Thursday, July 1, 2010

Blepharoplasty Complications – an Article Review

There is a really nice article in the March 2010 issue of the Journal of Plastic and Reconstructive Surgery which reviews complications of blepharoplasty surgery (full reference below). It is an article worthy of your time if you perform this surgery.

The article divides the complication into time periods which they occur: early (first week), intermediate (1-6 weeks), and late (after 6 weeks). Here is a list of the complications listed and discussed. The information included in my post does not cover all that is covered in the journal article as it is not meant to take the place of the article.

Early Postoperative Period (first week)

Vision Loss

The most feared complication of blepharoplasty is permanent visual loss. The most common cause is retrobulbar hemorrhage, although other causes such as globe perforation, ischemic optic neuropathy, and angle closure glaucoma have been reported.

Retrobulbar Hemorrhage

  • Incidence is 0.05%; associated permanent visual loss was diagnosed in 0.0045%. This corresponds to a one in 2000 risk of hemorrhage and a one in 10,000 risk of permanent visual loss.
  • Most occur within the first 24 hours after surgery (96%), and of these, more than half occur intraoperatively or within the first 6 postoperative hours.
  • The most common presenting symptoms are pain and pressure.
  • Treatment should be aggressive for the first 24 to 48 hours postoperatively, as vision has been reported to return in patients with “no light perception” that was present for 24 hours. (photo credit)

Globe Perforation: Inadvertent globe penetration can result from any periocular procedure. Globe perforation is an ophthalmic emergency and necessitates emergent ophthalmic evaluation.

Central Retinal Artery Occlusion Prompt ophthalmic consultation is necessary.

Corneal Abrasion is generally a rapidly reversible cause of decreased vision. The diagnosis is made by patient symptoms (pain, foreign body sensation, light sensitivity) and is usually apparent immediately after surgery.

Dry Eye Corneal irritation is common after blepharoplasty and symptoms are similar to, but less severe than, an abrasion. These symptoms will respond to ocular lubrication and cool compresses.

Eyelid Hematoma usually develop from bleeding orbicularis oculi muscle. Retrobulbar hemorrhage must be ruled out.

Infection, cellulitis or abscess formation, is exceedingly uncommon in the well-vascularized eyelid, but have been reported and can rarely lead to permanent visual loss or cavernous sinus thrombosis.

Eyelid Sloughing due to eyelid necrosis has been reported and can necessitate multiple eyelid reconstructive procedures

Chemosis or conjunctival edema can develop in the early or intermediate postoperative period as the result of incomplete eyelid closure, ocular allergy, or surgical edema with poor lymphatic drainage.

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Intermediate Postoperative Period (weeks 1 to 6)

Upper Eyelid Malposition

  • Ptosis can be seen following upper eyelid blepharoplasty. No statistics are available regarding frequency. Mechanical ptosis can result from postoperative edema or ecchymosis and should resolve with conservative treatment, including cool compresses.
  • Lagophthalmos occurs frequently in the postoperative period. Reasons include excessive skin removal, trauma to the orbicularis muscle or peripheral seventh cranial nerve, tethering of the eyelids by sutures or Steri-Strips, and postoperative pain, leading to guarding and incomplete closure. It is usually temporary. Lubrication and lid massage are advisable in the intermediate postoperative period.

Lower Eyelid Malposition is the most commonly reported complication after lower eyelid blepharoplasty. It may range from mild inferior scleral show to severe cicatricial ectropion in 1%. (photo credit)

Corneal Exposure

As in the early postoperative period, keratopathy may persist or become evident during the intermediate period. First-line treatment is expectant, with frequent ocular lubrication and taping. One condition worth mentioning is the patient with undiagnosed thyroid ophthalmopathy who undergoes blepharoplasty that unmasks lid retraction and keratopathy.

Lacrimal System Dysfunction Epiphora can result secondary to dry eye, exposure keratopathy, or an impaired lacrimal pump. Dysfunction usually returns to normal, but extended tearing requires further evaluation for punctal malposition or canalicular damage.

Strabismus and Extraocular Muscle Disorder Diplopia is a rare but potentially disabling complication of blepharoplasty.

Signs that make diplopia less worrisome are preoperative history of strabismus, monocular diplopia that clears with blinking (suggestive of precorneal tear film abnormality), and intermittence.

Persistent binocular diplopia requires additional consideration. In a review of over 900 blepharoplasty procedures, the risk of persistent strabismus was approximately 0.2 percent.

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Late Postoperative Period (after 6 weeks)

Upper Eyelid Malposition

Ptosis If the ptosis was not present preoperatively, then it may be the result of direct trauma to the levator aponeurosis or secondary attenuation from postoperative edema or hematoma. If secondary attenuation has occurred, additional surgery should be delayed until 3 months postoperatively.

Upper Eyelid Retraction and Lagophthalmos

Lagophthalmos in the late postoperative period is the result of excessive skin excision or incorporation of the orbital septum in skin closure resulting in eyelid retraction. If conservative therapy fails or severe exposure keratopathy warrants, surgical correction should be considered.

Lower Eyelid Malposition

Late lower eyelid malposition is complex and requires careful consideration based on anatomical concepts. Identification of the affected lamella (anterior, middle, or posterior), usually the result of deficient tissue or cicatrization, is the key to successful reconstruction. In addition, horizontal laxity must be considered as a potential component of malposition. …………..

Malar Festoons are more likely to occur in patients who are predisposed to fluid accumulations (ie history of thyroid disease, renal failure, sinusitis, allergies). (photo credit)

Patients who are at higher risk should be treated intraoperatively with intravenous steroids. Postoperative oral steroids are useful. Furosemide (Lasix, 20 to 40 mg daily) early in the postoperative course is helpful. Although persistent malar festoons can be excised, the success rate is low. If the underlying condition is systemic, eyelid surgery cannot locally correct the problem.

Dry Eye Syndrome

True dry eye disease in a postblepharoplasty patient can only be diagnosed after ample time has been allowed for resolution of common early and intermediate sicca symptoms. …...

Initial treatment of dry eye consists of ocular lubrication. Treatment failure should prompt ophthalmologic examination, with consideration of antiinflammatory eyedrops (such as topical cyclosporine) or punctal occlusion.

REFERENCES

Blepharoplasty Complications; Lelli, Gary J. Jr; Lisman, Richard D.; Plastic and Reconstructive Surgery. 125(3):1007-1017, March 2010; doi: 10.1097/PRS.0b013e3181ce17e8

Minor Complications after Blepharoplasty: Dry Eyes, Chemosis, Granulomas, Ptosis, and Scleral Show; Pacella, Salvatore J.; Codner, Mark A.; Plastic and Reconstructive Surgery. 125(2):709-718, February 2010; doi: 10.1097/PRS.0b013e3181c830c7

1 comment:

Anonymous said...

I have subclinical hypothyroid (TSH 5.25) and hereditary fat pads under my eyes. I really want an upper and lower blepharoplasty and will likely have a transcutaneous lower bleph with some skin excision. What are the chances that I will develop malar festoons? What other complications could arise? Thanks!