This article presents common and rare complications following blepharoplasty, with discussion of avoidance of these complications through presurgical planning and review. Management of the complications is provided, with surgical details supported by images and advice for the best approaches. The complications discussed include hemorrhage, infection, corneal abrasion, ptosis, lacrimal gland injury, and residual excess skin.
Key points
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Preoperative assessment and counseling of expectations is essential to avoid complications and to maximize patient satisfaction after blepharoplasty surgery.
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Photograph the patient before surgery at multiple angles to help address patient concerns if questions arise after surgery.
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Upper eyelid blepharoplasty markings should take into account the patient’s natural eyelid crease, desired crease placement, and ethnic background.
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Eyelid fullness is a sign of youth; avoid excessive resection of soft tissue.
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Become familiar with the management of all complications of surgery.
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Be cautious of the possibility of dry eye syndrome in the patient who has had previous laser in situ keratomileusis and is undergoing blepharoplasty.
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Avoid the temptation to intervene too early after surgery when unexpected results occur. Many imperfections resolve spontaneously.
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Blepharoplasty revisions are expected. It is important not to intervene until stability has been attained.
Introduction
Blepharoplasty is one of the most common cosmetic operations performed in the United States. In addition to cosmetic improvement, patients may also benefit from functional improvement with increased field of vision and quality of life. As the population continues to age, the demand for both cosmetic and functional blepharoplasty will increase.
With the growth of the information age, patient expectations and desires for precise results and minimal downtime after surgery are growing. Even patients undergoing functional blepharoplasty expect a rejuvenated appearance. In essence, every patient is a cosmetic patient. However, even in the most skilled hands, delayed healing, other complications, or unexpected results may occur. Unless properly counseled, patients may perceive normal healing (postoperative bruising and swelling) as an untoward effect; however, with the proper patient education, surgeon skill, and training, most adverse outcomes of blepharoplasty can be minimized and prevented.
It is important to recognize not only how but why complications from blepharoplasty occur. Most postoperative complications are in 1 of 4 categories:
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Inaccurate preoperative assessment
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Improper surgical technique
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Miscalculations in judgment
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Idiosyncratic outcome (unexplained complication)
Categorizing unexpected results into 1 of these 4 groups and recalling each of them before surgery is important and helps to continually improve surgeon skills and results.
Introduction
Blepharoplasty is one of the most common cosmetic operations performed in the United States. In addition to cosmetic improvement, patients may also benefit from functional improvement with increased field of vision and quality of life. As the population continues to age, the demand for both cosmetic and functional blepharoplasty will increase.
With the growth of the information age, patient expectations and desires for precise results and minimal downtime after surgery are growing. Even patients undergoing functional blepharoplasty expect a rejuvenated appearance. In essence, every patient is a cosmetic patient. However, even in the most skilled hands, delayed healing, other complications, or unexpected results may occur. Unless properly counseled, patients may perceive normal healing (postoperative bruising and swelling) as an untoward effect; however, with the proper patient education, surgeon skill, and training, most adverse outcomes of blepharoplasty can be minimized and prevented.
It is important to recognize not only how but why complications from blepharoplasty occur. Most postoperative complications are in 1 of 4 categories:
- 1.
Inaccurate preoperative assessment
- 2.
Improper surgical technique
- 3.
Miscalculations in judgment
- 4.
Idiosyncratic outcome (unexplained complication)
Categorizing unexpected results into 1 of these 4 groups and recalling each of them before surgery is important and helps to continually improve surgeon skills and results.
Preoperative considerations
The cornerstone of any successful operation is an adequate preoperative evaluation, consisting of a patient history, examination, and medical evaluation. Patient counseling should stress expected results, normal time frame and range of wound healing response, possible unexpected results, and potential need for revision. Preoperative evaluation for blepharoplasty and brow ptosis is discussed elsewhere in this issue by Czyz and colleagues. A detailed photodocumentation of the preoperative state is an essential step in the surgery. Preoperative photographs of the eyelids and periorbita at multiple angles serve as a basis for comparison after surgery, and may help dispel patient concerns about supposed changes that were present before surgery.
Intraoperative considerations
Anesthesia
Most blepharoplasty procedures are performed under local anesthesia with or without monitored anesthesia care. General anesthesia can be used if additional facial surgery is added. Even when performed under general anesthesia, local anesthetic with vasoconstrictors is administered to aid in hemostasis. The type of anesthetic used should be individualized to each patient and according to surgeon preference.
We use a 1:1 mixture of 2% Xylocaine with epinephrine 1:100,000 and 0.75% bupivacaine. For upper eyelid blepharoplasty, we typically inject 2–4 mL per lid. Potential risks of anesthetic injection are intravascular injection and damage to vital orbital structures ( Fig. 1 ). Our injection technique always directs the needle away from the globe. In addition, gentle traction is applied to the upper eyelid to separate it from the globe, minimizing the risk of globe penetration ( Fig. 2 ). To completely anesthetize the deeper nasal fat pat, we inject additional anesthetic retroseptally in this quadrant ( Fig. 3 ).
If lower eyelid surgery is added, we typically perform surgery with monitored anesthesia care. Additional sedation is often needed during local anesthetic injection for patient comfort. It may be helpful to have an assistant steady the head during injection for added support. To decrease the risk of sneezing during administration of local anesthetic, the addition of fentanyl or alfentanil to propofol infusion has been advocated. Fifteen minutes should be allowed after injection to achieve the hemostatic effect of the epinephrine before incision.
Marking and Measuring
Marking eyelid crease
The skin marking for blepharoplasty is one of the most crucial portions of the operation. Although the technical aspect of blepharoplasty is straightforward, marking is an art. We typically mark within the patient’s natural eyelid crease unless an altered lid crease is desired. If no crease or an ill-defined crease is present, our general guidelines are to mark the eyelid crease 7 to 8 mm above the lash line centrally in white men and 8 to 10 mm in white women ( Fig. 4 ). The degree of lateral hooding, medial skin redundancy, and ethnicity also influence marking placement. For example, in Asian patients, the eyelid crease should be marked lower, no higher than 5 to 6 mm above the lash line in men and 6 to 7 mm in women. The crease is completed across the length of the lid, tapering medially at the upper punctum and laterally at the lateral canthus. When lateral hooding is significant, the marking should extend laterally past the canthus, angled superiorly for a length sufficient to reduce lateral skin excess. Medial skin redundancy, when present, is best managed by angling the skin marking superiorly 3 to 4 mm medial to the superior punctum. If the marking is angled inferiorly, aesthetically displeasing medial canthal webbing may occur and the incision is more noticeable.
Marking skin excision
The amount of skin to be removed is assessed with the pinch technique using a nontoothed forceps. The skin excess is pinched between the arms of the forceps with the lower arm beginning at the demarcated crease. The intervening skin is incorporated between the arms of the forceps ( Fig. 5 ). This technique is performed in the nasal, central, and temporal eyelid, with the excess skin marked at each point. The points are then connected in an arc and made continuous with the crease to form an ellipse for excision. Varying amounts of skin can be incorporated into the pinch depending on the desired result. The end point of redundant skin marking should not exceed mild eversion of the lashes.
Postoperative Complications
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Hemorrhage prevention
No matter how meticulous the surgical technique, bleeding is inevitable with skin incisions, and bruising should be expected following surgery. Bleeding is especially inevitable in blepharoplasty because the eyelid has a rich vascular supply. Whether or not to stop anticoagulation for elective blepharoplasty is continually debated. The preoperative evaluation should include a thorough history of anticoagulant use, including herbs and supplements. When possible, these medications and supplements should be discontinued. Our practice is to discontinue medications 7 to 10 days before surgery if the medication or supplement is taken for preventative reasons. However, if the medication is to treat a disease, the prescribing physician should be consulted as to whether the medication can be discontinued in the perioperative period. Current recommendations suggest anticoagulation therapy be discontinued before blepharoplasty, lacrimal surgery, and orbital surgery; however, randomized controlled studies substantiating this have not been performed. There is anecdotal evidence that Arnica montana reduces ecchymosis following blepharoplasty. However, in the only reported placebo-controlled, randomized, double-masked study, there was no evidence to suggest that A montana reduces or improves ecchymosis resolution following surgery.
Hemorrhage treatment
Preseptal hematoma
If hemorrhage does occur after surgery, bleeding may spread diffusely through interstitial tissues or may collect as a focal hematoma ( Fig. 6 ). The first step in evaluating a postoperative hematoma is to rule out the presence of a retrobulbar hemorrhage (discussed later) and ensure that vision has not been compromised. Once a retrobulbar hemorrhage has been excluded (no visual compromise), the application of mild, direct, firm pressure with ice to the site of the hematoma is appropriate. Although preseptal hematomas are not usually a threat to vision, the appearance can be a significant source of stress for the patient. In addition, they may lead to varying degrees of cicatrization, eyelid malposition, pigmentary disturbances, and discomfort. Conservative measures such as ice, sleeping with the head of the bed elevated, time, and reassurance are all that is typically needed. On occasion, a focal hematoma may require surgical evacuation, depending on its size, progression, and lack of response to more conservative therapy.
Retrobulbar hematoma
Although rare, with an incidence of 0.05%, a retrobulbar hematoma is a potentially serious consequence of blepharoplasty surgery. Arterial bleeding, whether deep or superficial, is likely the source of the bleed. The orbital volume is 30 cm 3 and there is little room for tissue expansion. Therefore, as the blood collects in the orbit, the eye becomes proptotic and loss of normal slack in the optic nerve occurs, which can lead to compression of the nerve or its blood supply. This orbital compartment syndrome can lead to significant visual compromise or blindness. The patient typically complains of severe pain and pressure in and around the eye and decreased vision. Clinical signs include ( Fig. 7 ):
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Proptosis
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Decreased vision
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A tense orbit
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Increased intraocular pressure
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Limitation of eye movements
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A relative afferent pupillary defect
