Lower eyelid surgery: complications

Complications of blepharoplasty usually result from excessive skin or fat resection, insufficient hemostasis, or inadequate preoperative assessment. Less commonly, undesirable consequences may result from an individual physiological response to wound healing despite technically correct performance of the surgery. Therefore, the goal of reducing the number of postoperative complications of blepharoplasty should be their prevention by identifying and correcting known risk factors.

Ectropion

One of the major complications following lower eyelid surgery is malposition, which can range from a slight scleral exposure or rounding of the lateral canthus to overt ectropion and eversion of the lower eyelid. In most cases resulting in permanent ectropion, the underlying etiologic factor is improper handling of excessive lower eyelid tissue laxity. Other causes include excessive skin or myocutaneous flap excision; inferior contracture along the plane of lower eyelid retraction and orbital septum (more common with the skin flap technique); inflammation of the fat pockets; and, rarely, destabilization of the lower eyelid retractors (a potential, although uncommon, complication of the transconjunctival approach). Temporary ectropion is associated with eyelid stress due to reactive edema, hematoma, or muscle hypotonia.

Conservative measures may include:

• a short postoperative course of steroids, as well as cold compresses and head elevation to treat swelling;
• alternating cold and warm compresses to speed up the resolution of hematomas and improve circulation;
• repeated eye-contact exercises to improve muscle tone;
• gentle massage in an upward direction;
• Supporting the lower eyelid with a patch (upward and outward) to improve corneal protection and tear collection.

When it is found within the first 48 hours that the skin excision was excessive, plastic surgery is performed using a preserved autologous skin flap. If the situation becomes clear later, conservative measures are taken to protect the eye until the scar matures, and then a full-thickness flap (preferably upper eyelid skin or retroauricular skin, or foreskin in men) is used to replace the defect. Eyelid shortening surgery is often combined with skin grafting, which is the mainstay of treatment for eyelid atony. Treatment of persistent compaction resulting from hematoma formation or inflammatory response from fat pockets usually consists of local injections of long-acting corticosteroids.

Hematomas

Subcutaneous blood accumulation can usually be minimized preoperatively by optimizing hemostasis and normalizing blood pressure; intraoperatively by gentle tissue handling and meticulous hemostasis; postoperatively by elevating the head, using cold compresses, and limiting physical activity; and by providing adequate pain relief. If a hematoma develops, its extent and timing should dictate its treatment.

Small, superficial hematomas are fairly common and usually resolve spontaneously. If they organize to form a compacted mass and resolve slowly and inconsistently, steroid injections may be used to speed healing. Moderate to large hematomas recognized after several days are best treated by allowing them to liquefy (7-10 days) and then evacuating them by aspiration through a large-bore needle or a small puncture with a #11 blade. Large, early-onset hematomas that are progressive or are accompanied by retrobulbar symptoms (decreased visual acuity, ptosis, orbital pain, ophthalmoplegia, progressive conjunctival edema) require immediate wound exploration and hemostasis. Retrobulbar symptoms require urgent ophthalmologist consultation and orbital decompression.

Blindness

Blindness, although rare, is the most feared potential complication of blepharoplasty. It occurs at a rate of approximately 0.04%, usually within the first 24 hours after surgery, and is associated with the removal of orbital fat and the development of a retrobulbar hematoma (most commonly in the medial fat pocket). The most likely causes of retrobulbar hemorrhage are:

• excessive tension of the orbital fat, leading to rupture of small arterioles or venules in the back of the orbit;
• by retracting the transected vessel behind the septum of the eye after separating the fat;
• inability to recognize a crossed vessel due to its spasm or the action of adrenaline;
• direct trauma to the vessel as a result of blind injection behind the septum of the eye;
• secondary bleeding after wound closure associated with any impact or phenomenon that has led to an increase in arteriovenous pressure in this area.

Early recognition of progressive orbital hematoma can be facilitated by delaying wound closure, avoiding occlusive and compressive eye patches, and increasing the period of postoperative observation. Although many treatments have been described for visual impairment associated with increased intraorbital pressure (wound revision, lateral canthal dissection, steroids, diuretics, anterior chamber paracentesis), the most effective definitive treatment is immediate orbital decompression, which is usually accomplished through resection of the medial wall or orbital floor. Of course, consultation with an ophthalmologist is advisable.

Retention lacrimation (epiphora)

Assuming that dry eye issues are managed preoperatively or intraoperatively (sparing and staged resection), postoperative epiphora is more likely to be caused by dysfunction of the collecting system than by hypersecretion of tears (although reflex hypersecretion may occur due to concomitant lagophthalmos or vertical retraction of the lower eyelid). This reaction is common in the early postoperative period and is usually self-limited. It may be caused by: 1) eversion of the punctum and blockage of the lacrimal canaliculi due to edema and wound distension; 2) impaired lacrimal pump due to atony, edema, hematoma, or partial resection of the suspensory band of the orbicularis oculi; 3) temporary ectropion due to lower eyelid strain. Outflow obstruction caused by injury to the inferior canaliculi can be prevented by making the incision lateral to the punctum. If damage to the canaliculi does occur, primary repair with a silastic stent (Crawford tube) is recommended. Permanent eversion of the punctum can be corrected by coagulation or excision of the conjunctival surface below the canaliculi.

Complications in the area of the suture line

Milia, or incisional cysts, are common lesions seen along the incision line. They arise from epithelial fragments trapped beneath the surface of healed skin or possibly from occluded glandular ducts. They are usually associated with simple or continuous cutaneous sutures. The formation of these cysts is minimized by closure of the wound at the level of the subcutaneous layer. When this occurs, treatment consists of incising the cyst (with a No. 11 blade or epilating needle) and plucking the sac. Granulomas may form at or beneath the suture line as nodular thickenings, the smaller ones treated with steroid injection and the larger ones with direct excision. Suture tunnels result from prolonged suture intrusion, with migration of the superficial epithelium along the sutures. Prevention consists of early removal of sutures (3-5 days), and radical treatment consists of tunnel dissection. Suture marks also refer to the prolonged presence of sutures, and their formation can usually be avoided by using rapidly absorbable suture material (catgut), early removal of monofilament sutures, or suturing the wound subcutaneously.

Complications in wound healing

Hypertrophic or protruding eyelid scars may develop, although rare, due to poor incision placement. If the epicanthal incision is placed too medially, a bowstring or webbing appearance may develop (a condition usually correctable with Z-plasty). A portion of the incision beyond the lateral canthus (which usually overlies a bony prominence) that is placed too obliquely downward or sutured with excessive tension may be susceptible to hypertrophic scarring, and as it heals, the eyelid is subject to a vertical contraction vector that favors scleral exposure or eversion of the eyelid. If the lower eyelid incision is placed too far superiorly or too close to the lateral portion of the upper eyelid incision, the contraction forces (in this case favoring downward retraction) create a condition that predisposes to lateral canthus overhang. Proper treatment should aim to reorient the contraction vector.

Wound dehiscence may occur as a result of suturing under excessive tension, early suture removal, infection (rare), or hematoma formation (more common). Skin dehiscence is most common at the lateral aspect of the incision, using the myocutaneous or cutaneous technique, and treatment consists of support with adhesive strips or repeated suturing. If tension is too great for conservative treatment, an eyelid suspension technique or skin grafting to the lateral aspect of the eyelid may be used. A scab may form as a result of devascularization of the area of skin. This occurs almost exclusively with the cutaneous technique and usually occurs on the lateral aspect of the lower eyelid after extensive undercutting and subsequent hematoma formation. Treatment consists of local wound care, evacuation of any hematoma, promotion of a line of demarcation, and early skin grafting to prevent cicatricial contracture of the lower eyelid.

Skin color change

Areas of incised skin often become hyperpigmented in the early postoperative period, due to bleeding beneath the skin surface with subsequent deposition of hemosiderin. This process is usually self-limiting and often takes longer in individuals with more heavily pigmented skin. Avoidance of direct sunlight is especially important in these patients in the postoperative period, as it may cause irreversible pigmentation changes. Recalcitrant cases (after 6-8 weeks) may be treated with camouflage, peeling, or depigmenting therapy (e.g., hydroxyquinone, kojic acid). Telangiectasias may develop after skin incision, particularly in areas beneath or near the incision. They occur most frequently in patients with preexisting telangiectasias. Treatment may include chemical peels or laser dye removal.

Eye injury

Corneal abrasions or ulcerations may result from accidental rubbing of the corneal surface with a tissue or cotton swab, improper handling of an instrument or suture, or desiccation resulting from lagophthalmos, ectropion, or preexisting dry eye. Symptoms suggestive of corneal damage, such as pain, eye irritation, and blurred vision, should be confirmed by fluorescein staining and slit-lamp ophthalmologic examination. Treatment of mechanical damage typically involves the use of antibacterial eye drops with lid closure until epithelialization is complete (usually 24-48 h). Treatment of dry eye consists of adding an ocular lubricant, such as Liquitears and Lacrilube.

Extraocular muscle dysfunction may occur, manifested by double vision, and often resolves with resolution of the edema. However, permanent muscle damage may develop due to blind clamping, deep penetration into the cellular pockets during pedicle isolation, thermal injury during electrocoagulation, improper suturing, or Volkman-type ischemic contracture. Patients with evidence of persistent dysfunction or incomplete recovery of muscle function should be referred to an ophthalmologist for evaluation and specific treatment. Contour irregularities Contour irregularities are usually due to technical errors. Excessive fat resection, especially in patients with a prominent inferior orbital rim, results in lower lid concavity and sunken appearance of the eye. Failure to remove sufficient fat (often in the lateral pocket) results in surface irregularities and permanent bulges. A ridge below the incision line usually results from inadequate resection of the orbicularis oculi strip before closure. Areas of thickening or lumps below the suture line can usually be attributed to unresolved or organized hematoma, tissue reaction or fibrosis following electrocautery or thermal injury, or soft-tissue response to fat necrosis. Treatment is directed at the specific cause in each case. Persistent fat prominences are resected, and areas of eyelid depression may be corrected with sliding or free fat or skin-fat grafts and advancement of the orbicularis oculi flap. Some patients with such prominences or ridges respond well to topical triamcinolone (40 mg/cc). In selected cases, additional reduction of the inferior orbital rim may be necessary to reduce the severity of the sunken eye. Unresolved hematomas and areas of thickening related to the inflammatory response may be treated with steroids.

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