As a continuation of the discussion on ‘Complications of Blepharoplasty: Part 1’, below are some of the more dreaded and rare complications.
Infection after a blepharoplasty is rare. Usually the patients are put on an antibiotic ointment for the first post-operative week. Late and chronic infection with atypical mycobacteria is a possibility and will present as red, raised nodules along the incisions. Treatment is the appropriate antibiotic. In the case of atypical mycobacteria, the nodules should be removed as well.
This is a very rare complication and is due to over-aggressive dissection of the orbital fat usually. In the supero-medial quadrant lies the trochlea. Deep dissection of the medial fat pad could lead to damage. In the lower eyelid, removal of the fat can result in damage to the inferior oblique, which runs between the central and medial fat pads. This can lead to torsional diplopia and may need an evaluation by a strabismus surgeon if disabling.
Cautery fires can lead to severe facial burns and can be harmful to the patient, the surgeon and/or staff in the operating room. There are three elements needed to create a cautery fire: (1) an oxidizer, which is usually the oxygen coming from the nasal canula, (2) a fuel - either the drape or alcohol preparation, and (3) an igniter - the cautery or laser. Most cautery fires are from miscommunication between the surgeon and staff. It is extremely important to let the anesthesiologist know when you are about to cauterize, so that they can turn down or off the oxygen. It should be at least below 2L. As well, the way the patient is draped plays a role in the risk of a cautery fire. Leaving the full face exposed minimizes the risk of a pocket of oxygen forming beneath the drapes. If a cautery fire should develop, put out the flames, remove the drapes, discontinue the oxygen and cautery, address the burns.
This is the complication that could lead to blindness, so is the most important to avoid. There are many vessels in the orbit that are encountered during a blepharoplasty while removing fat. If one bleeds, an expanding hematoma can result, compressing on the optic nerve, compromising ocular perfusion and leading to visual loss. Preoperatively, have the patient stop all blood thinners for at least 2 weeks if not medically contraindicated. During the surgery, use meticulous hemostasis and make sure the blood pressure is well controlled. Avoid excessive traction on the orbital fat. Post-operatively, have the patient elevate the head 30 degrees and use ice packs for 2 days to constrict the vessels. The patient should refrain from all heavy lifting, bending or straining for one week and wait to restart blood thinners for one week. If an orbital hemorrhage should occur, it will likely be in the first 12 to 24 hours. The patient will present with pain, proptosis, ecchymosis and visual impairment. It is important to alert the patient of these signs and symptoms so that they know to come in immediately if they occur. Open the surgical wounds first and look for any active bleeds. Lower the intraocular pressure with drops and oral medications. Steroids can be used. If the intraocular pressure does not come down, a lateral canthotomy with inferior cantholysis may be needed and possibly a bony decompression.
In summary, it is best to avoid complications by effective communication with your patient first and foremost, as well as your staff. Make sure your patient is a good surgical candidate with realistic expectations. Know your anatomy and know how to avoid and treat potential complications.
Complications of Blepharoplasty: Part 1
Pearls for Blepharoplasty