Blepharoplasty: Eyelid surgery

These are not complications, but the eyelid's normal response to surgery:

• Periorbital swelling and bruising, which are practically universal. Bruising of the lower eyelid takes about 10 days to resolve; that of the upper eyelid improves sooner. It is common to wait two weeks before returning to social life without corrective makeup.
• Temporary dry eyes and watering, with a gritty or foreign-body sensation. These are managed with artificial tears and a lubricating ointment at night.
• Mild blurred vision in the first hours or days.
• Sensitivity to light during the first weeks.
• Numbness of the upper eyelid and eyelashes after upper blepharoplasty, due to temporary involvement of the sensory nerve branches. Sensation returns gradually over 2–4 months, often with tingling or itching along the way.
• Mild chemosis (swelling of the conjunctiva, giving the white of the eye a watery or bulging appearance) and small reddish subconjunctival hemorrhages. They have no functional significance, only a cosmetic one.
• Temporary asymmetry between the two eyelids while the swelling subsides.
• A scar that is pink at first, which matures and becomes concealed in the eyelid crease over the following months.

Stitches are removed during the first week. Exercise is not advised in the first few days because it prolongs bruising and swelling.

A second group of non-serious issues that may appear during recovery or in the first few months. In a series of 200 transcutaneous blepharoplasties, the overall incidence of complications was 9.5%, and most resolved with clinical treatment and outpatient follow-up, without surgery:

• Prolonged chemosis, which can take several weeks to resolve completely. It is more common in the lower eyelid and especially when canthoplasty is also performed: in the series cited it appeared in 6% of all patients, but in 61.5% of the patients who underwent canthoplasty.
• Persistent dry eye. This is the most common complaint after periorbital surgery. In a review of 202 patients, symptoms persisted for more than two weeks in 10.9% and for more than two months in 2%; most resolved with conservative management. Paradoxically, it can present with reflex tearing.
• Lower eyelid malposition. In the series of 200 cases it affected 3%, mostly eyelid retraction and, exceptionally, ectropion. Mild retraction due to edema usually subsides on its own within days or weeks. All cases of malposition occurred in patients who had not had lateral canthal anchoring in the primary surgery.
• Scleral show, or exposure of the white of the eye below the iris, caused by descent of the lower eyelid.
• Persistent asymmetry once the result has settled, which may require a minor touch-up.
• A thickened scar or color changes along the incision line.
• Granulomas or inclusion cysts along the suture line, which can be resolved in the office.
• Undercorrection or overcorrection: residual bags, or excessive removal that leaves the groove hollow and gives an aged appearance. Removing too much fat is harder to correct than removing too little.
• Delayed healing, especially in patients who smoke or have diabetes.

A small percentage of patients opt for a minor revision months after the initial surgery.

These are the serious complications, with low incidence rates but which every well-informed patient should know about before signing a consent form:

• Retrobulbar hematoma. This is the most feared complication: deep bleeding behind the eyeball that raises intraorbital pressure and can compromise the optic nerve. Symptoms appear within the first 24 hours, with two peaks: between the surgery itself and the first hour, and between the sixth and twelfth hours. High blood pressure is the most frequent risk factor, along with coagulopathy and anticoagulant medication. It is an emergency with a defined treatment, which is why we place so much emphasis on blood pressure control and on the scheduled discontinuation of antiplatelet drugs.
• Vision loss. A survey of ASAPS and BAAPS surgeons covering more than 750,000 blepharoplasties recorded 39 cases of vision loss, which puts the overall incidence at around 1 in 20,000 procedures, and permanent loss at approximately 1 in 30,000. Retrobulbar hematoma was the main cause.
• Lagophthalmos and exposure keratopathy. Because of excessive skin resection, the eye does not close completely, the cornea is left exposed and it may ulcerate. Pre-operative evaluation of dry eye and Bell's phenomenon is the decisive step in preventing it.
• Established ectropion, which requires surgical correction.
• Diplopia (double vision) due to injury to the extraocular muscles, a rare but potentially disabling complication of lower eyelid surgery. It usually appears early, between the immediate post-operative period and the first week.
• Wound infection, which is uncommon given the excellent blood supply to the area.
• Post-operative eyelid ptosis due to involvement of the levator aponeurosis.
• Reactions to anesthesia, assessed and minimized by the anesthesiologist in the pre-operative evaluation.