Lower eyelid plastic surgery: complications

Complications of blepharoplasty are usually the result of excessive resection of the skin or fat, insufficient hemostasis or inadequate preoperative assessment. More rarely, an individual physiological response to wound healing may lead to undesirable consequences, despite the technically correct operation. Therefore, the task of reducing the number of postoperative complications of blepharoplasty should consist in their prevention by isolating and correcting known risk factors.

Ectropion

One of the main complications after the plasty of the lower eyelids is their misposition, which can be seen from a small outcrop of the sclera or rounding of the lateral corner of the eye gap to the apparent ectropion and inversion of the lower eyelid. In most cases, leading to a permanent ectropion, the main etiologic factor is the incorrect actions with excessive weakness of the tissues of the lower eyelid. Other causes include excessive excision of the cutaneous or musculocutaneous flap; lower contracture along the plane of retraction of the lower eyelid and septum partition (more with the technique of skin flap); inflammation of the fat pockets; and, rarely, the destabilization of the retrovators of the lower eyelid (a potential, although infrequent, complication of the transconjunctival approach). Temporary ectropion is associated with a load on the eyelid due to jet edema, hematoma or muscle hypotension.

Conservative actions can include:

• a short postoperative course of steroids, as well as cold compresses and a head lift for the treatment of edema;
• alternation of cold and warm compresses to accelerate the resolution of hematomas and improve circulation;
• repeated exercises in the form of eye reduction to improve muscle tone;
• careful massage in the upward direction;
• support the lower eyelid with a plaster (up and out) to improve the protection of the cornea and collect tears.

When during the first 48 hours it turns out that the excision of the skin was excessive, plastic is applied with a canned autolocut of the skin. If the situation becomes clearer, conservative measures protecting the eye are applied before ripening of the rumen, and then a full-fledged flap (preferably, the upper eyelid or the bovine skin or the foreskin in men) is used to replace the defect. The operation to shorten the eyelids in many cases is combined with a skin graft, which is the main direction of the treatment of atony eyelids. Treatment of permanent seals resulting from the formation of a hematoma or an inflammatory response from the fat pockets, usually consists of local injections of prolonged-acting corticosteroids.

Hematomas

The accumulation of blood under the surface of the skin can usually be minimized before the operation, by optimizing hemostasis and normalizing blood pressure; during surgery, by careful handling of tissues and careful hemostasis; after the operation, by lifting the head, cold compresses and limiting physical activity; and also by adequate anesthesia. If a hematoma develops, the method of its treatment should be dictated by the prevalence and time of manifestation.

Small, superficial hematomas are quite frequent and are usually stopped on their own. If an organization takes place with the formation of a compacted mass and its resolution is slow and inconsistent, injections of steroids can be used to accelerate the healing process. Moderate and large bruises, recognized after a few days, are better treated by allowing them to fluidize (7-10 days), and then evacuating, by aspiration through a large diameter needle or a small puncture with blade number 11. Large, early-onset hematomas that build up or accompanied by retrobulbar symptoms (decreased visual acuity, ptosis, ophthalmic pain, ophthalmoplegia, progressive edema of the conjunctiva), require immediate revision of the wound and hemostasis. With retrobulbar symptoms, urgent consultation of the ophthalmologist and ophthalmic decompression is required.

Blindness

Blindness, although rarely developed, is the most terrible potential complication of blepharoplasty. It occurs at a frequency of about 0.04%, usually within the first 24 hours after surgery, and is associated with the removal of the orbital fiber and the development of retrobulbar hematoma (most often in the medial fat pocket). The most likely causes of retrobulbar hemorrhage are the following:

• excessive tension of the ophthalmic fat, leading to rupture of small arterioles or venules in the back of the orbit;
• the retraction of the crossed vessel behind the septum of the eye after separation of the fat;
• The inability to recognize a crossed vessel because of its spasm or the action of adrenaline;
• direct injury of the vessel as a result of blind injection behind the septum of the eye;
• secondary bleeding after wound closure, associated with any effect or phenomenon leading to an increase in arterio-venous pressure in this area.

Early detection of the progressive ocular hematoma can be alleviated by delaying suturing the wound, abandoning the closing and pressing eye patch and increasing the period of postoperative follow-up. Although many methods have been described for the treatment of vision impairment associated with increased intraocular pressure (wound revision, dissection of the lateral angle of the optic opening, injection of steroids, diuretics, anterior chamber paracentesis), the most effective decisive treatment is immediate orbital decompression, which is usually performed through resection of the medial wall or the bottom of the eye socket. Certainly, consultation of the ophthalmologist is desirable.

Retinal lacrimation (epiphora)

Assuming that issues related to dry eye syndrome are resolved before surgery or during surgery (thrifty and gradual resection), the cause of the postoperative epiphora is rather the dysfunction of the collecting system rather than the high secretion of tear fluid (although reflex hypersecretion may occur due to concomitant lagophthalmus or vertical retraction of the lower eyelid). Such a reaction is often found in the early postoperative period and usually passes by itself. Its causes can be as follows: 1) reversal of the lacrimal point and blockage of lacrimal ducts due to edema and dilatation of the wound; 2) disturbance of the lacrimal pump due to atony, edema, hematoma or partial resection of the supporting band of the circular eye muscle; 3) a temporary ectropion due to the burden on the lower eyelid. Obstruction of the outflow caused by damage to the lower tubules can be prevented by drawing a lateral tear point. If the tubular damage did occur, a primary recovery with a silastic stent (Crawford tube) is recommended. Permanent reversal of the lacrimal point can be corrected by coagulation or excision of the conjunctival surface below the tubules.

Complications in the area of the seam line

Milia, or incisional cysts, are frequent formations observed along the line of the incision. They come from epithelial fragments that fall under the surface of the healed skin, or, perhaps, from the occluded ducts of the glands. They are usually associated with simple or continuous cutaneous sutures. The formation of these cysts is minimized by closing the wound at the level of the subcutaneous layer. If this occurs, the treatment consists in opening the cyst (blade No. 11 or epilating needle) and pulling out the bag. In the seam line or under it granulomas can be formed in the form of nodular thickenings, the smaller of which are treated with injections of steroids, and large ones by direct excision. Suture tunnels are the result of a long suture filament in the tissues, which is accompanied by the migration of the superficial epithelium along the filaments in depth. Prevention is the early removal of seams (3-5 days), and radical treatment - in the dissection of the tunnel. Seam marks also refer to the prolonged presence of sutures, and their formation can usually be avoided using a rapidly resorbing suture (catgut), removing early monofilament sutures or suturing the wound subcutaneously.

Complications of wound healing

Hypertrophic or protruding scars on the eyelids can develop, albeit rarely, due to incorrect placement of the incision. If the incision in the epicanthal region is initiated too medially, a bowstring or cobweb can be formed (a condition usually available by Z-plating correction). A part of the cut behind the lateral angle of the eye gap (which usually lies over the bone protuberance), which is too obliquely down or sutured with excessive tension, may be prone to hypertrophic scarring, and with healing on the eyelid, a vertical contraction vector acts to expose the sclera or inverse the eyelid. If the incision of the lower eyelid is too far up or too close to the lateral part of the incision of the upper eyelid, the force of contraction (in this case contributing to pulling downwards) creates a condition predisposing to the overhanging of the lateral angle of the eye gap. Proper treatment should be aimed at reorienting the contraction vector.

As a result of suturing under excessive tension, early removal of sutures, the development of an infectious process (rarely) or the formation of a hematoma (more often), a wound may become divergent. The discrepancy of the skin is most often observed in the lateral part of the incision, with the use of musculoskeletal or dermal techniques, and the treatment consists in supporting adhesive strips or re-suturing. If the tension is too high for conservative treatment, the technique of suspending the eyelid or transplanting the skin into the lateral part of the eyelid can be applied. As a result of the devascularization of the skin, a scab may form. This is observed almost exclusively with skin technology and usually occurs in the lateral part of the lower eyelid after extensive incision and subsequent formation of a hematoma. Treatment consists of local wound care, the evacuation of any hematoma, in promoting the formation of a demarcation line and early skin transplantation to prevent scarring of the lower eyelid contracture.

Skin discoloration

The areas of the cut skin often become hyperpigmented in the early postoperative period, which is associated with bleeding under the surface of the skin with subsequent deposition of hemosiderin. This process is usually subjected to independent reverse development and often takes longer for people with more pigmented skin. In the postoperative period it is necessary, especially for these patients, to avoid direct sunlight, as this can lead to irreversible changes in pigmentation. Persistent cases (after 6-8 weeks) can be subjected to camouflage, peeling or depigmenting therapy (for example, hydroxyquinone, kojic acid). After cutting the skin, telangiectasias can develop, especially in areas under or near the incision. They are most common in patients with pre-existing telangiectasia. Treatment can consist of chemical peeling or removal by a dye laser.

Eye damage

Abrasions or ulceration of the cornea may be the result of accidental rubbing of the cornea surface with a tissue or cotton swab, improper handling of the instrument or suture material, and also drying, developed as a result of lagophthalmus, ectropion or already existing dry eye syndrome. Symptoms that speak of corneal damage, such as pain, eye irritation and blurred vision, should be confirmed by fluorescein staining and ophthalmic examination under the slit lamp. Treatment of mechanical damage usually involves the use of antibacterial eye drops with the closure of the eyelid until the end of epithelialization (usually 24-48 hours). Treatment for dry eye syndrome consists in the addition of an eye lubricant, such as Liquitears and Lacrilube.

An outbreak of extraocular musculature that manifests itself in a double image may occur, which often occurs after the resolution of the edema. However, due to the imposition of a blind clamp, deep penetration into the cell pockets with the isolation of the pedicle, thermal damage during electrocoagulation, improper suturing, ischemic contracture of the Volkman type, permanent muscle damage can develop. Patients with signs of sustained impairment or incomplete recovery of muscle function should be referred to an ophthalmologist for examination and special treatment. Contour irregularities Contour irregularities usually occur due to technical errors. Excessive resection of fat, especially in patients with a protruding lower edge of the orbit, leads to concavity of the lower eyelid and the sunken appearance of the eye. The inability to remove a sufficient amount of fat (often in the lateral pocket) leads to uneven surfaces and the formation of permanent bulges. The comb that forms below the incision line is usually the result of inadequate resection of the circular muscle of the eye before stitching. The areas of densification or lumpiness below the seam line can usually be attributed to an unresolved or organized hematoma, tissue reaction or fibrosis after electrocoagulation or thermal damage, or through the response of soft tissues to fat necrosis. Treatment in each case is directed to a specific cause. Permanent fat bulges are resected, and the areas of denture on the eyelid can be corrected by sliding or free fat or skin-fat grafts, as well as by moving the flap of the circular eye muscle. Some of the patients with such protuberances or protrusions respond well to the local administration of triamcinolone (40 mg / cm3). In some cases, to reduce the severity of the eye's westernization, you can additionally reduce the lower edge of the orbit. Unresolved hematomas and thickening areas associated with an inflammatory response can be treated with the administration of steroids.

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