Although these side effects are very common and expected, following a blepharoplasty operation, many patients become very stressed when they appear and despite the fact that they have been aware of such sequelae. Postoperative edema usually worsens during the initial 24–48 h after surgery. The degree of swelling is often directly related to surgical factors such as ecchymosis, excessive cauterization, extensive tissue manipulation or excision, and dissection in the lateral canthal area resulting in lymphatic disruption. Therefore, measures to avoid such intraoperative manipulations should be taken in order to reduce the incidence of severe edema. Moreover, ice water compresses right after surgery and continuous use for 72 h reduce the possibility of severe edema and bruising.

If, even though, the onset of severe and bruises cannot be avoided, either medication or other treatments can help to delay further deterioration and resolve the problem faster.

Use of Arnica orally or locally has been claimed to help, and some patients ask for this even without mentioning them the treatment.

Light treatments with low-emission diode (LED) high-intensity phototherapy devices, emitting in red and near-infrared spectrum, have also proved to help in wound healing and as anti-inflammatory tools. Everyday treatments postoperatively during the first week help in accelerating edema and partial bruising resolve. Low-level laser therapy with devices emitting in the same spectrum as LED provide the same results.

Massage-induced lymphatic drainage is also very helpful. Special exercises instructed to the patients using their fingers and applying smooth and efficient pressure periodically on the affected area have also been advocated in our practice in such cases.

Treatments start right after diagnosis of severe or annoying edema in the first follow-up visit of the patient.

Chemosis of the eye is a medical condition, in which the conjunctiva of the eye becomes swollen. The condition is mainly caused by the exudation of the small capillaries of the eye, presenting an abnormal permeability. Chemosis occurs when the eye has been irritated, representing however a nonspecific sign. The conjunctiva will appear as if having liquid in it. The inflammation of the conjunctiva leads to an overall gelatinous appearance. The degree of the swelling varies from one patient to the other and, sometimes, it can become so inflamed that the patient will have difficulties closing the eye (completely or partially). Due to the inflammation, the eyeball might appear as if moved from its original position (it should also be noted that the eyeball is not covered by the excess fluid) (Fig. 7.1).

The cause of conjunctival chemosis is multifactorial, and includes exposure, periorbital edema, postoperative lymphatic dysfunction, mechanical injury during surgery or pharmaceutical agents. It appears intraoperatively or in the first postoperative week, with an average duration of 4 weeks, depending on the mechanism which caused it.

Authors have classified chemosis in four different types as follows [1]:

In most cases, chemosis resolves spontaneously with the use of local lubricating and anti-inflammatory agents.

Transconjunctival incision can be a triggering factor of chemosis formation, particularly if not performed accurately and precisely. Transconjunctival infiltration of local anesthetic solution in lower blepharoplasty in a superficial plane under the conjunctiva might also cause chemosis due to dispersion of fluid under the conjunctiva. In both cases, the effect is temporal and resolves with local treatment in due course.

Surgical procedures for fluid drainage with conjunctivectomy or temporary tarsorrhaphy have also been reported, but in very rare cases. Prevention of chemosis-triggering factors during surgery is the most appropriate and important procedure to avoid this complication.

This quite common complication following a blepharoplasty operation can be triggered by several factors such as intraoperative canthopexy, postoperative temporary lagophthalmos, concurrent upper and lower blepharoplasty, and transcutaneous approaches violating the orbicularis oculi muscle.

Patients may experience dry eyes within the first few weeks after surgery. Persistent dry eye can occur and, in some cases, can be due to a preexisting problem or a surgical complication.

Some factors that can make it more likely to develop dry eyes after an upper eyelid blepharoplasty include thyroid problems, bulging eyelids, prior history of dry eyes, poor eyelid skin tone, weak eyelid ligaments, certain autoimmune diseases, defects in the tear duct pathways, as well as removal of too much eyelid skin during surgery, or significant postoperative swelling.

When these factors can be identified preoperatively, measures can be taken to avoid or reduce the risk of permanent dry eye. Depending on the nature of the problem, a conservative eyelid skin removal may be needed. In other patients, special lid-tightening procedures, such as SSTT, can be performed in addition to eyelid surgery to avoid problems. In some cases where there is a high risk of developing dry eyes, complete avoidance of blepharoplasty surgery may be advised.

Treatment of dry eye early on after a blepharoplasty includes the application of natural tears or medical eyedrops as well as lubricating ointments to keep the eyes moist. If dry eye persists for more than a few weeks despite topical treatment, special care and ophthalmological evaluation should be undertaken.

While permanent dry eye after eyelid surgery can be prevented in many instances, dry eye syndrome is a risk of surgery. Patients should be aware of all the risks of surgery, even when they are low.

In our series, we have noticed a low evidence of dry eye syndrome after blepharoplasty surgery, due to meticulous preoperative patients’ assessment and continuous efforts for precise surgery and avoidance of tissue damage during the operation. However, in 17% of patients, despite all the appropriate measures, dry eye symptoms have developed following blepharoplasty, which in the vast majority were transient and quickly resolved after local treatment.

Treatment of dry eye syndrome should be initiated right after patients complain of dryness of the eyes and include the following.

In severe cases, most unlikely to my experience, occlusive patches, contact eye lenses, and lipid and hormonal treatments have been used.

Epiphora is an excessive tearing condition of the eyes caused by a reflex tear secretion due to several factors. The eyelid blinking dysfunction after blepharoplasty is a common side effect due to postoperative swelling of the eyelid tissues. This dysfunction interferes with the tear pump mechanism.

The swelling can also cause the puncta to turn inward or evert by swelling or tissue contraction caused by incision lines or laser resurfacing, which also causes epiphora.

Lagophthalmos also can increase reflex tear secretion, due to primary dryness of the eyes, leading to relative epiphora.

Epiphora, if present, following a blepharoplasty operation and caused by the above reasons, is transient and resolves with edema reduction by time.

However, measures have to be taken during surgery not to damage important anatomical structures which can lead to very persistent and difficult-to-correct epiphora. Damage to the lacrimal outflow system can occur if the incision line is carried too medially and too close to the horizontal midline. The punctum is a useful landmark for the upper lid and lower lid incision. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Incisions should be at least 4–5 mm above the punctum to avoid the canaliculus. In the lower lid blepharoplasty, the medial part of the lower eyelid incision should stop lateral to the punctum, both in the transconjunctival and the subciliary type of incision.

Mild and transient epiphora has very rarely been noticed in some of our patients as a reflex tear secretion developed due to dry eye syndrome after blepharoplasty operations, and in all cases resolved spontaneously with eye lubrication, after diagnosis.

Levator muscle and levator aponeurosis are two anatomical features that should be protected from injury during upper blepharoplasty operation.

Symptoms similar to ptosis, but not due to levator muscle or aponeurosis injury, can occur on the next postoperative day in several patients. However, this is a result of the consequent edema of the eyelid and the muscle itself, and the experienced surgeon who has identified and preserved the levator muscle and aponeurosis will not be alarmed.

As described in Sect. 4.​3.​3, the levator muscle and its aponeurosis is the plane where the upper blepharoplasty fat removal is performed. To avoid any injury, incision to the septum should be performed high up toward the upper part of the skin incision, and the levator elements should be identified before fat removal, as the pulling of the freed fat pad upward can bring together the superficial part of the levator aponeurosis. Gentle detachment of the aponeurosis is required with a q-tip and not sharp instruments at this stage. The excision of the fat pad with CO₂ laser should also provide protection of the underlying aponeurosis with a backstop which in most cases is a cotton pad or q-tip Fig. 7.2. The same protection measures, as for the levator aponeurosis in upper blepharoplasty, also apply in the lower eyelid transconjunctival or subciliary approach, to protect the inferior oblique muscle injury.