This is an informed-consent document that has been prepared to help inform you of brow lift surgery, its risks, as well as alternative treatments.

It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your plastic surgeon.

INTRODUCTION
The forehead and eyebrow region often show noticeable signs of aging. Looseness in these structures may cause drooping eyebrows, eyelid hooding, forehead furrows, and frown lines. In brow lift surgery, the structures responsible for these problems are tightened or altered to smooth the forehead, raise the upper eyebrows, and improve frown lines. A brow lift may be performed alone, or in conjunction with other procedures, such as a facelift, or eyelid surgery.

Recent advances in brow lift surgery make it possible to perform the procedure through a variety of approaches, including endoscopy. Brow lift surgery is individualized for each patient. The surgical incisions used may vary with the technique selected by your surgeon to meet your needs. The brow lift cannot stop the process of aging.

ALTERNATIVE TREATMENTS
Alternative forms of treatment consist of not treating the laxness in the forehead and upper eyebrow region by a brow lift surgery. Improvement of skin looseness and skin wrinkles may be accomplished by other treatments or surgery. Risks and potential complications are associated with alternative forms of treatment or surgery.

RISKS of BROWLIFT SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand the risks involved with brow lift surgery. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your plastic surgeon to make sure you understand all possible consequences of brow lift.

Bleeding- It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood (hematoma). Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as this may increase the risk of bleeding. Accumulations of blood under the skin may delay healing and cause scarring. Non-prescription "herbs" and dietary supplements can increase the risk of surgical bleeding.

Infection- Infection is unusual after this type of surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary.

Change in skin sensation- Diminished (or loss) of skin sensation in the face and scalp area may not totally resolve after brow lift surgery. Chronic itching sensations can occur within the scalp and brow following a brow lift.

Skin contour irregularities- Contour irregularities, depressions, and wrinkling of skin may occur after brow lift.

Skin scarring- Excessive scarring is uncommon. In rare cases, abnormal scars may result. Scars may be unattractive and of different color than surrounding skin. There is the possibility of visible marks from sutures, staples, or hardware used during a brow lift. Additional treatments including surgery may be necessary to treat abnormal scarring.

Change in surgical approach for brow lift- In some situations, depending on factors discovered only at the time of surgery, your surgeon may have to make changes in surgical technique and approach to the brow lift procedure. This may require changing from an endoscopic (closed) procedure to a standard (open) brow lift.

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.

Nerve injury- There is the potential for injury to both motor and sensory nerves during a brow lift procedure. Weakness or loss in movements of the forehead or upper eyebrow may occur after surgery. Most individuals will notice a return of motor function; permanent weakness is rare. Injury may also occur in the sensory nerves of the forehead, scalp, and temple regions. Diminished sensation may normally occur in the scalp region after a brow lift surgery. Permanent numbness or painful nerve scarring is rare.

Damage to deeper structures- Deeper structures such as the eye, nerves, blood vessels, skull bone, and muscles may be damaged during the course of surgery. The potential for this to occur varies with the type of brow lift surgical procedure performed.

Asymmetry- The human face is normally asymmetrical. There can be a variation from one side to the other in the results obtained from a brow lift procedure.

Delayed healing- Wound disruption or delayed wound healing is possible. Some areas of the brow and scalp may heal abnormally and slowly. Some areas of skin may die, requiring frequent dressing changes or further surgery to remove the non-healed tissue. Smokers have a greater risk of skin loss and wound healing complications.

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

Seroma- Fluid accumulations infrequently occur beneath the skin. Should this problem occur, it may require additional procedures for drainage of fluid.

Long term effects- Subsequent alternations in forehead and upper eyebrow appearance may occur as the result of aging, weight loss or gain, sun exposure, or other circumstances not related to brow lift surgery. Brow lift surgery does not arrest the aging process or produce permanent tightening of the forehead. Additional surgery or other treatments may be necessary to maintain the results of a brow lift procedure.

Eye irritation- Irritation or dryness in the eyes may occur after a brow lift or when the patient has eyelid surgery performed at the same time.

Pain- Very infrequently, chronic pain may occur after brow lift.

Hair Loss- Hair loss may occur within the scalp or surgical incisions. The occurrence of this is not predictable. Hair loss may resolve slowly or in rare cases be permanent.

Hardware and deeper sutures- Some surgical techniques use small screws or permanent deep sutures to help suspend brow structures. In very unusual circumstances, a screw could penetrate through the skull. Intracranial injury is rare, but possible. If this occurs, additional treatment may be necessary. It may be necessary to remove hardware or deeper sutures at a later time.

Eyelid disorders- Disorders that involve abnormal position of the upper eyelids (eyelid ptosis), loose eyelid skin, or abnormal laxness of the lower eyelid (ectropion) can coexist with sagging forehead and eyebrow structures. Brow lift surgery will not correct these disorders. Additional surgical procedures may be necessary.

Unsatisfactory result- You may be disappointed with the results of surgery. Infrequently, it is necessary to perform additional surgery to improve your results.

ADDITIONAL SURGERY NECESSARY
There are many variable conditions which influence the long term result of brow lift surgery. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with these procedures. Other complications and risks can occur but are even more uncommon. Should complications occur, additional surgery or other treatments 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.

HEALTH INSURANCE
Most health insurance companies exclude coverage for cosmetic surgical operations such as brow lift or any complications that might occur from surgery. Please carefully review your health insurance subscriber-information pamphlet.


FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional costs may occur should complications develop from the surgery. Secondary surgery or hospital day-surgery charges involved with revisionary surgery would also be your responsibility.

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(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, every patient is unique and informed-consent documents should not be considered all inclusive in defining other methods of care and risks encountered when medical care is reasonable and directed at obtaining appropriate results. Your plastic surgeon may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge.

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 of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

My Dominican Republic plastic surgery reminds you that all cosmetic surgery carries a risk, has limitations which could include disappointment with the results.

You should agree about the anticipated outcome of your surgery and concur about your expectations of the results.

You should discuss alternative treatments and thoroughly understand the risk of the procedures

If any dispute may arise the surgeon is only liable if litigation takes place in the Dominican Republic under Dominican Republician Law.

It is important that you read the above information carefully and have all of your questions answered before signing the consent.

CONSENT FOR SURGERY / PROCEDURE or TREATMENT

1. I hereby authorize Dr. __________________________ and such assistants as may be selected to perform the following procedure or treatment:

___________________________________________________________
I have received the following information sheet:

 

INFORMED-CONSENT BROWLIFT SURGERY
___________________________________________________________

2. I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.

3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death.

4. I acknowledge that no guarantee has been given by anyone including My Dominican Republic plastic surgery or any of the staff employed by My Dominican Republic plastic surgery as to the results that may be obtained.

If any litigation may arise as result of the surgery it can only be done in the Dominican Republic under Dominican Republician Law and that My Dominican Republic plastic surgery its management or staff can not be held liable in any way what so ever.

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

6. IT 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

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-6). I AM SATISFIED WITH THE EXPLANATION.

__________________________________________________________
Patient or Person Authorized to Sign for Patient

Date __________________________ Witness______________________