AESTHETIC EYELID SURGERY

(BLEPHAROPLASTY)

Intended to eliminate my complaints, the doctor told me that I need the below-named operation and explained the
information written in this form verbally.
A. GENERAL INFORMATION
Aesthetic eyelid operation is a surgical intervention that aims to remove the excess parts of the skin and eyelid
muscle that causes sagging and baggings in upper and lower eyelids together with the fat pockets underneath. Eyelid
aesthetics can correct the droopings in the lids and eyelid baggings. It can also correct the visual space restriction
formed in old persons with the upper lid coming in front of the eye. However, it does not remove the wrinkles and
crow’s feet formed around the eye, it does not remove the dark circles under the eyes or eyebrow droops. For such
problems, additional surgical interventions are needed.
The most eligible candidates for this type of a surgical intervention are the people who want a better appearance
however are in realistic expectations by understanding that perfection might not be possible. These persons must at
the same time be persons who do not have a physical or mental disease, a psychiatric problem hindering operation.
You must give accurate and complete replies to the questions your doctor will ask you to learn whether you have such
a problem or not and provide detailed information about your medical history.
If the person wants and the plastic surgeon approves, aesthetic eyelid operation may be made together with other
operations.

B. THE ALTERNATIVE TREATMENT OPTIONS:

The aesthetic eyelid surgery is an optional operation that is not compulsory to be made. One of the alternative
options is not having the operation by not taking the possible risks of this surgery. Other than this, the drooping in the
upper eyelids may be partially eliminated with a brow lift surgery. If you have the complaint of drooping in the upper
eyelid and restriction of visual space named as ‘’Ptosis’’ in medicine, different eyelid surgeries will help you for this
condition. Again, the wrinkles around the eyelid can be reduced to some extent by alternative skin treatments like
chemical skin peel (Peeling) or laser application. The alternative methods also have some risks and potential
complications of their own.

C. ANESTHESIA:
-To obtain information about anesthesia and its risks, see the anesthesia information form. If you have drawbacks,
questions in this respect, see your anesthesiologist.
D. THE RISKS OF THE AESTHETIC EYELID SURGERY (BLEPHAROPLASTY) PROCEDURE :
All the surgical procedures absolutely carry some risks and it is very important for you to understand the risks
associated with this operation that you are considering to have. The person who requests a surgical procedure should
make a decision by comparing the probable benefits he/she will see from the procedure with its possible risks. Even
the below-mentioned risks are not seen in the operated persons most of the time, these risks are present. You must
comprehend each one well and ask your doctor the ones that you think you have not understood and discuss the
details.

1- Bleeding (Haematoma): During or after the operation, bleeding may occur under the eyelids or inside around the
eyeball. If bleeding and blood accumulation forms around the eyeball after the operation, an emergency surgical
procedure or treatments may be needed. Never use aspirin during the last 10 days prior to the operation. Aspirin
increases the bleeding risk. High blood pressure, especially if it has not been taken under control with drugs, increases
the chance of bleeding. Blood accumulation under the skin may delay recovery and cause formation of unexpected
scars.
2- Infection : In this type of surgical application, the probability of formation of wound infection is very low. If wound
inflammation occurs in the operation place after the surgery, antibiotic treatment and additional surgical interventions
may be needed.

3- The scars on the skin: Although a good wound recovery that does not generally leave any evident traces is seen at
the consequence of this surgical intervention, rarely abnornal scars may occur in the eyelids, sides of the eye and the
tissues under the skin. These traces may sometimes show color differentiation from the surrounding normal skin.
Whether these traces will be more or less cannot be predicted. Sometimes small skin cysts may develop. If so,
additional surgical interventions or other additional treatments may be needed to eliminate the traces.

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4--Formation of damage in the hypodermic tissues: During the aesthetic eyelid surgery, the nerves, tear ducts, blood
veins and muscles around the eyelids may be damaged. These damages may be in temporary or permanent character.

5- Formation of blindness: Formation of blindness after an aesthetic eyelid surgery is an exceptionally rare
complication. Nevertheless, it may occur during or after surgery at the consequence of bleeding and blood
accumulation inside, around the eyeball. Whether this condition will occur or not cannot be predicted and detected in
advance.

6--Asymmetry: Normally there is not a complete symmetry in the human face and between the eyelids. The structures
on both sides of a line that divides the face in two centrally are not identically the same. After the aesthetic eyelid
operations, partial differences between the two sides may also be seen.

7- Formation of eye dryness: After the eyelid aesthetic, decrease in tear secretion and dry eye complaint may develop.
In whom this rarely forming condition may occur cannot be predicted. If you normally have eye dryness complaint,
please inform your doctor. Throughout and after the operation of these people, special precautions may be necessary
to be taken.

8- Dermatological diseases: Eyelid aesthetic is an operation that aims to tighten the loose eyelids and to remove the
eye bags. On the skin of the eyelids, dermatological diseases and skin cancers may develop independently from the
aesthetic surgery.

9- Ectropion (the lower eyelid remaining turned outwards) : After aesthetic eyelid surgery, rarely, the lower eyelid might
be pulled outwards by slightly moving away from the eyeball. To correct this condition which is named as ‘’Ectropion’’ in
the medical language, sometimes additional surgical interventions may be needed.

10- Inability to close the eyelids completely and the eyeball to remain partially open: This complication which is seen
exceptionally rare may sometimes lead to problems like inability of the cases to close their eyes completely after the
surgery and formation of dryness in their eyes and inflammation in the eye. If this condition develops, additional
medical and surgical interventions may be needed to correct it.

11 – Losses in eyelashes: During or after the operation, temporary or permanent eyelash losses may occur in
eyelashes of the lower eyelid. This is not a predictable problem.

12- Allergic reactions: In rare conditions, allergic reaction to dressing materials or plaster, to drugs that are used in
dressing or the surgical suture threads may develop. In case that allergic reactions occur to the drugs that are used
during or after the operation, additional treatment may be applied.

13- Delay of healing: Late healing of the wounds or the stitches to open is possible. In this condition, additional
dressings or surgical intervention may be needed. In smokers, there is increase in the risk of wound infection, heart or
lung complications and thrombosis. Also in some diseases like diabetes and hypertension, the probability of delay in
wound healing and complication development increases in comparison to normal.

14- Unsatisfactory, insufficient result: There is the possibility of formation of a bad result after the aesthetic eyelid
surgery (Blepharoplasty). These may be as unpleasant looking surgical scars, losses of sense and function,
asymmetries. The result may also cause a disappointment for you beyond meeting your expectations. If the result of
the operation is not seen sufficient, additional correction surgeries may be considered. Medical and Surgical practices
are not definitive sciences. Although good results are generally expected, there is no guarantee about the results that
will be obtained.
15 - Long-term results: After the operation, throughout your life, changes in the appearance of your eyelids will occur
due to causes completely independent from the surgery like aging, gaining and losing weight, damage with the effect
of the sun and being subject to accidents. Eyelid aesthetic does not stop the process of aging. In the future, re-
correction surgeries may be needed.

16 – Surgical Anesthesia: Both local and general anesthesia carry some risks. Complication development, injury and
even death are within the bounds of possibility for all anesthesia types and sedations.
17- Complications: Each operation, besides the risks they carry in general, may also have undesired consequences
originating from its own peculiarity and whose possibilities of arising are in different ratios. Your doctor who performs
the operation may not charge any fees for the interventions that will be made to eliminate these problems, however
the material and hospital expenses required to be paid to the hospital after the treatment of these complications that
could be made outpatiently or inpatiently by operation must be met by the patient.

E. WARNING:

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The information provided in this form is intended to describe the risks about the suggested surgical operation and any
alternative treatments. However, it should not be considered that the surgical operation or alternative treatments
described here cover all of the risks which may be possibly encountered. Your plastic surgeon may furnish you with
different information, regarding a particular patient or depending on his medical knowledge. It is not intended that this
information form shall contain all the possibilities or facts regarding a standard or stable medical practice. The medical
practice standards are adjusted to the personal condition of each patient and are in a continuous change and
development with the progress of the medical scientific build-up and technology.
This form is issued to inform the patient and his/her relatives of the operation to be performed and to take the
patient’s consent, provision of this information completely is an obligation in professional respect and it is a legal
requirement to cause it to be read and signed. It is very important that you carefully read all the issues and information
as described above and all your questions that you could not find the answers to in this in information form to be
answered before you sign this form.

F. PATIENT’S CONSENT TO THE OPERATION OR TREATMENT TO BE APPLIED:

1. I herewith agree that my doctor and his assistants perform the treatment or operation as described below.
I have read through the patient information form regarding the Aesthetic Eyelid (Blepharoplasty) operation. Further, I
have been furnished with all the other information and necessary explanations in a verbal form.
2. I have understood that operations other than those described above may be required in the event that any
unforeseeable conditions occur during or after the operation or during anesthesia. I give my consent that the said
doctor and his assistants may decide upon and perform any practices which may be required in such a case. I approve
any and all practices which may be required for treatment and any and all treatments which shall be administered in
any subsequent cases.
3. I approve the use of any anesthetic medication to be required for the operation. I have understood that all the
anesthetic methods may cause complications, tissue damage or death.
4. I have understood that no guarantee is made for the results which may be obtained through operation.
5. I have understood that a surgeon other than the doctor designated above may perform or participate in the
operation. This may be a doctor who is in his residency training. I have understood that in the event that an organ or
any tissues are removed during the operation, they may be retained for testing purposes for a while and then destroyed
by the hospital.
6. However, I/we consent that any additional operations/analyses may be performed and any blood and blood
products may be used without obtaining prior consent in any necessary circumstances which may occur during the
operation/analysis (I/we have understood that blood transfusion may be required during the operation/analysis).
7. The doctor has told me that if any sudden events which may threaten my life occur during the operation, they shall
be treated in a proper way. I have told that pictures and video films may be taken during the operation. They may be
used in medical training unless my identity is revealed.
8. I have further understood that the result which I desire may not exactly be obtained due to problems which may
occur during or after this operation and that any adverse results and undesired complications which I have read in the
patient information form may occur.
9. I have understood that there may be observers in the operation room for medical training purposes.
10. The doctor has told me my medical condition and the planned operation. I have understood that the operation has
some risks and the possible consequences thereof. I have understood that I have other options than operation. The
doctor has explained the other options and the risks thereon.
11. I consent to the consultation of a non-resident doctor to assist in the diagnosis and treatment procedures upon my
doctor’s request whenever necessary.
12. I undertake to leave the floor where I stay and the hospital by informing my doctor and nurse if I am required to
leave the hospital during my stay at hospital once the patient admission formalities have been completed.
13. I have understood/consented that I shall comply with the prescription of the doctor, that I shall not ever take any
medication without the knowledge of my doctor and nurse on my own and that I shall not bring in any food and
beverage from the outside.
14. The original language of this letter of consent is Turkish and it has been translated and told me/us into my/our
language word by word by the interpreter.
15. I/We agree and approve that this letter of consent has been read and entirely explained to me/us, that I/we have
read it, that the empty spaces have been completed all together and that I/we have understood its contents.

Name, Surname and Signature of the Patient: Doctor Name Surname/Stamp and Signature:  
   

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Name, Surname and Signature of the Patient’s Relative or

Witness:

** If the patient is an infant or under the care of a guardian, approval (consent) of his/her guardian is obtained.