause scarring.

Blindness

Blindness is extremely rare after blepharoplasty. However, it can be caused by internal bleeding around the eye during or after surgery. The occurrence of this is not predictable. Any sudden increase in eye pain or vision change is a reason to go to the emergency room or call emergency services.

Infection

Infection is unusual after this surgery. Should an infection occur, however, additional treatment including antibiotics or surgery may be necessary. The risk is increased in smokers and diabetics.

Scarring

You will have a scar. Although good wound healing after a surgical procedure is expected, abnormal scars may occur, both within the eyelid and deeper tissues. In rare cases, abnormal scars may result. Scars may be unattractive and of a different color than surrounding skin. There is the possibility of visible marks in the eyelid or small skin cysts from sutures. Additional treatments may be needed to treat scarring. Keloids may occur if you are prone to them. Webbing can recur. We will do everything we can to prevent this, but despite our best efforts, it can still recur and can be worse. Recurrent webbing can interfere with eyelid function and lead to the necessity for further reconstructive surgery.

Patient signature

Damage to Deeper Structures

Deeper structures, such as nerves, blood vessels and eye muscles may be damaged during the course of surgery. The potential for this to occur varies with the types of blepharoplasty procedure performed. Injury to deeper structures may be temporary or permanent.

Asymmetry

The human face and eyelid is normally asymmetrical. There can be variation from one side to the other following blepharoplasty surgery.

Chronic Pain

Chronic pain may occur infrequently after blepharoplasty surgery. Pain and/or discomfort during the procedure, as well as after the procedure, varies in intensity and duration by individual.

Skin Disorders/Skin Cancer

A blepharoplasty is a surgical procedure to tighten the loose skin and deeper structures of the eyelid. Skin disorders and skin cancer may occur independently of eyelid surgery.

Ectropion

Displacement of the lower eyelid away from the eyeball is a rare complication. Further surgery may be required to correct this condition.

Corneal Exposure Problems

Some patients experience difficulty closing their eyelids after surgery and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments or surgery and treatments may be necessary.

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Unsatisfactory Result

There is the possibility of a poor result from eyelid surgery. Surgery may result in unacceptable visible deformities, loss of function, wound disruption and loss of sensation. You may be disappointed with the results from surgery. You may need additional surgery. Surgery is not an exact science. Dr. Ende will attempt to give you the best results possible. However, you may not receive the result you expected because individual results vary. Complications can develop that are unexpected and not even contemplated. Additional surgical procedures, such as brow lift, may be needed to correct eyebrow sagging which contributes to upper eyelid problems. The surgery may not improve or change your appearance. Having a realistic expectation is important. If you have any concerns, discuss them with Dr. Ende prior to surgery.

Allergic Reactions

In rare cases, local allergies to tape, suture material or topical preparations have been reported. Systemic reactions, which are more serious, may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.

Eyelash Hair Loss

Hair loss may occur in the lower eyelash area where the skin was elevated during surgery. The occurrence of this not predictable. Hair loss may be temporary or permanent.

Delayed Healing

Wound disruption or delayed wound healing is possible. Some people may need extra healing time and may not be able to return to work or normal activities for a prolonged period.

Delayed Return to Activities

Bruising, discomfort and pain, although usually not as severe as after a traditional facelift, can be in some instances. Some people may need extra time and may not be able to return to work or normal activities for a prolonged period.

Smokers

Smokers have a greater risk of complications because smoking causes constriction of the blood vessels supplying the skin. Delayed wound healing, skin loss (necrosis) and infection are all complications that can occur at a higher rate in smokers.

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Long-Term Effects

Subsequent alterations in eyelid appearance may occur as the result of aging, weight loss or gain, sun exposure or other circumstances not related to eyelid surgery. Blepharoplasty surgery does not arrest the aging process or produce permanent tightening of the eyelid region. Future surgery or other treatments may be necessary to maintain the results from the blepharoplasty.

Other Effects

Certain systemic or neurological conditions and or diseases, such as multiple sclerosis, lupus, diabetes, HIV, etc., may worsen, be aggravated, or appear to worsen with the stress of any surgical procedure.

Surgical Anesthesia

Both local and general anesthesia involve risk. There is the possibility of complications, injury and even death from all forms of surgical anesthesia or sedation. Allergic reactions may occur.

Additional Surgery Necessary

There are many variable conditions in addition to risk. Potential surgical complications may influence the long-term results of eyelid surgery. Even though risks and complications occur infrequently, the risks cited are particularly associated with blepharoplasty surgery. Other complications and risks may occur but are even more uncommon. If complications occur, additional surgery or other treatment may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. A touch-up procedure is occasionally required and there may be a facility fee for the supplies used.

I understand that a touch up is the only recourse for dissatisfaction with my results.

Touch-Ups

Results cannot always be predicted with accuracy prior to initial surgery. In some instances, some patients may require a secondary procedure to achieve better results. The decision to have an additional procedure will be determined by Dr. Ende. If a touch-up procedure is required, there may be a facility fee for supplies used.

I understand that I may need a secondary procedure based on my discussion with Dr. Ende. I understand that a touch-up procedure is the only recourse for dissatisfaction with my results.

Patient signature

Follow-up Care

Post-operative care is an important part of your post-surgical experience. It is your obligation to make sure that you keep all of your post-surgical follow-up appointments and you promptly contact Dr. Ende in case of a medical emergency. I understand that if I seek medical care outside of Dr. Ende, Dr. Ende is not responsible for any expenses incurred.

Advertising

I understand that my results may not be the same results as the patients’ depicted in the advertising. Individual results and recovery will vary. The advertising statements and photographs do not constitute a promise or guarantee of any particular outcome or anything else.

Disclaimer

Informed consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered.

Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve.

1. For purposes of advancing medical education, I consent to the admittance of observers to the operating room.

2. I consent to the disposal of any tissue, medical device or body parts which may be removed

3. The following information has been explained to me in a way that I understand:

A: The above treatment or procedure to be undertaken

B: There may be alternative procedures or methods of treatment

C: There are risks to the procedure or treatment proposed

D: The advertising statements and photographs do not constitute a promise or

guarantee of any particular outcome or anything else

I consent to the treatment or procedure and the above listed items. I am satisfied with the explanation.

Patient signature

I understand that the success of the procedure is, to a great extent, dependent upon my closely following Dr. Ende’s instructions. Post-operative care, activities and precautions have been explained to me and I understand them.

I also consent to the administration of such anesthetics as may be considered necessary and advisable by Dr. Ende. I am aware of risks involved with anesthesia, such as allergic or toxic reactions and even cardiac or respiratory arrest.

I also consent to have my photographs used for medical, educational and scientific purposes. I also consent to have my photographs used for internet advertising. I understand that I do have the option of crossing the prior sentence out, but the first sentence in this paragraph may not be crossed out.

Refunds: There is a strict no refund policy for any treatments performed. I understand that the procedure does what it does, and that Dr. Ende puts his best effort and experience into every single patient. I understand that I am paying for Dr. Ende to perform this procedure as well as the cost of the material used and staff time/overhead and that I am not paying for any specific results implied or hoped for. While Dr. Ende takes a great deal of pride in his results and will do anything within his power to make me satisfied, additional procedures or products will have a cost associated with them.

I further understand that if a touch up or further medical treatment is required, I will need to be seen by Kevin Ende MD at NJ Eye and Ear or Englewood Hospital. I understand that touch up, followup, or emergency visits will be free of charge in the office, but additional products and procedures will be at standard pricing. Any visits to Englewood Hospital for emergencies will be billed at Englewood Hospital’s standard rates or through your medical insurance provider.

I have had sufficient opportunity to discuss this condition and treatment with Dr. Ende, 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.

I certify that I will not leave slanderous/libelous reviews on any website. Speaking with Dr. Ende and allowing time to heal are necessary steps after every procedure, and I will not immediately jump to conclusions about my outcome before healing is complete. Slanderous statements unnecessarily scare future patients away from having procedures and realizing their dreams as well as having a negative financial impact on the practice. Due to HIPPA rules, Dr. Ende cannot reply to or combat any slanderous reviews online which will no doubt negatively impact his practice. I understand that Dr. Ende will use any resources available to him to combat libelous and slanderous statements including seeking financial compensation due to monetary damages through the legal system.

Patient signature

I have been informed by Dr. Ende that patients need to be escorted home by a responsible adult and accompanied by an adult for at least 24 hours post-operatively. I understand that this is the policy of the practice. I acknowledge that I am responsible for ensuring that I have an escort to assist me in my transport home after surgery. I further acknowledge that should I fail to have an escort home, I am responsible for any staff salary overtime that this causes. I voluntarily release Dr. Ende from any liability regarding the above conditions if I knowingly choose to violate this policy. I assume all responsibility for my own well being following my surgical procedure if I knowingly go against medical advice.

Patient signature date

Witness date

Facility Consent Addendum

Consent for Treatment:

I, the above named and undersigned patient, give my consent for care at and by the medical, nursing, and allied health professional staff of NJ Eye and Ear which may include routine diagnostic procedures and such medical treatment as Dr. Ende or his designees may find are needed. I acknowledge that no promises or guarantees have been made to me about the results of any examinations, treatments or procedures I may receive while at NJ Eye and Ear.

Release of Medical Records:

I authorize NJ Eye and Ear to release all or any part of my medical record to hospitals or medical service companies, insurance companies, workers compensation carriers, welfare funds or other organizations or agencies that may be concerned with the payment of costs related to my treatment and any other organization or agency to which the center is permitted to release such information under applicable laws. In the event that I am transferred to a hospital post-operatively, I authorize NJ Eye and Ear to obtain a copy of the hospital discharge summary.

Financial Arrangements:

I authorize and direct my insurer or payor to pay directly to NJ Eye and Ear any or all benefits, up to the amount of my bill, accruing to me in connection with my treatment. I agree that, in consideration of the services that were provided to me, I individually obligate myself to pay the amount promptly in accordance with the regular rates and terms of the facility. I understand, therefore, that to the extent permitted under applicable laws and contractual arrangements, I am financially responsible to the center for any amounts not covered by insurance. Furthermore, I understand that my insurer or payor may require certain health care services to be authorized before they are furnished to me. I individually obligate myself to pay the account of the center with respect to the services that I choose to receive notwithstanding that my health insurer or payor has refused to give preauthorization for all or any portion of my services.

Pre-Certification:

Your insurance company will be called to pre-certify your procedure. Please make sure that we have the correct insurance information. It is important to notify us if you have different plans for physician and hospital services. I understand that the reimbursement may be sent to me instead of NJ Eye and Ear. Upon receipt of the insurance payment, I will forward the check and the explanation of benefits to NJ Eye and Ear. In addition, I understand that my insurance plan may still hold me responsible for a deductable and/or coinsurance.

Signature

Facility Charge:

When your procedure is performed at NJ Eye and Ear, there will be a facility fee included in your overall fee. There is a charge for the use of NJ Eye and Ear’s procedure room included in your overall quote. Fees will vary according to the type of procedure that is being performed. Patient responsibility is dependent upon individual insurance plans.

Collection Expenses: (excludes Medicaid and Medicare)

Should my account with NJ Eye and Ear be referred to an attorney or outside agency for collection, I will pay all reasonable collection expenses (including attorney’s fees) associated with the collection effort. I acknowledge that all delinquent accounts will bear interest at the legal rate.

Professional Fees:

These are fees that are billed by Dr. Ende for his services in performing your procedure. These fees are within the range considered usual and customary for this area. Patient responsibility will vary according to each insurance plan.

Anesthesia:

The hospital or surgical facility outside of NJ Eye and Ear will have an anesthesiologist that will bill your insurance for their services. Discuss with the facility directly any questions that you have pertaining to billing.

Biopsies:

If a biopsy is required during the course of your procedure, a tissue sample will be sent to a laboratory to be analyzed by a pathologist. You may receive a separate bill from the pathologist. Dr. Ende may not anticipate the need to perform a biopsy with your procedure, but may need to make an intraoperative decision to due so without your verbal or written consent of that specific area. You hereby give general consent for an unexpected biopsy to be performed during the routine course of your procedure.

Advanced Directive:

It is Dr. Ende’s policy regardless of an advanced directive or instructions from a healthcare surrogate or power of attorney that if an adverse event occurs during treatment, Dr. Ende will initiate resuscitative or other stabilizing measures, and transfer you to an acute care hospital for further evaluation. Dr. Ende does not honor DNR orders at NJ Eye and Ear.

Signature

Clothing and Valuables:

I fully understand that the center is not responsible for any personal property brought in or retained in a storage area at any time. I fully understand that any valuables should be given to a family member or other responsible party for safekeeping. No reimbursement for lost or stolen items will occur. You may call the Englewood, NJ police if you choose to do so.

Acknowledgement of driving risks:

I have been informed by NJ Eye and Ear that I should not drive for at least 20 hours after completion of my procedure. A responsible adult, upon discharge from NJ Eye and Ear will accompany me home and stay with me over night.

Signature

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