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Topic 29 - 1
Treatment of Upper Eyelid
Blepharoplasty Complications 
revision blepharoplasty introduction Risks & Revision rising crease

" You manage your office with extreme care and are very nice to deal with. My only gripe is that now at age 46, I have twenty year old girls chasing after me. This is NOT easy."
-- S.G., a former patient

Cosmetic Complications

Many so-called "complications" of upper eyelid lift blepharoplasty are more accurately categorized as "patient dissatisfaction" or surprise with the final result (as opposed to true impairment of eyelid function or vision).

Such patient disappointment is most typically the result of:

• unrealistic expectations

• poor choice or execution of the procedure by an inexperienced surgeon

• asymmetric or overly high creases

• undercorrection

Unrealistic expectations is, obviously, a difficult problem to undue once surgery has been performed. The only effective "treatment" is a careful and honest discussion between the patient and surgeon about what can and cannot be achieved by blepharoplasty. It goes without saying that it is far preferable for such a talk to take place before rather than after surgery.

Poor execution by an inexperienced surgeon can create uneven results and excessive scarring. The best approach is referral to a more experienced eyelid surgeon, who may need to retrace most (if not all) of the steps of the operation and undertake revision as needed.

Asymmetric or high creases, in which the creases of the two upper eyelids are unmatched in height or shape, is not a rare outcome. Sometimes the problem in unrelated to blepharoplasty, per se, but rather caused by a separate (but possibly unrecognized) problem that existed even before the operation, such as brow droop or ptosis. In these cases, a patient may elect to have these remaining deficiencies corrected with the appropriate additional surgical procedures or simply ignore the imbalance if it is mild. Keep in mind that small eyelid asymmetries are more the rule rather than the exception, whether or not a person has ever undergone blepharoplasty. While techniques to lower a crease are complex, the opposite (or lower) crease may usually be raised slightly by the removal of a small amount of additional skin accompanied by deep fixation.

Poor result after blepharoplasty one year earlier

• The most common reason for patient dissatisfaction is overly conservative removal of upper eyelid skin. It is important to emphasize that the main goal of blepharoplasty is to improve the appearance without creating a stark "surgical" look. Such healthy conservatism will invariably leave an occasional patient slightly undercorrected. Fortunately, this condition is easily remedied by the further excision of excess tissue. Most commonly, only skin needs to be removed and healing is rapid.

If excessive fat has been removed from the upper eyelid, the resulting hollowness and/or high eyelid crease may be difficult to repair. Fat grafts obtained from the patient's own body can be implanted into a space created between the closing muscle (orbicularis muscle) and opening muscle tendon (levator aponeurosis) to create more fullness and provide a tissue buffer to help lower the crease. The result of such surgery is not entirely precise due to limitations imposed by the presence of previous scarring and the unpredictable survival of implanted fat. More than one procedure may by required to achieve the best possible contour.

Functional Complications

The most common complications causing true functional impairment include:

• ptosis, or the creation of a droopy upper eyelid

• lagophthalmos, or tissue shortage preventing adequate closure

Ptosis may be caused by direct surgical injury to levator muscle or aponeurosis (the elevating muscle and tendon) or by a tethering of levator action by the placement of deep fixation sutures. Surgical injury (most commonly, cutting or stretching of the tendon) requires further surgical exploration and repair by a specialist in eyelid reconstructive surgery. Tethering, on the other hand, is most commonly caused by a restriction of levator action from sutures placed to accomplish deep fixation (see Chapter 13: Upper Eyelid Blepharoplasty). In the majority of such cases, the ptosis resolves fully without additional surgery over a matter of two to four weeks.

Lagophthalmos, or inadequate eyelid closure due to excessive skin removal or internal scarring, is a serious problem that risks compromising the health of the eye surface. While very mild cases may respond to massage or implantation of a gold or platinum eyelid weight designed to assist in closure, advanced cases require the grafting of new skin from a distant donor site (most commonly, from the area behind the ear). Results are generally only partial and may be cosmetically disappointing. View results before and after upper eyelid skin grafting.

• The most uncommon but feared complication of upper (and lower) blepharoplasty a permanent catastrophic loss of vision caused by the build up of blood in the tissues of the socket behind the eyeball. "Retrobulbar hemorrhage" can occur suddenly and is most commonly heralded by the onset of very significant pain and a graying of the vision.

For management to be successful, treatment must be initiated without delay. Stitches may be removed to open the wounds and release any trapped blood. The eyelid tendons may be disinserted to take undue pressure off the eyeball by allowing it to bulge forward. As a last resort, orbital decompression (removal of socket bone separating the orbit from the sinus cavities) may help.

• Excessive bleeding that remains localized within the eyelid and does not extend into the deeper socket may form a large clot that discolors and distorts the eyelid.

While such "hematomas" do not usually threaten the vision, the wound may need to opened in order to stop any continued bleeding or to evacuate the clot (which promotes healing).

Next: Late Complication:
The Rising Eyelid Crease

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