Key points

Introduction

Esthetic and functional surgery in the periocular region falls into the domain of oculoplastic surgeons, as well as plastic surgeons and otorhinolaryngologists with training in facial plastic surgery. The presence of the eye in the vicinity of the surgically targeted tissues requires careful attention. Inadvertent touching of the ocular surface by instruments, suture material, or cautery can easily lead to corneal and/or conjunctival damage. Disastrous consequences, such as ocular penetration by a needle during administration of local anesthetic or postseptal hemorrhage, can lead to blindness. Disruption of the eyelid protective function, caused in particular by excessive upper lid tissue removal or ptosis overcorrection, can lead to exposure of the cornea. This requires aggressive lubrication with artificial tears and gels to prevent epithelial compromise and risk of corneal ulceration, which can be vision threatening.

This article provides a description of 8 common eyelid procedures that are routinely performed under local anesthesia, with or without mild intravenous sedation. It is important to tell the patient that a needle is being injected close to the eye, that he or she will feel a pinch as the needle is being injected, and that it is imperative that he or she not move. When injecting near the eye, it is important for the surgeon to stabilize his or her hand on the patient’s face, so that if there is any surprise movement, the hand will follow, and any undesired complication is avoided. We instill a drop of 0.5% proparacaine or 0.5–1% tetracaine into each eye before injection of local anesthesia and add additional drops during the procedure as an adjunct as required. We prefer a 50:50 mix of lidocaine 2% with epinephrine (1:100,000) and bupivacaine 0.5% as the local anesthetic for the procedures discussed. Small-gauge (25 to 30 G) needles are used.

Postoperative care includes ophthalmic antibiotic ointment applied 3 to 4 times daily for 2 weeks. This causes temporary blurring of vision, so patients are advised to time application with activities, such as driving and reading, accordingly. We recommend acetaminophen, with or without codeine, for pain control. Patients are instructed to apply ice-cold water compresses at all times while awake for the first 72 hours to minimize bruising and swelling. We suggest that they place ice and water in a large bowl and alternate between 2 facecloths every 5 minutes to maximize the effect. We recommend that patients sleep on their back with their head elevated for the first couple of weeks following surgery to minimize swelling and reduce the risk of wound dehiscence.

Serious complications are rare. The rate of postoperative infection in the highly vascularized eyelid tissues is less than 1% in our experience. We reserve routine oral antibiotic use for hard palate mucosal grafting to the eyelid where infection in the oral cavity is the principal concern, and following lateral tarsal strip where infection, albeit rare, can lead to dehiscence of the strip and failure. Postseptal hemorrhage is an uncommon but vision-threatening complication and may occur in any procedure in which the orbital septum is violated. The incidence following blepharoplasty has been estimated at 1/2000 to 1/25,000. Orbital fat removal increases the risk, as vessels are directly severed. Cutting of clamped fat pedicles followed by bipolar cautery before release and subsequent retraction posteriorly into the orbit, or use of a CO ₂ laser for cutting are 2 commonly used techniques that are believed to reduce the risk. Blepharoplasty is associated with a multitude of complications. We have comprehensively reviewed the prevention and management of many of the complications of blepharoplasty in a freely accessible article available in PubMed Central.