Reforme Consultation

Plastic & Reconstructive Surgeon Patient Details Patient is a 45-year-old female, self-employed graphic designer. Permission for GP contact was granted. Consent for use of anonymised photos for educational purposes was not discussed. Source Of Inquiry Patient was referred by a friend who previously underwent a similar procedure with "Dr. Thomas Kelly". Refer to Medical Questionnaire and Treatment Questionnaire in Patient Folder for medical history. Chaperone Chaperone present or available at patient's request. Patient Requesting Medical Advice About Patient is requesting advice regarding upper eyelid blepharoplasty to address concerns about hooded eyelids and a tired appearance. Patient desires a more refreshed and alert look. Allergy History No allergies reported to Azithromycin, Lorazepam, Adrenaline, Lignocaine, Latex. No adverse effects to past local anaesthetic injections reported. Medical History Patient has a history of controlled hypertension, managed with daily medication. Patient is not exposed actively or passively to nicotine. Patient is not using recreational drugs. Past Treatment History Patient had a previous rhinoplasty 10 years ago with no complications. Ongoing Medications Amlodipine 5mg, tablet, once daily, ongoing. No history of being unable to lie flat for 2 hours. No history of operations or diagnosed hernias in the treatment area. No Implant in treatment area or vicinity (eg pacemaker, internal defibrillator, hip or bone implants). No history of thrombophlebitis, clots, DVT, PE. No history of liver disorders or Cytochrome 450 deficiency. DRUG INTERACTIONS WITH MEDICATIONS TO BE USED FOR SURGERY No mild to moderate drug interactions identified. Absolute And Relative Contraindications Of Treatment No history of keloidal scarring. No ongoing history of Pregnancy / Breastfeeding. Body dysmorphic disorder not suspected. No history of consumption of blood thinners or supplements that increase bleeding, high potency fish oils, aspirin. No ongoing infections including dental infections, urinary infections, skin infections. No active acne, inflammatory lesions, infections in treatment area. No active cold sores (herpes labialis), eczema or psoriasis in treatment area. Psychological Questionnaire Score Psychological questionnaire score is designed for evaluating the psychological impact of the presenting problem and treatment desired and to document the patient's score on the psychological questionnaire section of the medical questionnaire and the reasons for seeking treatment. Patient Scores Patient scored 5 on the psychological questionnaire, indicating mild concern about her appearance affecting self-confidence. Expectations From Treatment Patient expects a natural-looking rejuvenation that reduces the appearance of heaviness in her upper eyelids. Patient hopes to look less tired and more approachable. DOES PATIENT NEED CAPRINI SCORE ASSESSMENT Caprini score assessment is required. Patient Evaluation HEIGHT (cms): 165 cms WEIGHT (kg): 68 kg BMI 25 PR: 72 bpm BP: 128/80 mmHg SAT (ON AIR): 98% On Examination Visual inspection revealed mild dermatochalasis of the upper eyelids bilaterally. There was slight hooding of the lateral aspects of the upper eyelids. No evidence of ptosis or lacrimal gland prolapse. Skin texture was good, with mild sun damage. Medical Impression / Diagnosis Bilateral upper eyelid dermatochalasis. Treatment Options Discussed Option 1: Patient was taken through the option of not having treatment, including no change to current appearance and no surgical risks. Option 2: Upper eyelid blepharoplasty was discussed as a surgical option to remove excess skin and a small amount of fat from the upper eyelids. This procedure addresses the hooded appearance and can significantly improve the patient's tired look, thereby enhancing self-confidence and self-esteem. Informed Consent Patient was taken through suitable treatment options including not having treatment. Patient was explained the treatment process, pros and cons and pre/post care requirements. Case studies with before and after photos were used for illustration. Patient understands photos are for illustration only and do not guarantee results. All patient questions were answered satisfactorily. Patient was given relevant treatment introduction, consent and pre-after care forms. Patient will follow up for a second consultation after considering information. Patient was warned about limitations of medical and surgical treatments and inability to guarantee results. Patient was informed about 10 - 20% reported patient dissatisfaction rates in cosmetic surgery. Treatment Plan 1. Schedule a second consultation to address any further questions and review informed consent. 2. Pre-operative blood tests and medical clearance from GP due to history of hypertension. 3. Upper eyelid blepharoplasty procedure planned for 1 November 2024. 4. Post-operative care instructions including cold compresses, head elevation, and avoiding strenuous activity for two weeks. 5. Follow-up appointments at 1 week, 1 month, and 3 months post-surgery.