Last month I discussed pearls of blepharoplasty and promised to write about potential complications this month. I have broken this up into 2 parts. Below is part 1. Next issue will be part 2…the more dreaded complications. The 2 parts are by no means all-inclusive, and most are related to upper eyelid blepharoplasties.
The key to approaching complications of blepharoplasty surgery is to avoid them…at all costs. This means, from the beginning, effective communication with your patient and a discussion of realistic goals. Prior to surgery, know your upper eyelid anatomy well and make sure your patient is healthy.
Unequal Lid Crease Height:
This can occur if measurements of the lid crease incision are not made carefully or if the incision is not made carefully. It is important to always mark the natural lid crease and use calipers to assure symmetry prior to making the cut. To treat this complication, in general it is easier to lower the higher lid crease than vice versa.
Residual Tissue:
Tissue can be left behind if measurements were done too conservatively or inaccurately. Fat can be left behind if it was not prolapsed efficiently during the surgery. Excess tissue should be pinched up until the lashes slightly evert. That being said, it is much better to be conservative and have to go back in to remove more tissue than be aggressive and have to go back in and replace tissue. During the fat removal, gentle retrobulbar pressure should be applied to prolapse the fat forward, especially medially.
Inclusion Cysts:
If the edges of the skin are not everted during closure, inclusion cysts can result. These can easily be removed under a little local anesthesia.
Asymmetric Superior Sulcus:
This complication results from unequal fat removal. The removed fat can be saved for comparison. It is easier to remove fat from the full side than to replace fat in the deep side.
Ptosis:
Ptosis can be due to edema of the levator aponeurosis or from direct trauma to the levator. The number one rule before performing a blepharoplasty is to know your anatomy. Realize where the levator is in relation to where you are cutting. Be very careful when removing the preaponeurotic fat, as the levator is directly beneath. If the patient does have post-operative ptosis, wait until all swelling has subsided before any surgical correction is considered. If ptosis remains, consider a levator advancement or conj-mullerectomy.
Lagophthalmos and/or Lid Retraction:
Lagophthalmos can result from excessive skin removal resulting in an inability to close the eyes. When making the measurements for tissue removal, pinch up the excess tissue so that the eyelashes just begin to evert. Make sure to leave at least 11mm beneath the lower brow hairs to prevent pulling the brow down toward the lashes. It is always better to remove too little than too much. Lagophthalmos can improve with massage, but some require a skin graft. Lid retraction can result from over-aggressive cautery of the levator and septum. Pinpoint cautery is best when you are down to the level of the levator. Severe cases may require lysis of affected tissue.
Webbing:
Webbing can occur if the incision is brought too far medially. It is wise to end the incision at the punctum. If webbing should occur, it can be repaired with multiple Z plasties.
Related Article:
Complications of Blepharoplasty: Part 2
Pearls for Blepharoplasty