Complications of Blepharoplasty: Prevention and Management

Hindawi Publishing Corporation Plastic Surgery International Volume 2012, Article ID 252368, 10 pages doi:10.1155/2012/252368 Review Article Complications of Blepharoplasty: Prevention and Management James Oestreicher and Sonul Mehta Division of Orbital, Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada M5S 3A5 Correspondence should be addressed to James Oestreicher, Received 14 October 2011; Revised 5 February 2012; Accepted 12 February 2012 Academic Editor: Moustapha Hamdi Copyright © 2012 J. Oestreicher and S. Mehta. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. The surgery involves removing redundant skin, fat, and muscle. In addition, supporting structures such as canthal tendons are tightened. Other conditions such as ptosis, brow ptosis, entropion, ectropion, or eyelid retraction may also need to be corrected at the time a blepharoplasty is performed to ensure the best functional and aesthetic result. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. Finally, management of complications is just as important as surgical technique. 1. Preoperative Assessment In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. Reassuring the patient that privacy will be maintained helps facilitate the patient’s ability to articulate his or her desired outcome. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occurs—otherwise, surgery should not be done. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. Patients’ concerns can vary immensely, ranging from a particular dislike of lateral hooding, a “staring” or “overdone” look (very common), a sunken look (a common concern in younger patients), to a fear of blindness to concerns about the length of the recovery period and intra- and perioperative pain. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further “improvement”, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. Once patient’s concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. Allergies and a list of medications should be noted. Patients taking aspirin, anticoagulants, nonsteroidal anti-inflammatory agents, vitamin E, gingko, and other herbal medications should stop them, if possible, up to 3 weeks preoperatively. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. Important measurements to evaluate include palpebral fissure, marginal reflex distance, amount of lagophthalmos, and lid crease height. A slit lamp examination and Schirmer’s test are necessary in this author’s view. 2 2. Surgical Planning When planning to perform an upper lid blepharoplasty, determining the amount of excess skin in the upper lids, the amount of excess or prolapsed fat, the position of the lacrimal glands, and the extent of lateral hooding and medial bulging are important. When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. The patient’s racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. Old photographs are useful to determine the patient’s youthful upper eyelid fold configuration. It must be understood that old photographs do not represent a guarantee or even a goal, but rather act as a guidepost. Many people never had a full “wide open” upper lid and appeared “heavylidded” in younger years and their lid crease height is at 7 mm, not 10 mm. Usually, it is a mistake to try and change their upper eyelid nature too drastically, unless this desire and postoperative appearance is made abundantly clear. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Any adjunctive procedures to be performed should also be determined. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct, coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening, and lower eyelid tightening or lateral canthopexy. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. The authors favor CO2 laser blepharoplasty with a transconjunctival lower lid approach. CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). 3. Complications It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. As the surgeon, it is important to be aware of the potential complications of surgery. Complications of blepharoplasty can be minor or serious. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. Establishing trust and communication is essential to a doctor-patient relationship, perhaps even more important in a completely elective, aesthetic procedure with high expectatio (...truncated)