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Recognizing and Managing Complications in Blepharoplasty

Published:October 17, 2013DOI:https://doi.org/10.1016/j.fsc.2013.08.002

      Keywords

      Key points

      • Always err on the conservative side, as it is far easier to remove more tissue than to replace deficient tissue.
      • Be patient during the healing process; time heals many imperfections and avoid early interventions.
      • Proper preoperative counseling of patients is essential to maximize patient satisfaction with surgery.
      • Preoperative and prior patient photographs are necessary to review before surgery and also help to document improvement.
      • Upper eyelid markings are crucial to achieving optimal results and many complications can be avoided with proper markings.

      Introduction

      The earliest attempts at removing excess skin, puffiness, and wrinkling of the eyelid skin was during the tenth and eleventh centuries by Arabic surgeons.
      • Swaddle J.P.
      • Cuthill I.C.
      Asymmetry and human facial attractiveness: symmetry may not always be beautiful.
      Today, blepharoplasty has become the second most common cosmetic procedure performed in the United States.

      International Communications Research. 2011 AAFPRS Membership Study. January 2012:1–35.

      It is one of the least invasive cosmetic surgeries available and, when performed correctly, is very safe and yields excellent results. It is one of the most effective ways to rejuvenate the periocular area. However, devastating complications, ranging from permanent vision loss to cosmetic deformity can occur following blepharoplasty. Most complications result from unrecognized changes in anatomy, errors in measurements, or overzealous removal of tissue (Table 1). This article outlines the most common blepharoplasty complications that occur, and offers preventive measures to avoid such complications.
      Table 1Causes, avoidance and correction of blepharoplasty complications
      ComplicationCausesAvoidanceCorrection
      Residual upper lid skinUnderestimation of dermatochalasisLearn and use proper pinch techniqueRevision with skin excision
      Eyelid ptosisUnrecognized preoperatively, trauma to levator aponeurosis during blepharoplastyMeasure MRD preoperativelySurgical correction of ptosis
      Superior sulcus deformityOveraggressive removal of fat during blepharoplastyEvaluate superior sulcus preoperatively; judicious fat excision, medial onlyAugment superior sulcus with fillers (autologous, hyaluronic acid)
      Eyelid crease asymmetryUneven marking of eyelid creaseMeasure eyelid crease with caliper at various points across lidCrease revision with fixation to levator aponeurosis
      Eyelid retraction/ectropionOverly aggressive skin removal, scarring of the middle lamellaConservative skin excision; minimize cauteryMiddle lamellar release with posterior lamellar grafting
      Canthal webbingExtending incision too close to lid margin medially or laterallyProper marking preoperativelyZ-plasty, canthoplasty, skin grafting
      Brow ptosisUnrecognized preoperatively; overaggressive skin removal from upper eyelid accentuates brow ptosisEvaluate eyebrow position with patient in the relaxed state preoperativelyCorrect eyebrow ptosis
      LagophthalmosOverly aggressive skin removal from upper or lower eyelidsConservative removal of skinFull-thickness skin grafting; midface lifting, posterior/middle lamellar grafting
      Globe perforationMisdirection of needle during injection of local anestheticNever direct needle at globeEmergent referral to ophthalmologist for complete eye examination
      Hemorrhage (preseptal, retrobulbar)Excessive venous or arterial hemorrhageStop anticoagulation; ensure surgical field is dry; avoid valsalvaEmergent canthotomy/cantholysis (retrobulbar); conservative measures (preseptal hematoma)
      Infection (preseptal, orbital)Bacterial, fungalPrep with betadine; instruct patient to keep area clean and dry; antibiotic ointmentPreseptal: Trial of broad-spectrum oral antibiotics

      Orbital: Admit to hospital for intravenous antibiotics; ophthalmology consult
      DiplopiaTraumatic injury to extraocular muscles; injection of local anesthetic into extraocular muscles; suture incorporation of muscleAvoid deep injectionReferral to strabismus specialist
      Lacrimal gland injuryInadvertent resection of the lacrimal glandRecognize appearance of lacrimal gland prolapseSupportive measures with artificial tears, ointments
      Horizontal eyelid phimosisLateral canthal dehiscenceEnsure lower crux of canthus is reapproximated to superior cruxCanthus-sparing canthopexy/canthoplasty
      Corneal abrasionExposed cornea during surgery; accidental trauma during surgeryCorneal protectors with ointmentReferral to ophthalmologist
      FireSpontaneous combustion of flammable material, spark, and oxygenAvoid use of cautery, moisten field during cautery use, turn off supplemental oxygenSupportive measures
      Wound dehiscencePoorly tied sutures, patient noncompliance (rubbing, exertion)Proper suture techniqueDebride wound and resuture
      Suture granulomaForeign body reaction to sutureUse smallest sutures possibleObservation, trial of steroid cream, excision
      The dissatisfied patientUnrealistic expectations, unexpected bruising or postoperative healing, personality differenceFull disclosure of risks of surgery, realistic expectations of surgeryReassurance, empathy frequent office visits

      Inadvertent errors in assessment

      Residual Skin Excess

      A conservative approach to blepharoplasty is essential, as the consequences of overaggressive tissue removal are more difficult to correct than the consequences of residual skin excess. Patients should be counseled preoperatively that approximately 5% to 10% of patients will need additional residual skin removed following blepharoplasty and that removing more skin later does not limit the final cosmetic result. Residual dermatochalasis usually results from an underestimation of how much dermatochalasis is present and is noted most commonly on the lateral eyelid.
      In any patient desiring further removal of eyelid skin, evaluation for eyebrow ptosis should be performed. If concurrent eyebrow ptosis is present, removal of more skin will only exaggerate the eyebrow ptosis. For these patients, the eyebrow ptosis should be addressed before revising the blepharoplasty. If eyebrow ptosis is not present, the surgeon must ensure adequate skin remains for the eyelid to properly close after revision. Historically, this has been 20 mm measured in the center of the eyelid, from the lash line to the base of the brow. If the patient has cosmetically altered the brows with tattoos, the natural brow height should be used.
      Patients may request more skin to be removed when there is questionable residual skin present. Explanation of the importance of proper lid function and avoidance of lagophthalmos informs the patient of additional risk and usually dissuades the patient from seeking further revision. Revision should be considered only after healing is complete, usually 3 to 6 months after the initial surgery.

      Eyelid Ptosis

      If unrecognized, uncorrected eyelid ptosis limits the cosmetic result of a blepharoplasty. Ptosis is defined medically as a margin-to-reflex distance-1 of 2.5 mm or less. However, many patients recognize even more subtle differences between the eyelid heights, and even as little as 0.5 mm will be intolerable to some patients. Therefore, the margin-to-reflex distance must be measured preoperatively with the patient in the relaxed state to document asymmetry. Preoperative discussion with the patient regarding preexisting ptosis is essential to avoid postoperative disappointment.
      In the early postoperative period, eyelid ptosis following blepharoplasty is not uncommon. It can be the result of postoperative edema and should not be worrisome; however, if ptosis persists after resolution of postoperative edema, it is possible the levator muscle/aponeurosis was traumatized or disinserted during blepharoplasty (Fig. 1). If the levator function is decreased following surgery, damage to the muscle should be expected and likely the patient will require levator advancement to correct the ptosis. Sound knowledge of the eyelid anatomy is essential to avoid inadvertent damage to surrounding structures. The levator muscle is located directly beneath the preaponeurotic fat pad; therefore, dissection beyond the fat pads should be limited to avoid levator injury (Fig. 2).
      Figure thumbnail gr2
      Fig. 2Fat pads of the upper and lower eyelid.

      Superior Sulcus Contour Deformity/Hollowing

      Trends in upper and lower blepharoplasty rejuvenation techniques have shifted from fat resection to fat conservation.
      • Hamra S.T.
      The role of orbital fat preservation in facial aesthetic surgery. A new concept.
      • Lam S.
      • Glasgold M.
      • Glasgold R.
      Complementary fat graphing.
      A youthful upper eyelid is full, especially in the lateral aspect.
      • Fezza J.P.
      The sigmoid upper eyelid blepharoplasty: redefining beauty.
      With time, the central fat pad atrophies, while the medial fat pad become more prominent; this can cause a tear drop–shaped deformity in an otherwise hollowed eyelid (Fig. 3).
      • Oh S.R.
      • Chokthaweesak W.
      • Annunziata C.C.
      • et al.
      Analysis of eyelid fat pad changes with aging.
      Overaggressive resection of fat during upper eyelid blepharoplasty can result in a hollowed superior sulcus that is particularly aging. The volume of the upper eyelid is in part made up of the medial and central fat pads, as well as the eyebrow fat pad. The composition of these fat pads is different. The medial fat pad is lighter in color due to variations in carotenoid composition and possibly from enrichment of orbital stem cells.
      • Sires B.S.
      • Saari J.C.
      • Garwin G.G.
      • et al.
      The color difference in orbital fat.
      • Korn B.S.
      • Kikkawa D.O.
      • Hicok K.C.
      Identification and characterization of adult stem cells from human orbital adipose tissue.
      Targeted removal or repositioning of the medial upper eyelid fat may be necessary if a patient has a tear drop nasal fat accumulation.
      • Massry G.G.
      Nasal fat preservation in upper eyelid blepharoplasty.
      • Lee J.W.
      • Baker S.R.
      Esthetic enhancements in upper blepharoplasty.
      • Oh S.R.
      • Chokthaweesak W.
      • Annunziata C.C.
      • et al.
      Analysis of eyelid fat pad changes with aging.
      Preoperative examination should include observation of the medial and lateral eyelid contour to evaluate the prominence of the medial and central fat pads.
      Figure thumbnail gr3
      Fig. 3Natural hollowing of the upper eyelids in an 89-year-old Caucasian woman. No eyelid surgery has been performed.

      Asymmetric Eyelid Crease

      Although there are studies both for and against symmetry equaling beauty in a face, almost all faces have some asymmetry.
      • Swaddle J.P.
      • Cuthill I.C.
      Asymmetry and human facial attractiveness: symmetry may not always be beautiful.
      Patients seeking cosmetic or functional blepharoplasty, however, expect relative symmetry postoperatively. After blepharoplasty, some patients will notice asymmetry between their eyes that was present preoperatively, but never recognized. For this reason, it is essential to have high-quality preoperative photographs documenting asymmetry.
      However, errors in preoperative assessment and markings, in some cases, may lead to avoidable asymmetry postoperatively (Fig. 4). Complete preoperative examination of eyelids for ptosis, globe prominence, and thyroid eye disease is necessary to avoid suboptimal results.
      Figure thumbnail gr4
      Fig. 4Asymmetric eyelid creases (black arrows) following blepharoplasty.
      Marking of the skin is the most critical portion of the upper eyelid blepharoplasty surgery. Although there are standard guidelines, the markings are for the most part artistic and decided on by the surgeon. Some variations in markings exist that will yield slight differences in results, but in general the better outcome is in the eye of the beholder (Fig. 5). Usually, respecting the patient’s natural eyelid crease is desired, unless the patient wishes an altered lid crease. If no obvious crease is visible or if the crease is heightened due to levator dehiscence, marking the eyelid crease 7 to 8 mm above the lash line in Caucasian men and 8 to 10 mm above the lash line in Caucasian women yields are good guidelines. Guidelines in Asian men are a crease set between 5 to 6 mm and Asian women at 6 to 7 mm.
      Figure thumbnail gr5
      Fig. 5Eyelid blepharoplasty markings. (A) The lower mark usually courses along the patient’s natural eyelid crease and nontoothed forceps are used to grasp the redundant skin with the lower forceps grasping at the inferior mark. (B) The completed mark for upper eyelid blepharoplasty. (C) As a guideline, usually the potential skin to be removed should “disappear” when patients open their eyes.
      The crease extends in a fairly mild arc from lateral to medial canthus. Beyond the puncta, the marking should angle superiorly to avoid medial canthal webbing postoperatively. Laterally, beyond the lateral canthus, the marking should also angle superiorly to address any hooding. Then, 2 nontoothed forceps should be used to pinch the excess skin while avoiding lagophthalmos. This should be performed centrally, medially, and laterally to mark the redundant skin. These points should then be connected in a smooth arc. The patient is then asked to open his or her eyelids and the upper and lower markings should blend together (see Fig. 5C).
      Initially, asymmetry between the eyelids is common and the patient can be reassured. However, once the healing is complete, if significant asymmetry exists, revision may be considered. In general, it is easier to raise a crease rather than lowering one. A higher crease may be created by making a new incision above the previous mark and fixating the orbicularis at the new height to the levator aponeurosis. Lowering the crease is more difficult, and requires making a lower incision at the new lower level with advancement of the preaponeurotic fat or placing free fat pearls to prevent readhesion at the higher level. Although good results can be obtained, these results are often not as desirable as appropriate initial marking.

      Eyelid Retraction/Ectropion

      One of the most troublesome complications following lower eyelid blepharoplasty is eyelid retraction and cicatricial ectropion, as they are not only cosmetically deforming, but can cause agonizing symptoms of foreign body sensation and decreased vision (Fig. 6A). Eyelid retraction often results from scarring of the middle lamella during lower eyelid blepharoplasty. Eyelid ectropion is typically caused by aggressive removal of skin during lower eyelid blepharoplasty and unrecognized lower eyelid laxity. To avoid this, judicious skin removal should be performed during lower eyelid blepharoplasty only if significant redundancy of the skin exists. In general, at most only a few millimeters of skin should be removed. Many patients only require lower eyelid fat recontouring rather than skin excision. It is important to explain to patients preoperatively that lower eyelid blepharoplasty addresses the contour of the lower eyelid rather than removal of skin. The crepelike quality and deep rhytids of the skin will not change with blepharoplasty. Often a skin treatment, such as a chemical peel or laser resurfacing, is needed to address this.
      Figure thumbnail gr6
      Fig. 6(A) Severe eyelid retraction following lower eyelid blepharoplasty. (B) Postoperative photo demonstrating correction of the lower eyelid retraction with Enduragen implant to both lower eyelids.
      Correction of eyelid retraction can be performed with autologous tissue, such as hard palate, dermis fat, or acellular dermis, to build up the posterior with complete release of the middle lamella (see Fig. 6B).
      • Borrelli M.
      • Unterlauft J.
      • Kleinsasser N.
      • et al.
      Decellularized porcine derived membrane (Tarsys(R)) for correction of lower eyelid retraction.
      • Oestreicher J.H.
      • Pang N.K.
      • Liao W.
      Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients.
      • Korn B.S.
      • Kikkawa D.O.
      • Cohen S.R.
      Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases.
      • Korn B.S.
      • Kikkawa D.O.
      • Cohen S.R.
      • et al.
      Treatment of lower eyelid malposition with dermis fat grafting.
      Skin grafting is considered the last option and will likely be necessary only in severe cases. Although reconstructive efforts result in restored lid position, often the function and cosmetic result is not as ideal as if the retraction and ectropion did not occur.

      Canthal Webbing

      An unsightly complication following blepharoplasty is webbing of the tissue at the medial or lateral canthus. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. Laterally, this results when the upper and lower incisions join to create an inferior angle or if too much skin is removed. This is more likely to occur in Asian patients, or any patient with a lower-set eyelid crease and patients with brow ptosis. Proper marking is essential to avoid this complication.

      Brow Ptosis

      Accurate preoperative assessment of the facial and eyelid anatomy is essential to achieving a sound cosmetic result. Identification of the eyebrow ptosis preoperatively is essential. Regardless of the amount of skin to be removed during blepharoplasty, at least 20 mm of skin should remain on the upper eyelid to allow for proper eyelid closure following surgery. If brow ptosis is unrecognized and the amount of remaining skin is not measured, excessive skin can be removed, leading to lagophthalmos and further exaggeration of the eyebrow ptosis (Fig. 7). This is a difficult problem to fix and may require skin grafting to ameliorate the problem. In cosmetic patients, this may not be an acceptable option, so supportive measures with aggressive lubrication should be initiated.
      Figure thumbnail gr7
      Fig. 7(A) Preoperative photo of patient complaining of his eyelids blocking vision. (B) Postoperative photo following blepharoplasty only. The result was limited, as his brow ptosis was not corrected at the time of surgery.

      Lagophthalmos

      Lagophthalmos, or the inability to close the eyelids following surgery, has various causes and usually is transient. Preoperatively, patients should be asked about previous eyelid and facial procedures. In particular, patients should be asked about previous eye surgery, such as laser in situ keratomileusis (LASIK), as these patients are more likely to develop symptoms from lagophthalmos following surgery.
      • Korn B.S.
      • Kikkawa D.O.
      • Schanzlin D.J.
      Blepharoplasty in the post-laser in situ keratomileusis patient: preoperative considerations to avoid dry eye syndrome.
      Early postoperative lagophthalmos is usually due to edema, decreased patient effort because of pain, or temporary orbicularis dysfunction and usually resolves with time. Artificial tears and ointment may be necessary to ensure the cornea remains moisturized during this time. Persistent lagophthalmos extending beyond the postoperative period may require intervention. Patients may be able to tolerate mild lagophthalmos if they have an intact Bell phenomenon; however, more than 2 mm usually causes symptoms of tearing, foreign body sensation, conjunctival injection, corneal decompensation, and vision loss (Fig. 8).
      Figure thumbnail gr8
      Fig. 8Patient with lagophthalmos following overaggressive resection of eyelid skin.
      Causes of lagophthalmos include excessive removal of skin from the upper eyelid, orbicularis paresis due to facial nerve injury, excessive orbicularis resection, and eyelid retraction. Accurate preoperative assessment of eyelid and facial relationships and conservative markings is key to avoiding lagophthalmos. At least 20 mm of skin should remain, when measured from brow to lid margin in the center of the eyelid, after the excess skin is excised, in order for the lid to close properly (Fig. 9).
      Figure thumbnail gr9
      Fig. 9(A) Postoperative image of a patient following blepharoplasty with lagophthalmos due to overaggressive resection of skin. (B) Only 12 mm of skin remains from his lash line to inferior brow.
      The cosmetic patient who wants every last bit of redundant skin removed should be counseled that this is not possible nor desired. Proper explanation of the importance of eyelid function and reassurance that the primary goal of surgery is to improve appearance while respecting the role of the eyelids is often adequate to manage expectations. Also, informing patients that a touch up is possible to remove residual skin if necessary reassures them.

      Surgical complications

      Inadvertent Globe Perforation

      Use of local anesthetic is essential for patients during blepharoplasty, whether performed under intravenous sedation or general anesthesia. Our preference is to use a mixture of 0.375% marcaine mixed with 1% lidocaine with 1:200,000 epinephrine to anesthetize the eyelid and achieve hemostasis. Inadvertent perforation of the globe with the needle with subsequent injection of anesthetic is a devastating and avoidable complication.
      • Schrader W.F.
      • Schargus M.
      • Schneider E.
      • et al.
      Risks and sequelae of scleral perforation during peribulbar or retrobulbar anesthesia.
      • Ghosh S.
      • Mukhopadhyay S.
      • Mukhopadhyay S.
      • et al.
      Inadvertent intracorneal injection of local anesthetic during lid surgery.
      On injection, the needle tip should always be directed away from the globe. Once in the subcutaneous space, the anesthetic should be injected slowly to create a fluid wave that separates the tissues, creating more room for the needle tip to be advanced. Traction can also be placed on the upper eyelid and brow to elevate the upper lid from the globe to give addition space.

      Hemorrhage

      Regardless of the technique used, a small amount of hemorrhage is expected during surgery, with resultant ecchymosis. Patients should be informed preoperatively of this to manage postoperative concerns. A thorough preoperative history should be taken, including anticoagulation use and herbal supplements. To minimize bleeding during surgery, these medications should be discontinued if possible.
      • Heller J.
      • Gabbay J.S.
      • Ghadjar K.
      • et al.
      Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know.
      • Spyropoulos A.C.
      • Douketis J.D.
      • Gerotziafas G.
      • et al.
      Periprocedural antithrombotic and bridging therapy: recommendations for standardized reporting in patients with arterial indications for chronic oral anticoagulant therapy.
      Some patients elect to take the herbal supplement, Arnica montana, in hopes to improve postoperative bruising; however, most evidence has been anecdotal.
      • Riley D.
      Arnica montana and homeopathic dosing guidelines.
      One randomized trial of patients using A montana following face-lifts did show statistically significant improvement in postoperative ecchymosis.
      • Seeley B.M.
      • Denton A.B.
      • Ahn M.S.
      • et al.
      Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial.
      However, in the only randomized, placebo-controlled study available evaluating the effectiveness of A montana following blepharoplasty, no statistically significant improvement was found.
      • Kotlus B.S.
      • Heringer D.M.
      • Dryden R.M.
      Evaluation of homeopathic Arnica montana for ecchymosis after upper blepharoplasty: a placebo-controlled, randomized, double-blind study.

      Preseptal Hematoma

      Postoperatively, the residual or active hemorrhage may spread diffusely across the lid in the preseptal space or form a focal hematoma. This may result in an unsightly, swollen, sometime tense lid (Fig. 10). In these cases, it is essential to evaluate for a retrobulbar hematoma (discussed later in this article). In a preseptal hematoma, the vision is usually not compromised and pain is minimal. If the hematoma is deemed to be located only in the preseptal space, direct pressure and cold compresses should be applied. Preseptal hematomas are best managed with conservative measures, such as keeping the head elevated, applying ice, rest, and close observation. Attempts to evacuate or drain the hematoma is typically not necessary and may cause recurrent bleeding. The tension created in the preseptal space by the hematoma may tamponade the leaking vessel. Therefore, removal of the hematoma may cause recurrent accumulation. Preseptal hematoma is often very concerning to the patient due to delayed recovering and its appearance; however, they are rarely a threat to vision and to the final esthetic outcome. It is essential to counsel patients of this before surgery and if it does occur, reassure patients that the hematoma will resolve and the result will likely not be compromised.
      Figure thumbnail gr10
      Fig. 10Preseptal hematoma in the left lower eyelid following lower eyelid blepharoplasty.

      Retrobulbar Hematoma

      A retrobulbar hemorrhage is one of the most feared consequences of blepharoplasty (Fig. 11). Fortunately, this complication is rare, with an incidence of 0.055%. Permanent vision loss following blepharoplasty is even more rare, with an incidence of 0.045%.
      • Hass A.N.
      • Penne R.B.
      • Stefanyszyn M.A.
      • et al.
      Incidence of postblepharoplasty orbital hemorrhage and associated visual loss.
      Although most occur within 24 hours days after surgery, retrobulbar hemorrhages leading to permanent vision loss have been reported up to 9 days postoperatively.
      • Teng C.C.
      • Reddy S.
      • Wong J.J.
      • et al.
      Retrobulbar hemorrhage nine days after cosmetic blepharoplasty resulting in permanent visual loss.
      During blepharoplasty, the septum is often opened to remove or reposition the preaponeurotic fat pad. This creates a communication between the anterior and posterior orbit and a track for blood to travel into the orbit. Usually, retrobulbar hematoma is caused by arterial bleeding, either superficial or deep. The orbital volume is 30 mL, with little room for tissue expansion. Therefore, blood accumulation can lead to a compartment syndrome, with severe pain, proptosis, limitation of extraocular movements, increased intraocular pressure, and an afferent pupillary defect if the optic nerve is compressed. Vision loss can occur, as the vascular supply to the retina is compromised from increased pressure. It represents a true ophthalmic emergency. If the orbital compartment syndrome if not addressed, vision loss can be permanent.
      Figure thumbnail gr11
      Fig. 11Retrobulbar hematoma occurring 12 hours after blepharoplasty.
      If signs of retrobulbar hemorrhage are present following surgery, an emergent lateral canthotomy/cantholysis should be performed. Initially, the diagnosis of a retrobulbar hemorrhage is a clinical one, and the decision to perform canthotomy/cantholysis should not be delayed for radiographic studies to confirm findings. Complete release of the inferior crus should be performed first. The upper crus can be lysed as well, if needed. Once the canthotomy/cantholysis has been performed, the surgical wound should be explored for the offending vessel and cautery applied.

      Preseptal/Orbital Cellulitis

      The vascular supply to the eyelid is robust and fortunately, postoperative infections are rare. The most common pathogens are Staphylococcus and Streptococcus species.
      • Chaudhry I.A.
      • Shamsi F.A.
      • Elzaridi E.
      • et al.
      Outcome of treated orbital cellulitis in a tertiary eye care center in the Middle East.
      However, more unusual pathogens may invade the eyelids, including atypical mycobacteria. Necrotizing fasciitis has also been reported.
      • Mauriello Jr., J.A.
      Atypical mycobacterial infection of the periocular region after periocular and facial surgery.
      • Suner I.J.
      • Meldrum M.L.
      • Johnson T.E.
      • et al.
      Necrotizing fasciitis after cosmetic blepharoplasty.
      Additionally, methicillin-resistant Staphylococcus aureus has been an increasing source of postoperative infections following any surgery, including blepharoplasty.
      • Juthani V.
      • Zoumalan C.I.
      • Lisman R.D.
      • et al.
      Successful management of methicillin-resistant Staphylococcus aureus orbital cellulitis after blepharoplasty.
      If untreated, infections can spread rapidly and cause permanent vision loss, so early diagnosis and treatment are essential. Certain groups of patients, such as immunosuppressed patients, are at increased risk of developing infections postoperatively.
      If localized to the preseptal space, infection can be managed empirically as an outpatient with broad-spectrum antibiotics and close follow-up (Fig. 12). Presenting symptoms usually include erythema around the incision, heat, swelling, and discharge. Vision is usually unaffected, extraocular movements are normal, the pupils react normally, there is no chemosis, and proptosis is not present. If any of these findings are present, orbital cellulitis should be suspected and the patient should be treated more aggressively. This includes hospital admission for intravenous antibiotics, a complete examination by an ophthalmologist, and radiographic imaging to evaluate for the presence of an orbital abscess and extent of infection.
      • Chaudhry I.A.
      • Shamsi F.A.
      • Elzaridi E.
      • et al.
      Outcome of treated orbital cellulitis in a tertiary eye care center in the Middle East.
      If an orbital abscess is present and vision is compromised, the abscess should be drained surgically as soon as possible. If the vision is stable, intravenous antibiotics can be started and the patient monitored closely for improvement. In most cases, the patient requires 24 to 48 hours of antibiotics before clinical improvement will be seen. If there is no improvement or any evidence of deterioration, surgical drainage should be undertaken.
      Figure thumbnail gr12
      Fig. 12Preseptal cellulitis of the left upper eyelid demonstrating erythema and edema of skin. The edges of the cellulitis were marked with a pen to ensure the infection was improving daily.
      Atypical mycobacterial infections should be suspected when delayed wound infections present or multiple erythematous lesions are present. Cultures should be taken with appropriate culture media and an infectious disease consult may be required. Cultures can take weeks to be positive and systemic macrolides are typically necessary to eradicate the infection (Fig. 13).
      Figure thumbnail gr13
      Fig. 13(A) Left upper eyelid atypical mycobacterial infection following blepharoplasty. (B) Enlarged view of the infected area.

      Diplopia

      If a patient complains of double vision following upper and/or lower eyelid blepharoplasty, it is important to determine whether the diplopia is monocular or binocular. Monocular diplopia results from previous refractive error tear film disruption, corneal injury, or ointment. Binocular diplopia immediately following surgery may be due to infiltration of extraocular muscles with local anesthetic.
      • Guyton D.L.
      Strabismus complications from local anesthetics.
      • Rainin E.A.
      • Carlson B.M.
      Postoperative diplopia and ptosis. A clinical hypothesis based on the myotoxicity of local anesthetics.
      This can rarely lead to toxicity of the affected muscle, causing hypertrophy and fibrosis of the muscle, ultimately leading to diplopia in the opposite direction than it initially presented. Reversal of the diplopia postoperatively is suggestive of anesthetic infiltration of an extraocular muscle.
      • Capo H.
      • Guyton D.L.
      Ipsilateral hypertropia after cataract surgery.
      This is often seen with lower eyelid anesthesia as inferior rectus muscle function may be transiently diminished. In the early postoperative period, binocular diplopia may also be due to normal postoperative edema and will resolve as the edema improves. However, if diplopia persists in the postoperative period, referral to an ophthalmologist is warranted for a complete evaluation. The trochlea, or pulley of the superior oblique, is located just behind the orbital rim and can become damaged or scarred during aggressive nasal fat pad removal, leading to an iatrogenic Brown syndrome.
      • Wilde C.
      • Batterbury M.
      • Durnian J.
      Acquired Brown's syndrome following cosmetic blepharoplasty.
      In the lower eyelid, the inferior oblique travels between the medial and central eyelid and can easily be transected or cauterized during fat recontouring.
      • Pirouzian A.
      • Goldberg R.A.
      • Demer J.L.
      Inferior rectus pulley hindrance: a mechanism of restrictive hypertropia following lower lid surgery.
      In addition, fat redraping sutures may inadvertently incorporate the muscle or its fascial sheath. Strabismus surgery may be required to realign the eyes if the ocular deviation persists.

      Lacrimal Gland Injury

      The upper eyelid contains 2 fat pads: the medial and the preaponeurotic fat pads. The lacrimal gland rests in the lacrimal gland fossa, located just posterior to superolateral orbital rim and lateral to the preaponeurotic fat pad (Fig. 14). It functions as part of the accessory lacrimal system. The incidence of lacrimal gland prolapse had traditionally been described as approximately 10% to 15% of patients.
      • Smith B.
      • Lisman R.D.
      Dacryoadenopexy as a recognized factor in upper lid blepharoplasty.
      However, more recent reports indicate the incidence may be as high as 60%.
      • Massry G.G.
      Prevalence of lacrimal gland prolapse in the functional blepharoplasty population.
      With relaxation of the orbital tissues, the lacrimal gland may prolapse forward, creating a bulge in the superolateral eyelid contour. Thorough understanding of the eyelid anatomy is key, and it is essential to not mistake a prolapsed lacrimal gland as fat. Removal or damage to the lacrimal gland can lead to dacryops formation, dry eye, foreign body sensation, corneal decompensation, and vision loss. If a prolapsed lacrimal gland is identified preoperatively, it can easily be repositioned back into the lacrimal gland fossa.
      Figure thumbnail gr14
      Fig. 14Left upper eyelid demonstrating the nasal fat pat (white arrow), the central or preaponeurotic fat pad (yellow arrow), and lacrimal gland (black arrow).

      Horizontal Eyelid Phimosis

      Horizontal phimosis can occur following lower eyelid blepharoplasty due to horizontal contractile forces and also if the lateral canthus is disinserted from the orbital rim. It can lead to shortening of the horizontal fissure, giving patients a “small-eyed” look that is unacceptable, and may also cause tearing from poor lacrimal outflow (Fig. 15). It is generally accepted that the area of sclera visible laterally from the cornea should be larger than the area of sclera medial to the cornea. Horizontal laxity often needs to be addressed at the time of lower eyelid blepharoplasty. Some patients undergoing lower lid blepharoplasty require tightening of the lower eyelid, either in the form of canthopexy or canthoplasty. If present postoperatively, correction is possible through a canthus-sparing canthopexy.
      Figure thumbnail gr15
      Fig. 15Horizontal lid phimosis of the right eye following canthoplasty. The lateral canthus (white arrow) should rest closer to the orbital rim (yellow arrow). Note that the area of sclera lateral to the cornea is smaller than the area of the sclera medial to the cornea.

      Corneal Abrasion

      A corneal abrasion results from disruption of the corneal epithelium. This should be suspected when a patient complains of severe eye pain and tearing immediately following surgery and more serious complications (eg, retrobulbar hematoma) have been ruled out. Corneal abrasions usually occur from exposure of the cornea during a surgery or inadvertent injury to the epithelium during surgery. Corneal injury can be avoided by careful placement of corneal protectors with ointment into both operated and nonoperated eyes at the beginning of the case.
      Diagnosis is confirmed with fluorescein and a cobalt blue light. Once diagnosed, the treatment may include lubrication, patching, and a bandage contact lens. Although the corneal epithelium is very sensitive, it also heals very quickly. An ophthalmologist should see patients with corneal abrasions daily until the defect has completely resolved to prevent progression into a corneal ulcer.

      Fire/Burned Skin/Lashes

      There are approximately 100 intraoperative fires annually, with 15% resulting in serious injuries (Fig. 16).
      • Haith Jr., L.R.
      • Santavasi W.
      • Shapiro T.K.
      • et al.
      Burn center management of operating room fire injuries.
      Increasing use of electric cautery has been blamed with the increase in intraoperative fires since 1994; however, oxygen cannulas, and use of ethanol-based products and disposable drapes are contributing factors.
      • Rinder C.S.
      Fire safety in the operating room.
      To decrease the risk of fire, the surgeon should ensure the nasal cannula is above the drape to avoid an oxygen trap. If possible, the oxygen should be turned off when cautery is being used. The lashes and brow cilia should be moistened before cautery use. Finally, removal of saponified fat should be performed throughout eyelid fat pad sculpting and repositioning to lessen the risk.
      Figure thumbnail gr16
      Fig. 16Singed lashes (yellow arrow) of the right upper eyelid following intraoperative fire during lower eyelid blepharoplasty.

      Wound Dehiscence

      Many techniques exist on blepharoplasty closure, and the technique used is dependent on surgeon preference. Our preference of closure involves approximation of the orbicularis using 7-0 polygalactin suture and skin closure with 6-0 fast-absorbing gut suture. Nonabsorbable sutures work well also, yet patients are pleased not to need suture removal postoperatively. Absorbable sutures can create inflammation during wound healing, but we have not found this to be problematic. Should a dehiscence occur, the area should be deepithelialized and resutured. Proper counseling of patients to ensure they are not lifting anything heavy, exercising, or lowering their head below their waist will decrease the amount of dehiscences that occur. If the dehisced area is smaller than 1 cm, the wound may be observed and allowed to close via secondary intention. Conservative measures, such as continuing ointment until the area is fully healed, is all that is needed and once healed, usually the area is unrecognizable.

      Suture Granuloma

      Focal inflammation around any suture may occur following blepharoplasty. This is more common at the medial and canthus, where knots are placed. Although not painful, they can be very noticeable to patients. Most granulomas resolve with time. Topical steroids may be used to attempt to decrease inflammation. Alternatively, they can be excised in the office.

      The Dissatisfied Patient

      Although not a true complication, the dissatisfied patient following blepharoplasty can be a significant source of aggravation for the surgeon in the postoperative period. To avoid this, reasonable surgical expectations should be discussed. Numerous preoperative photographs should be taken from various angles at the initial consultation and in the preoperative suite. Asymmetry should be addressed preoperatively. Thorough discussion of the true postoperative course should be discussed and expectations should be set.
      Patients often adapt very quickly to their new appearance and often forget where they started. Additionally, after surgery most patients become more aware of “flaws” as they are looking more closely at the surgical area. Preoperative documentation of these patients is often very helpful to the surgeon to show that the imperfections were present preoperatively.

      Summary

      There is an artistic element to blepharoplasty surgery, and no matter how prepared and experienced a surgeon is, perfect results are not always achievable. True perfection is unobtainable, because patients and their facial expressions are dynamic. However, expert knowledge of eyelid and facial anatomy, combined with the knowledge of common pitfalls of blepharoplasty as outlined in this article, will yield reproducible, consistent results and keep the eye and periocular tissues protected.

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