blepharoplasty guide

Insider's Guide to

Chapter 28

Risks and Complications
of Blepharoplasty 


Section Three

Surgery is a lot like life – not fully predictable – and so there is always an element of risk. Different people vary in their responses to any given operation, doctors vary in their preferences and experiences, and "Lady Luck" may be kinder to you on some days than others.

It is important to understand that even the finest of eyelid surgeons will have some patients who suffer from unexpected complications. There is an old saying that goes something like this: "The only surgeon who doesn't experience complications is the surgeon who doesn't do much surgery." Despite what you may read or hear from friends or even medical personnel, problems following eyelid surgery, while uncommon, are not "one-in-a-million" events.

One of the most helpful things you can do if the unexpected does happen is to try your best to maintain a good working relationship with your surgeon. Hopefully, you did your homework before you selected your eyelid surgeon, and now is the time when such preparation can pay off. If you trusted your surgeon enough to do your blepharoplasty, trust him or her to work through any unforeseen problems. Assigning "blame" will get you nowhere.

All eyelid surgeons are trained to deal with the most common complications. If a complication is unusual or beyond your surgeon's abilities, a reputable doctor will not hesitate to refer you to a practitioner with a higher level of expertise. Listen to your doctor and always follow his or her advice. Don't panic and start running office to office; your level of confusion will quickly escalate. Remember that your doctor wants your result to be right just as much as you do.

If, for some reason, you do lose faith in your doctor (or you are the sort of person who has to cover every base), there is nothing wrong with requesting referral to another eyelid surgeon. While you may elect to seek a second opinion "behind your doctor's back", without good medical records and physician-to-physician communication, you may not be advancing your cause.

Take heart in the realization that most cosmetic eyelid surgery complications can be helped at least partially. If fact, some disappear by doing little more than waiting, so don't jump the gun. While additional surgery may sometimes be required, some such corrective procedures are relatively minor (although some, alas, can be very extensive).

Please note that Chapters 29 and 30 present only an overview of various corrective eyelid surgery approaches. A comprehensive discussion of the broad and complex field of eyelid reconstruction after blepharoplasty is well beyond the scope of this Guide.

Chapter 28

Risks and Complications of Blepharoplasty

This chapter presents those complications that may occur with all forms of surgery on or around the eyelids. When a procedure carries certain procedure-specific side-effects (such as complications, for instance, associated with eyebrow lift or Botox), those risks will be noted in the particular chapter detailing that operation.

Despite the comprehensive list that appears below, blepharoplasty is a relatively safe and effective operation when compared to many more widely invasive plastic and reconstructive surgical operations. The vast majority of patients who undergo cosmetic eyelid surgery are pleased with their results.

Slideshow: Complications After Eyelid Surgery

Infection: Infection is a risk with any and all surgery, including surgery on or around the eyelids. Because of the eyelid's good blood circulation, however, elective surgery performed under sterile conditions seldom results in serious infection.

Bleeding: Continued bleeding after blepharoplasty may require reopening of the eyelid wound and either cauterization of the bleeding vessel and/or evacuation of the clot ("hematoma"). The most common sites of bleeding are the fat pockets and the orbicularis muscle.

Wound separation: The edges of the eyelid skin closure may separate, especially in the first day or two after suture removal. A small separation may close spontaneously or with the help of supporting tape. A larger separation may require suturing. Generally, treated wound separations have minimal permanent effect on the final result.

Suture cysts: Tiny white cysts (milia) may develop in the suture line. While most disappear without treatment, removal of a resistant cyst is simple and quick.

Asymmetry: Eyelids that look good individually may not match as a pair, and such asymmetry introduced by surgery may be cosmetically disturbing. Asymmetries can involve the height and shape of the upper eyelid crease, excursion of the lower eyelid margin, residual skin or fat, and so on. If noticeable asymmetry persists past a reasonable waiting period of time (usually three to six months), your surgeon may suggest re-operation.

Insufficient skin removal: While blepharoplasty undercorrection is always preferable to overcorrection, an objectionable amount of undercorrection may call for a "touch-up" operation. Be aware that what sometimes appears to be an undercorrection may, in fact, represent a basic and inherent limitation of blepharoplasty surgery in that particular patient. For instance, mild hooding of upper eyelid skin on the side closest the temple may be secondary to a mild downward droop of a patient's eyebrow. Likewise, skin excess in the medial canthus towards the nose may be more related more to a patient's forehead droop than an underaggressive blepharoplasty. Remember two things: (1) blepharoplasty is an operation on the eyelids alone and can accomplish only so much for the face, and (2) attempting to leave eyelid skin "bone tight" in either the upper or lower eyelids is courting disaster.

Excessive skin removal: Excessive removal of upper eyelid skin may interfere with proper closure of the eyelids ("lagophthalmos") during blinking or especially when sleeping. Extreme shortage may distort the eyelid margin and create a widening of the palpebral fissure (opening between the eyelids) that is both cosmetically and functionally objectionable ("eyelid retraction"). Excessive removal of lower eyelid skin may cause the eyelid margin to pull away from the eye surface ("ectropion"). When mild, the main symptom may be overflow tearing due to the pulling away of the tear drain opening from the surface of the eye ("punctal eversion"). If more severe, the entire lid may be pulled downward. Problems resulting from skin overcorrection are annoying at best and dangerous at worst; almost all such complications require surgical intervention.

Insufficient fat removal: When insufficient fat removal creates a noticeable or asymmetric blemish, further removal may be indicated.

Excessive fat removal: Fat removal from the upper eyelid may create a lid crease that appears too high and deep ("superior sulcus defect"). Fat removal in the lower eyelids may create a hollowed-out appearance ("inferior sulcus defect"). Hollowness may develop either immediately or years after surgery.

Excessive muscle removal: Aggressive removal of orbicularis muscle from the upper eyelid may hollow the superior sulcus and in the lower eyelid may lead to weakened eyelid closure and support.

Excessive internal scarring: Internal scarring ("fibrosis") or shrinkage of the internal eyelid layers below the skin may cause distortion, limitation of movement, and retraction. Massage may help in mild cases, but surgery may be needed to improve appearance and function.

Excessive external scarring: Visible scarring on the skin may be aggravated by poor healing in damaged or sensitive skin, suboptimal placement of incisions (too high in the upper eyelid; too low in the lower eyelid), delayed suture removal, prolonged fragility with laser incisions, failure to follow postoperative instructions, and other factors.

Inappropriate crease: An upper crease placed too high tends to "feminize" the male eyelid. An overly high or arched upper crease in an Asian eyelid may "round the eye" and make it appear inconsistent with the rest of the face. Excessive upper skin removal and/or failure to fixate the crease during suture closure may allow the final scar to migrate higher and be visible.

Rounding at the lateral commissure: Rounding of the acute angle where the outer upper and eyelids come together may be caused by excess skin and/or muscle resection or a result of canthoplasty - canthopexy. If subtle, the deformity is best ignored; if more noticeable, surgical revision may be undertaken.

Drooping upper eyelid: Blepharoplasty may "unveil" a pre-existing but unrecognized drooping upper eyelid (that is, not a baggy lid but one that rides too low), a condition known as "ptosis". Less commonly, injury to the levator muscle and tendon (aponeurosis) may cause ptosis to appear in a previously healthy levator system. Mild ptosis after blepharoplasty is not rare and may persist for several weeks to months. If the condition does not resolve with time, exploratory surgery may be indicated.

Swelling on the eyeball surface: Collection of post-surgical inflammatory fluid (edema) or temporary disruption of lymphatic drainage (chemosis) may cause swelling on the eye surface that is uncomforabe and cosmetically frustrating. It is not rare and has been reported in over 10% of patients undergoing skin-incision lower blepharoplasty. Nearly all cases resolve within three weeks to three months. Chronic chemosis persisting six months or more may occur rarely and is of unknown cause. Lubrication, medicated eye drops, patching, and passing time are generally curative.

Injury to the lacrimal system: If the main tear-producing gland is injured, prolonged swelling in the outer portion of upper eyelid may persist for several weeks. No additional surgery is required. Injury to the drainage canal ("canalicular laceration") is rare but requires immediate repair by an ophthalmologist.

Double vision: If the muscles that move the eyeball are injured or scarring occurs in the fat surrounding the eye muscles, temporary or permanent double vision may result. The most vulnerable muscles are the superior and inferior oblique muscles and the inferior rectus muscle, all of which course within or near the fat of the eyelids. Attempt at correction of any resulting double vision ("diplopia") may require the services of an ophthalmologist specializing in eye muscle surgery ("strabismus surgery specialist")

Loss of vision: Very mild reduction of vision following blepharoplasty is not uncommon and is usually due to swelling, excessive tearing and mucus production, and/or secondary to ointments or drops used after surgery. Catastrophic loss of vision (that is, permanent blindness) occurs rarely (less than 1 in 10,000 cases) and is most often associated with brisk bleeding that makes its way to the area in back of the eyeball ("orbital or retrobulbar hemorrhage") and generates enough pressure inside of the socket to cut off the normal blood flow to the retina (although the exact mechanism is not fully understood). Other possible causes of vision loss include damage to the optic nerve, needle penetration of the eyeball, and advanced eye or orbital infection. Most deep orbital hemorrhage occurs within 48 hours of surgery and is not at all subtle, usually associated with intense pain, double vision, and a sudden bulging forward of the eye. Such symptoms indicate an extreme emergency and should be reported to the surgeon immediately. In most cases, emergency surgery by an ophthalmologist is necessary.

Complications of anesthesia: While hardly unique to cosmetic eyelid surgery, complications may occur from the anesthesia alone, including severe allergic reactions, blood pressure fluctuations, and serious heart and breathing difficulties. Such problems are more common with the administration of intravenous and/or inhaled anesthetic agents than with local anesthesia using oral sedation.

Unrealistic expectations: If you are expecting "perfection" from your surgery, you should be warned upfront that you are all but certain to be disappointed. It is important, therefore, to understand exactly what you should and should NOT anticipate from any given cosmetic eyelid surgery. If your expectations are inappropriate or inflated because of your lack of preparation or your surgeon's lack of explanation, no matter how wonderful the result may be from an objective point of view, you will not be satisfied. Put bluntly, perfection is never attained because no surgeon is perfect, no wound will heal perfectly, and most patients possess some anatomic limitations. If you can't accept this concept, you should not undergo cosmetic surgery.

Patient indecision: Some patients (generally, those inordinately afraid of being overcorrected) make a definite point of requesting a conservative approach ("I just want to look a little bit better") only to be disappointed by the expected undercorrection. This is not the fault of the surgery or the surgeon. While more surgery can be undertaken, such patients should be fully prepared to pay for the second operation.

Poor aesthetic choice: Not often mentioned in lists of blepharoplasty "complications" is the matter of inappropriate selection of procedure or poor aesthetic judgment on the part of the surgeon resulting in "technical" success but cosmetic "failure". For instance, if what you really need is an upper eyelid blepharoplasty but what you have done instead is a forehead lift, even though you may not experience any true medical "complication", you may still be very unhappy about the way you look. As with unrealistic expectations noted above, the best (and only) approach is avoidance. Be sure that you and your surgeon understand and agree upon exactly what you are getting yourself into.

Late complications: Most problems from surgery are apparent in the immediate post-operative period, but there are two notable exceptions:

(1) As aging progresses, some people (not the majority) naturally "absorb" a substantial amount of the fat from inside of their eye sockets. If fat removal or manipulation has been undertaken in such patients at an earlier age, the orbit may come to look hollow as the years pass. Predicting which patients will be most prone to this outcome is difficult.

Thus, conservative or no removal and minimal manipulation of eyelid fat are prudent preventatives.

(2) A skin approach (transcutaneous approach) to the deeper structures of the lower eyelid undertaken for any reason (e.g., blepharoplasty, midface lift, fat transfer, etc.) may cause increased internal scarring during healing. Over years, the stress from such tightening may promote stretching of the eyelid support system and the eventual development of noticeable eyelid retraction (as noted earlier).

The minimally-invasive transconjunctival approach to the lower eyelid is much less likely to lead to late problems.

Next: Treatment of Upper
Eyelid Complications


Chapter 01: Don't jump in blindly
Chapter 02: Do I really need this?
Chapter 03: When should I do it?
Chapter 04: Eyelid anatomy
Chapter 05: Why it all sags
Chapter 06: Cosmetic eyelid surgeons
Chapter 07: Blepharoplasty consultation
Chapter 08: Eyelid surgery prices
Chapter 09: Add-on costs
Chapter 10: Eyelid surgery facility
Chapter 11: Eyelid surgery anesthesia
Chapter 12: Blepharoplasty and insurance

Chapter 13: Upper eyelid plastic surgery
Chapter 14: Asian eyelid blepharoplasty
Chapter 15: Repair of eyelid ptosis
Chapter 16: Eyebrow lift surgery
Chapter 17: Lower eyelid plastic surgery
Chapter 18: Tissue-sparing lower lid surgery
Chapter 19: Canthoplasty and Canthopexy
Chapter 20: Eyelid fat repositioning
Chapter 21: Cheek and midface lift
Chapter 22: Eyelid skin resurfacing
Chapter 23: Botulinum toxin injection
Chapter 24: Eyelid fillers and fat grafting
Chapter 25: Eyelid and brow tattooing
Chapter 26: Secondary blepharoplasty
Chapter 27: Laser eyelid surgery

Chapter 28: Blepharoplasty risks
Chapter 29: Upper eyelid complications
Chapter 30: Lower eyelid complications

Chapter 31: Do's and don'ts before surgery
Chapter 32: The morning of the big day
Chapter 33: Experiencing the surgery
Chapter 34: Do's and don'ts after eyelid surgery
Chapter 35: Is this ever going to heal?
Chapter 36: Eyelid cosmetics
Chapter 37: Eyelid skin care
Chapter 38: Patient satisfaction and blepharoplasty
Chapter 39: Psychological considerations
Chapter 40: Recent advances and the future


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