In the previous months I have written a series of articles covering ocular complications of aesthetic procedures, including bolinum toxins, dermal fillers and lasers. This article will cover some of the complications of aesthetic surgery and will briefly discuss how to avoid and treat if needed.
One of the most common complications of aesthetic surgery is lagophthalmos.
This can result from excessive skin removal, performing a blepharoplasty in the setting of unrecognized brow ptosis, including the septum in your closure of a blepharoplasty, or from simple lateral canthal tendon dehiscence. As far as brow ptosis is concerned, it is extremely important to evaluate the patient thoroughly to look for true dermatochalasis versus ptosis, pseudoptosis or brow ptosis. If there is an element of brow ptosis, I make sure to measure at least 10 to 13mm beneath the lower edge of the brow during a blepharoplasty to make sure that the brow is not brought down further and closer to the lashes, which can lead to lagophthalmos. Lagophthalmos may require a skin graft is too much skin was removed. In the case of laxity of the lateral canthal tendon, sometimes it is sufficient to plicate the tendon.
Ectropion can also result from aggressive skin removal during a lower lid blepharoplasty.
Intra-operatively while measuring the amount of skin to remove, I have the patients look upwards and open their mouths to the full extent, in order to put the lower lid skin on maximum stretch.
7th nerve palsy is a dreaded complication of facelifts. If you are to venture out into this type of surgery, know your anatomy well. If this complication should arise and the nerve is damaged permanently, a horizontal lid tightening procedure, gold weight, or tarsorrhaphy may be needed.
Gold weights are manufactured by FCI Ophthalmics and MedDev. Both make thin profile gold and platinum weights that range from 0.6 grams to 1.8 grams. The Contour weights range from 0.6 grams to 2.8 grams for the gold weights and 0.6 to 2.4 grams for the 
platinum weights. They also have a great tantalum sizing set for ease of choosing the appropriate weight for your patient in clinic. Blinkeze are external weights by FCI for those who can not undergo surgery, or for a quick fix. IOP Ophthalmics also make gold weights with suture grooves ranging from 0.6 to 2.8 grams. The Slim Gold weights range from 0.8 to 1.6 grams and the ERGO weights range from 0.8 to 2.2 grams.
Any of the above mentioned lid abnormalities can lead to corneal problems, such as a corneal abrasion, ulcer or scar.
Ptosis is another lid malformation that can result from overaggressive dissection during a blepharoplasty or excessive edema.
Knowledge of the eyelid anatomy is paramount before surgery. In the case of direct damage to the levator, repair can be performed if recognized during the surgery. If ptosis is noticed after a blepharoplasty, allow adequate time for all swelling to subside and proceed with repair via an advancement or conjunctival-mullerectomy.
Diplopia is a rare complication of aesthetic surgery.
Aggressive dissection of the medial upper eyelid fat pad can injure the trochlea. More likely is damage to the inferior oblique during dissection between the medial and central lower lid fat pads. Damage to either will create torsional diplopia. Diplopia in some cases will resolve, but if not and if it is disabling for the patients, strabismus surgery may be needed.
A couple of zebras have been reported in the literature having to do with decrease in vision with aesthetic surgery. The first is a case of a woman who had blindness and necrotizing fasciitis after liposuction and fat transfer. She had fat removed from her abdomen and placed into her buttocks. She acquired necrotizing fasciitis and bacterial meningitis that seeded into the retroperitoneal space. This traveled into the neural foramina and up to the visual cortex causing a transient cortical blindness.
The last case is of a woman who noticed pain and decreased vision after anesthetic was injected into her eyelid. She had endothelial toxicity from bupivacaine and/or the preservatives in the injection. Take care when injecting into this delicate area as the skin is extremely thin and any faulty move of the needle can result in globe perforation.
In summary, it is important to choose the ideal patient with realistic expectations. Discuss the goals of aesthetic surgery. Know your surgical anatomy and know how to avoid and treat complications should they arise.