This article is designed to offer a deeper understanding of complications that can occur with blepharoplasty and to highlight the realm of surgical and nonsurgical therapeutic interventions for revision.
Key points
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Functional and/or cosmetic complications can arise from upper blepharoplasty surgery.
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A detailed understanding of anatomy is an essential component of successful revision.
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Revision options include surgical and nonsurgical interventions.
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A successful outcome to revision surgery depends on a clear understanding of the patient’s complaint, clinically identifying the problem, and clearly delineating realistic expectations for revision.
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One of the most common complications of blepharoplasty is dry eye syndrome, for which there are a variety of nonsurgical options.
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The most common cosmetic complications are crease and/or fold, under- and overcorrection, asymmetry, and volume loss.
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Maintenance of racial and gender characteristics is critical to patient satisfaction.
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Maintaining a nonjudgmental attitude toward other physicians is vital to creating a healthy relationship with the patient.
Introduction
Blepharoplasty surgery is typically a routine and rewarding procedure. However, on occasion, it can lead to adverse outcomes. Proper preoperative evaluation, patient selection, and appropriate procedure customization will prevent most complications. However, even in the best of hands, patient dissatisfaction may result from unrealistic expectations, inappropriate surgical plan, over- or undercorrection, asymmetry, or an unexpected surgical event. The patient who is dissatisfied may present from the physicians’ own practice or as a referral. This article characterizes upper blepharoplasty complications and elaborates on available treatment options for revision blepharoplasty.
One of the first hurdles in managing a patient who requires revision surgery is to understand the emotional needs of a dissatisfied patient and how to delicately navigate the revision process. The psychological status of a dissatisfied patient is often complex and requires time and attention to properly navigate. The ultimate success of revision blepharoplasty depends on listening carefully to the patient’s concerns and outlining a realistic plan developed to meet her or his goals.
Whether the patient’s primary blepharoplasty was performed for cosmetic or functional reasons, the ensuing complication can be cosmetic, functional, or both. Therefore, a common tactic in addressing blepharoplasty revisions is to divide the complications into two categories: functional or cosmetic. This article presents techniques to recognize the categories of blepharoplasty complications and ultimately identify options for managing these problems. It is important to understand that even the finest surgeons will have some patients who suffer unexpected outcomes and that, fortunately, most complications can be managed appropriately.
Introduction
Blepharoplasty surgery is typically a routine and rewarding procedure. However, on occasion, it can lead to adverse outcomes. Proper preoperative evaluation, patient selection, and appropriate procedure customization will prevent most complications. However, even in the best of hands, patient dissatisfaction may result from unrealistic expectations, inappropriate surgical plan, over- or undercorrection, asymmetry, or an unexpected surgical event. The patient who is dissatisfied may present from the physicians’ own practice or as a referral. This article characterizes upper blepharoplasty complications and elaborates on available treatment options for revision blepharoplasty.
One of the first hurdles in managing a patient who requires revision surgery is to understand the emotional needs of a dissatisfied patient and how to delicately navigate the revision process. The psychological status of a dissatisfied patient is often complex and requires time and attention to properly navigate. The ultimate success of revision blepharoplasty depends on listening carefully to the patient’s concerns and outlining a realistic plan developed to meet her or his goals.
Whether the patient’s primary blepharoplasty was performed for cosmetic or functional reasons, the ensuing complication can be cosmetic, functional, or both. Therefore, a common tactic in addressing blepharoplasty revisions is to divide the complications into two categories: functional or cosmetic. This article presents techniques to recognize the categories of blepharoplasty complications and ultimately identify options for managing these problems. It is important to understand that even the finest surgeons will have some patients who suffer unexpected outcomes and that, fortunately, most complications can be managed appropriately.
Evaluation
Subjective Complaints
The most important part of the patient interview is understanding the patient’s primary complaint. What are the patient concerns? Is there a problem with dryness, irritation, difficulty blinking, or closing the eye? Or is the patient more concerned about the cosmetic appearance with respect to symmetry, scarring, and volume? The patient’s own words often help make the distinction as to whether the issue is functional or cosmetic. Identification of the patient’s concerns is the basis for the process of identifying options available for addressing the problem.
Physical Examination
We will review specific components of the physical examination that are relevant to a patient who presents for revision upper eyelid surgery. See the article by Lam and colleagues elsewhere in this issue for the pertinent anatomy when examining a patient undergoing primary upper eyelid blepharoplasty.
Standard measurements
The margin reflex distance (MRD1), along with the levator-muscle function (LF), is important to record when documenting uncorrected ptosis after blepharoplasty. The MRD1 is the distance from a light reflex centered on the pupil to the upper lid margin when the patient is staring at a light source in primary gaze. A normal measurement is roughly 3 to 4 mm. A lesser value indicates upper eyelid ptosis. The LF is the upper lid excursion from down to up gaze (with the brow immobilized), with a normal value of approximately 15. A patient who has undergone standalone upper blepharoplasty may have had preexisting ptosis that was overlooked. Excising redundant eyelid skin should not cause ptosis (low MRD1). If a patient underwent only blepharoplasty and the MRD1 is low after the procedure, it is likely that there was preoperative ptosis that not addressed in the primary procedure.
Another important anatomic measurement is the height of the anterior lamella present from lid margin to brow. A measurement of less than 20 mm is a significant indicator of excessive skin excision. It is important to document whether there is subtle eversion of the lid or inability to close the eyelid due to anterior lamellar shortage.
Orbicularis function
Lagophthalmos (poor lid closure) may result not only from aggressive skin excision but also from damage to the orbicularis muscle itself. It is not uncommon for skin and muscle to be excised together during upper blepharoplasty so recording the function of the muscle following such surgery is critical. This is especially important for patients who may have had preoperative underlying weakness such as facial nerve palsy or Parkinson’s disease. In such cases, removing muscle at the time of surgery will lead to further impairment in orbicularis function with poor eyelid closure. Eversion of the eyelid margin on forced closure is suggestive of orbicularis damage.
Lacrimal function and basal secretion test
One of the most common complaints after blepharoplasty surgery is immediate postoperative dry eye symptoms. These complaints typically resolve within a few weeks. When the problem persists, there may be underlying of dry eye pathology that was unmasked by the procedure. Alternatively, aggressive skin excision or orbicularis damage may have caused de novo ocular exposure and dry eye symptoms. Lacrimal gland function can be assessed with a Schirmer test, which documents basal tear secretion and identifies if there is a quantitative problem with tear production. The slit lamp examination should include evaluation of meibomian gland function through tear film breakup time (TBUT; the time it takes for tears to evaporate), which will indicate if a qualitative disturbance in tear quality is present. This involves placing fluorescein drops in the eyes, asking the patient to blink, and assessing the time it takes for the dyed tears to evaporate. It is relevant to document the presence of tear instability and dysfunction in the setting of aggressive skin removal and/or diminished orbicularis function because diminished tear quality may further exacerbate the symptoms of dry eye.
Crease and upper eyelid position and contour
A significant factor affecting the satisfaction of a patient after upper blepharoplasty is the symmetry in the eyelid position, crease, fold, and contour. Typical racial and gender variations should be taken into account. Typical female eyelid anatomy features a higher lid crease in contrast to male eyelid anatomy. Asian patients may prefer to maintain their lid with the crease in its anatomically low normal position. These individualized patient preferences are much better discussed before the surgery instead of after.
Brow position
In the previous section, the MRD1 was discussed as it relates to uncorrected ptosis. Equally important is evaluating the height and contour of the brow. Patients may complain of “droopiness” of the eyelid temporally, alleging that not enough eyelid skin was removed at the time of blepharoplasty surgery, when, in fact, the low position of the brow causes the temporal eyelid hooding. Additionally a persistent “heavy” feeling after blepharoplasty surgery may relate to untreated brow ptosis.
Lash anatomy
Oftentimes overlooked preoperatively, the postoperative eyelash position may be a source of dissatisfaction for the patient. Eyelash ptosis (an inferiorly directed lash position) may lead to discomfort and visual compromise for the patient. Recognizing and addressing this subtle issue can lead to a functional, as well as cosmetic, benefit for the patient.
Medial and lateral canthus
Generally, canthal appearance and function is unaffected by upper blepharoplasty procedures. However the canthal anatomy itself may affect the outcome of the surgery. Patients who have canthal or upper eyelid laxity may experience suboptimal ptosis correction when added to primary blepharoplasty. Patients with frank floppy eyelid syndrome require lid tightening at the time of primary surgery to address their upper eyelid functional compromise. Untreated laxity may lead to exacerbation of symptoms after blepharoplasty due to weakening of the orbicularis muscle as a consequence of surgery.
Also, particularly in Asian patients, the medial canthus may be altered after surgery when an epicanthal fold is present. Scarring and webbing of the medial canthus in Asian patient can occur with manipulation of the epicanthal fold. Reviewing preoperative photographs can be helpful in understanding the natural genetic phenotype.
Complications
After identifying the anatomic changes in a patient with a blepharoplasty complication, the revision surgeon can turn his or her attention to analysis and categorization of the problem and correction of the deficit. There are two general categories of upper blepharoplasty complications: functional and cosmetic. Some deficits fall into both categories and some patients have a combination of the two. Nevertheless, it is useful to analyze each component of the problem to customize the most effective management plan.
| Functional Complications | Cosmetic Complications |
|---|---|
| Lagophthalmos | Hollowing |
| Orbicularis damage | Scarring |
| Dry eyes | Crease, contour, and eyelash irregularity |
| Untreated ptosis | Medial canthal/ epicanthal irregularity |
| Undercorrection |
Functional complications
Lagophthalmos
Skin overresection
Excess skin excision in upper blepharoplasty is one of the most common complications of surgery ( Fig. 1 ). Blepharoplasty surgeons often focus on maximizing the surgical outcome by aggressively debulking the eyelid. This excision-based approach to surgery can lead to potentially significant problems with eyelid closure. A rule of thumb to avoid skin-shortage–related lagophthalmos is to ensure that at least 20 mm of skin remains from inferior brow to lid margin. This assumes normal brow position and the measurement can be altered based on brow location if brow lifting is not added. Using the “skin pinch” test during marking for skin excision will also help prevent skin shortage issues. In this technique, the proposed excess skin is captured with a forceps while observing the position of the lid margin. If the lid margin everts and/or there is more than mild degrees of lagophthalmos, less skin is engaged for safe excision.
When a patient presents with lagophthalmos (related to skin shortage) after blepharoplasty there are surgical and nonsurgical management options.
Surgical options for lagophthalmos correction
In cases in which limitation of eyelid closure is severe, the definitive treatment is skin grafting.
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The eyelid skin is among the thinnest on the body. As such, appropriate harvest sites should best match the skin of the eyelid and include, in descending order, skin from the:
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Opposite upper lid
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Postauricular area
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Supraclavicular area.
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If donor skin in these harvest sites is inadequate, the inner upper arm, inner thigh, or, rarely, foreskin can be considered.
The recipient bed on the eyelid is typically fashioned through an eyelid crease incision. Secondarily, a supralash incision can be used. A marginal traction suture is used to place the upper lid on downward stretch. Dissection can be performed in the subcutaneous plane as needed to fully expand the defect with care to avoid damage to the orbicularis muscle (which can further limit eyelid closure). Hemostasis is assured but overzealous cautery must be avoided to maintain blood supply to the grafted skin.
Once fully created, the recipient bed is measured horizontally and vertically. The dimensions are noted and an appropriately sized full-thickness graft is harvested. The graft is thinned of subcutaneous tissue as needed, its size is adjusted as appropriate, and the graft is secured to the recipient bed with fibrin tissue glue and/or circumferential sutures. Focal 1 mm full-thickness skin ports can be created throughout the graft to allow egress of blood. The upper eyelid can be placed on stretch with a reverse Frost suture to optimize healing and the eye firmly patched for up to 7 days. In the most severe cases, a permanent lateral tarsorrhaphy and/or lid recession (levator or Mueller’s muscle) can be added.
Nonsurgical options for lagophthalmos correction
In more subtle cases of lagophthalmos related to skin shortage, or when the patients does not desire further surgical intervention, less invasive maneuvers are used to help address patient symptoms.
One elegant option is the use of chemodenervation to induce brow depression. The brow and upper eyelid are intimately related. As brow position changes the eyelid is secondarily effected. Changing the brow position with neurotoxin (Botox, Dysport) can induce brow depression and mechanical pressure on the upper eyelid, with resultant improved eyelid closure and reduction of exposure symptoms. It is important to counsel the patient on the potential consequences of this procedure, including brow immobility and ptosis.
Another nonsurgical option to reduce lagophthalmos is the addition of hyaluronic acid gel fillers to the upper lid. In this instance the filler is not added solely for volume augmentation but also to create a lamellar and/or scar expansion and, potentially, as a load (weight) to aid in closure.
Using tape to aid in closing the eyelids during sleep can be helpful in reducing nocturnal lagophthalmos.
Orbicularis Damage
The strength and tone of the orbicularis muscle may be impaired after blepharoplasty surgery with or without postoperative skin deficiency. Orbicularis weakness is more commonly seen when transcutaneous lower lid surgery and/or canthal suspension is added; however, it is also seen with stand-alone upper blepharoplasty. The orbicularis muscle is innervated by the zygomatic branch of the facial nerve, which enters the muscle lateral to the lateral canthus. Extended lateral incisions and the addition of canthal suspensions (when lower lid surgery is added) can contribute to orbicularis weakness.
In upper blepharoplasty, the preseptal orbicularis is often resected with the skin in the course of tissue excision, which can affect the involuntary lid closure. Involuntary blink is critical for the tear pump mechanics, reflex tear production, and maintaining tear film stability. Testing for orbicularis weakness is performed by asking the patient to maximally squeeze their eyelids shut while the examiner simultaneously opposes this action with digital counterpressure on the eyelids. Orbicularis weakness is confirmed with ease of lid opening or, in less severe cases, eversion of the eyelid margin.
Surgical treatment of orbicularis damage
Unfortunately there is no definitive surgical treatment to improve orbicularis muscle function.
Insertion of an upper eyelid gold weight is the ultimate solution for advanced orbicularis paralysis—similar to the treatment of facial nerve palsy patients. An appropriately sized gold or platinum weight can be surgically implanted in the pretarsal space via an upper eyelid incision. A nonsurgical equivalent of the eyelid gold weight can be accomplished by injecting hyaluronic acid into the pretarsal space to act as an upper eyelid load.
Canthal suspension procedures with associated muscle tightening may improve the length-tension dynamics of the orbicularis, thereby maximizing its contractility. Canthoplasty is a low-risk, minimally invasive maneuver that may be worthwhile—especially in the setting of upper eyelid laxity.
Other surgical options for improving the problems related to orbicularis weakness include skin grafting and partial lateral tarsorrhaphy.
Nonsurgical options for treating orbicularis damage
Nonsurgical supportive therapy for orbicularis function deficit–related lagophthalmos include therapies to improve ocular lubrication (see later discussion on nonsurgical management of dry eye).
Dry Eye
Perhaps the most common problem a patient faces after upper blepharoplasty is new or worsening dry eye symptoms. Patients may complain of grittiness, foreign-body sensation, blurring, discharge, and red eyes. The problem is often multifactorial, related to skin deficiency, poor lid closure, and reduced tear production. The patient may have had an unrecognized preexisting dry eye condition that was exacerbated by surgery. Preoperatively, patients manifesting even subtle degrees of dry eye should have the condition detailed in depth and maximally managed before proceeding with blepharoplasty. If it is deemed safe for patients with dry eye syndrome to proceed with surgery, they will be better equipped to handle side effects should they occur after surgery.
When treating postoperative dry eye, it is important to determine whether the problem is a qualitative (tear quality) or quantitative (tear production) in nature, or a combination. The Schirmer and TBUT measurements previously described will help differentiate the nature of the problem. Dry eye symptoms can be very troublesome to patients. Fortunately there are a variety of treatment options to minimize dry eye symptoms.
Surgical options for treating dry eye
Conservative management is the best initial option.
If symptoms persist, or are severe enough to warrant a procedure, then lacrimal punctual occlusion by cautery or open intracanalicular suturing is a useful step toward improving ocular surface lubrication.
Last resort options include (as previously mentioned) skin grafting, upper eyelid gold weight placement, and permanent lateral tarsorrhaphy.
Nonsurgical options for treating dry eye
The frequent use of preservative-free artificial tears and ointment is the initial step in treating dry eyes.
If symptoms persist, punctual occlusion (with plugs) should be considered. Punctal and canalicular plugs come in a variety of shapes and sizes, but they are all designed to obstruct lacrimal outflow and maximize ocular surface lubrication. Ideally, intracanalicular plugs, along with small punctual plugs, should be avoided because these tend to migrate and are difficult to retrieve if necessary.
Once the quantitative component of tears has been maximized, efforts to improve the qualitative component (quality of tears), if needed, is useful. Lid hygiene maneuvers (baby shampoo, lid scrubs) and warm compresses may increase the lipophilic component of the tear film and prevent tear evaporation. The use of oral fish oil 1000 mg by mouth twice per day has also been known to improve ocular lubrication.
It is helpful to spend time with patients discussing specific environmental factors that might worsen dry symptoms, such as overhead and tabletop fans, and factors that can reduce ambient humidity (local climate, season, and home thermoregulation.) Using a humidifier in the bedroom at night can be a useful adjuvant therapy.
Finally, taping the eyelids closed at night and tissue expansion or lid load with hyaluronic acid filler can be considered when eyelid closure is a significant causative factor.
Untreated Ptosis
Management of ptosis begins with identifying the problem. The MRD1 is recorded and used as reference for the severity of ptosis. The LF should be documented to plan the appropriate procedure for correction. Unrecognized preoperative ptosis masked by dermatochalasis at the time of initial evaluation is, as previously mentioned, a common cause of ptosis after blepharoplasty ( Fig. 2 ). Excess skin does not lead to true eyelid ptosis and lid position should always be determined preoperatively.
