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Complications of Blepharoplasty
Brian Leatherbarrow, FRCOphth1 Konal Saha, FRCOphth2
Address for correspondence Brian Leatherbarrow, FRCOphth, Department of Oculoplastic and Orbital Surgery, Manchester Royal Eye Hospital, Manchester, Greater Manchester, United Kingdom (e-mail: brianleatherbarrow@btinternet.com).
1 Department of Oculoplastic and Orbital Surgery, Manchester Royal

Eye Hospital, Manchester, Greater Manchester, United Kingdom 2 Corneoplastic Department, Queen Victoria Hospital, East Grinstead, United Kingdom Facial Plast Surg 2013;29:281 288.

Abstract
Keywords

complications blepharoplasty

This article provides a comprehensive discussion on the complications of blepharoplasty. We discuss the importance of preoperative counselling and surgical planning to provide the patient with a satisfactory outcome. Strategies are presented to manage common complications.
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Blepharoplasty is a surgical procedure to improve the aesthetic appearance of the eyelids or, speci cally in relation to the upper eyelids, to improve visual function and patient comfort, including to ease watering in speci c cases of wick syndrome.1 It generally means a surgical procedure involving the excision of varying amounts of skin and the excision or repositioning of some orbicularis oculi muscle and/or eyelid fat. The key function of the eyelids is to protect the globe. The key aim of a blepharoplasty is to achieve the best aesthetic result for a patient without compromising the function of the eyelids in maintaining a healthy and comfortable ocular surface.

The lower eyelids should be assessed in the context of the midface. Careful assessment of the following is required: Skin type and quantity: A change in the quality versus the quantity of skin should be documented (i.e., the presence of ne lines or folds). The presence of an ectropion in upgaze suggests a shortage of lower eyelid skin and/or midface descent. Poor appreciation of these factors can lead to postoperative lower eyelid ectropion and/or eyelid retraction. Eyelid laxity: Surgery on the lower eyelid in the presence of signi cant laxity can often lead to ectropion and/or retraction. Assessing laxity remains subjective despite tests having been described to help assess and document severity such as the eyelid distraction test and the snap-back test. Although frequently indicated, lateral canthal support should not be considered routine in all cases of lower eyelid blepharoplasty,2 especially in the presence of a negative vector (see below). Fat herniation: Lower eyelid fat herniation is often most clearly appreciated in upgaze. Fat herniation should be distinguished from edema by applying gentle pressure to the upper eyelid looking for increased prominence of the lower eyelid fat pads. Edema does not tend to become more prominent. Overestimation of the degree of fat herniation and consequent overexcision can lead to a hollow, skeletonized appearance. Globe prominencethe negative vector: The relationship between the corneal surface and the inferior orbital rim should be assessed in the lateral view. A corneal surface lying in a plane anterior to the lower orbital rim results in the lower eyelid having a negative vector; this is a risk factor for lower eyelid retraction following overzealous eyelid tightening and lower eyelid blepharoplasty. Orbital

Preoperative Patient Assessment and Counseling

The management of a patient seeking a blepharoplasty begins from the rst contact with the patient. The patients presenting problems need to be clearly and carefully identi ed and their aims and expectations managed. As patients who request such surgery for aesthetic reasons are generally seeking a rejuvenation of their face rather than a radical change in their appearance, photographs of the patient at different stages of their life can be very helpful in documenting the changes that have developed over time. It is always helpful to request that these are brought to the consultation when the patient schedules an appointment. Altering a patients appearance in a way that is not expected by the patient will lead to signi cant dissatisfaction. Careful note should be made of a patients eyebrow shape, position, fullness, and resulting upper eyelid skin show, both in the resting position and with animation during the course of the consultation.

Issue Theme Periocular Aesthetic Rejuvenation; Guest Editor, Naresh Joshi, FRCOphth

Copyright 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0033-1349362. ISSN 0736-6825.

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decompression has been used to address this issue prior to blepharoplasty but should not be considered routine.3 Careful assessment allows an accurate risk analysis to be performed. This may dissuade high-risk patients from proceeding with surgery. A careful past medical history must be taken to identify medical and ocular comorbidities, a previous history of hypertrophic scar formation, and the use of anticoagulant drugs or antiplatelet agents (including herbal remedies such as ginkgo biloba). A detailed past ophthalmic history must be taken to identify patients who wear contact lenses, who have undergone corneal laser refractive surgery or any other ocular surgery, or who have a dry eye problem. Particular note should be made of previous periocular surgery, particularly previous blepharoplasty surgery, as this is associated with a higher risk of postoperative complications. A nonsurgical aesthetic treatment history should also be taken to document the use of periocular and facial botulinum toxin injections, dermal ller injections, laser skin resurfacing, or skin peels. The preoperative management of anticoagulants and antiplatelet agents should be undertaken in consultation with the patients general practitioner or physician. Thorough preoperative patient assessment and counseling are the rst important steps to be taken to minimize risks and potential complications of a blepharoplasty.

Fig. 1 Lateral canthotomy the lateral commissure is opened with scissors.

Complications of Blepharoplasty Surgery

Visual Loss
By far the most serious complication of blepharoplasty surgery is blindness. This is usually due to the sudden occurrence of a postoperative retrobulbar hemorrhage. Although rare, this is a devastating complication of an operation performed most commonly to improve a patients aesthetic appearance. The incidence of a postoperative retrobulbar hemorrhage following blepharoplasty is estimated at 1:2,000 with an incidence of 1:10,000 of permanent visual loss.4 The patient must be counseled about this risk preoperatively. The surgery must be performed meticulously with strict attention to intraoperative hemostasis. Undue traction on orbital fat must be avoided. A lower lid blepharoplasty is associated with a higher risk of postoperative bleeding than an upper lid blepharoplasty. Particular care must be taken when debulking the medial fat pads. It is important to ensure that all risk factors for bleeding are addressed preoperatively. No patient should undergo blepharoplasty surgery involving the removal of orbital fat if hypertension is uncontrolled, if there is a history of a bleeding disorder, or if the patient is taking anticoagulants or antiplatelet drugs. The patient must be given postoperative instructions about restrictions on activity following surgery. The patient must be able to return to hospital immediately in the event of any sudden orbital pain, proptosis, or decrease in vision. A patient with a retrobulbar hematoma usually complains of a steady, boring, or lancinating pain. The patient may also report scintillating scotomata or complete visual loss and may
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exhibit mydriasis with a relative afferent pupil defect, proptosis with resistance to retropulsion, and hemorrhagic chemosis. If a patient develops a sudden orbital hemorrhage with proptosis or a subconjunctival hemorrhage and decreased visual acuity with a relative afferent pupil defect, the surgical wound must be opened immediately to drain the hematoma and a lateral canthotomy and inferior cantholysis should be performed to achieve an emergency orbital decompression (Figs. 13). Because the potential visual consequences of a retrobulbar hemorrhage are so severe, aggressive intervention is required. If possible, the surgeon should not wait for signs of optic nerve compression (i.e., a reduced visual acuity, visual eld loss, and an afferent pupillary defect) to arise, because irreversible damage may have occurred by that time. Rather, excessive pain and proptosis necessitate immediate surgical decompression. The surgical wound should be opened and carefully explored. Medical decompression of the orbit with corticosteroids (methylprednisolone 1000 mg intravenously [IV]) and carbonic anhydrase inhibition (acetazolamide 500 mg IV) should be organized immediately, and

Fig. 2 Lateral cantholysis the lateral canthal tendon is cut.

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contact lenses. The consistent continued use of frequent arti cial tears is imperative in these patients who may also require additional procedures at a later date (e.g., punctal plug placement or punctal cautery). Patients who require arti cial tears more frequently than three to four times per day should be advised to use a preservative-free preparation.

Lower Lid Retraction

Lower lid retraction and inferior scleral show are wellrecognized complications of a transcutaneous lower lid blepharoplasty (Fig. 4). These complications are very rarely seen following a transconjunctival lower lid blepharoplasty. There are several causes: 1. Overresection of skin leaving a vertical skin shortage 2. Middle lamellar contracture 3. Presence of a negative vector with a relative prominence of the globe
Fig. 3 The lateral lower eyelid is now free of the lateral orbital rim decompressing the orbit anteriorly.

if necessary, osmotic diuresis (mannitol 50 to 100 g IV over 30 minutes) may also be used. The patients intraocular pressure should be monitored using a Perkins tonometer or a tonopen, and the patients fundus should be examined to ensure patency of the central retinal artery. Visual loss from inadvertent globe perforation can occur during the course of a blepharoplasty but this complication is rare. It should not occur when the surgery is undertaken by a suitably trained and experienced oculoplastic surgeon.

Oculocardiac Reex
The oculocardiac re ex, characterized by intraoperative bradycardia or dysrhythmia, can be triggered by traction on the extraocular muscles or orbital fat pads or by pressure on the globe. A profound bradycardia or even asystole can occur. Younger patients are more susceptible to the severe effects of this re ex. The anesthetist monitoring the patient should be aware of the possibility of a dysrhythmia occurring and should alert the surgeon who should in turn release any tissue to which traction is being applied. Atropine or glycopyrrolate should be kept drawn up in a syringe and available immediately in the event of a severe dysrhythmia.

A patient with middle lamellar contracture will have lower lid tethering, and the lid cannot be moved upward over the eye by the examining surgeon. This is in contrast to the patient with lower lid retraction associated with an overresection of skin only. A mild degree of lower eyelid retraction may be managed conservatively with postoperative vertical eyelid traction and massage. This should be commenced 10 to 14 days following surgery. The patient is instructed to push and hold the lateral aspect of the eyelid vertically while looking upward with the tips of two ngers touching the eyelid margin. This is undertaken for a few minutes, following which the patient is instructed to apply a lubricant ointment to the skin of the lower eyelid (e.g., Lacrilube [Allergan, Irvine, CA]) and to massage the eyelid upward. This regimen should be undertaken for 3 to 4 minutes three to four times a day for 4 to 6 weeks. A mild degree of lower lid retraction can resolve with this treatment. A greater degree of lower lid retraction will require surgical intervention. The aim is to avoid the requirement to add skin with the use of a skin graft wherever possible. A suborbicularis oculi fat (SOOF) lift or a midface-lift combined with a lateral canthal resuspension or lateral lower lid tightening (a lateral suture canthopexy or a formal lateral tarsal strip procedure depending on the degree of eyelid/

Dry Eye
A dry eye problem following blepharoplasty surgery is most often seen in patients who have a preexisting tear lm insuf ciency and is usually associated with an incomplete blink or frank lagophthalmos. The patient should be carefully examined preoperatively to exclude a dry eye problem. The patients tear lm and the tear lm breakup time should be assessed along with an examination of the tear meniscus, the cornea, and conjunctiva after the instillation of uorescein drops. Any blepharitis should be noted and treated. A patient who is found to have any blepharitis or dry eye problem must be counseled accordingly. This can be particularly important in patients who have undergone corneal refractive procedures (e.g., laser-assisted in situ keratomileusis) or who wear

Fig. 4 Bilateral lower eyelid retraction following bilateral lower eyelid transcutaneous blepharoplasty.
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Lower Lid Riding High with Weakness of Movement on Downgaze

The lower eyelid margin may be high following transconjunctival lower eyelid blepharoplasty and may not move down on downgaze, obstructing the patients vision. This is caused by dissociation of the lower eyelid from the inferior retractors and may be prevented by suture closure of the conjunctival wound at the time of surgery. This complication can be managed by reinserting the retractors to the tarsus with absorbable suture through a transconjunctival approach.

Fig. 6 The patient with the lower eyelid ectropion managed with a lower eyelid full-thickness skin graft immediate postoperative image.

Epiphora
Epiphora is common in the rst few postoperative days following a lower lid blepharoplasty. Corneal irritation (which triggers hypersecretion of tears, lagophthalmos, or an incomplete blink), conjunctival chemosis (which interferes with the even distribution of the lm over the cornea), and

Lower Lid Ectropion

A temporary postoperative lateral lower eyelid ectropion may occur as a result of postoperative wound edema, wound contraction, and/or hypotonicity of the orbicularis oculi muscle following a transcutaneous lower lid blepharoplasty. Denervation of the orbicularis muscle should be avoided by ensuring that the wound is stepped. Following a subciliary incision, the skin is undermined to the inferior aspect of the tarsus before any incision is made through the orbicularis muscle. A frank ectropion (Fig. 5) occurs when signicant lower eyelid laxity has not been addressed or where caution has not been exercised in resetting of the orbital septum or in the degree of skin resection undertaken. This will usually require a lateral canthal resuspension or tightening procedure combined with the release of the septal attachment to the inferior orbital margin via a transconjunctival approach. In the presence of a signicant degree of vertical skin shortage and/or middle lamellar contracture, the management options are the same as those discussed under lower lid retraction (Figs. 68).
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Fig. 7 Early postoperative image, with a degree of graft contracture and thickening.

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lateral canthal tendon laxity) may prevent the need for a skin graft following an overresection of skin. With these procedures skin is effectively recruited into the lower lid but only in patients who have an associated midface ptosis. In the absence of a midface ptosis, patients who have a signi cant vertical skin shortage will require skin grafts combined with a lateral canthal resuspension or lateral lower lid tightening. Soft tissue expansion can also be considered for selected patients with a vertical skin shortage with no midface ptosis but such a procedure is associated with a signi cant interim disgurement and a lengthy recovery time. Middle lamellar contracture will require the division of the scar tissue via a transconjunctival approach with the placement of a posterior lamellar graft (e.g., a hard palate graft or a free tarsoconjunctival graft).5,6 A dermal graft can also be used but this will leave a donor site scar. This has the advantage, however, of providing a source of fat pearls for grafting in patients who have also developed lower lid hollowing following an overresection of lower lid fat. A lateral orbital wall decompression undertaken via an upper lid skin crease incision, possibly combined with a medial orbital wall decompression undertaken via a transcaruncular approach, is an option for the management of the patient with postblepharoplasty lower lid retraction who has a negative vector, but the patient has to be counseled very carefully about the associated risks, particularly the risk of postoperative diplopia.

Fig. 5 A left lower eyelid ectropion following lower eyelid transcutaneous blepharoplasty.

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Fig. 8 Late postoperative image, showing a satisfactory result.

Fig. 9 Frank lagophthalmos following overresection of skin during upper and lower eyelid blepharoplasty.

lower eyelid ectropion (which removes the inferior punctum from its normal contact with the globe) are the usual causes of early postoperative epiphora. All patients undergoing a blepharoplasty should be discharged with instructions to use frequent topical lubricant drops and an ointment at bedtime until their re ex blink has recovered or until any conjunctival chemosis has resolved to prevent any corneal exposure problems. Continued epiphora following blepharoplasty surgery may occur as a consequence of lagophthalmos with a secondary punctate epithelial keratopathy and a secondary re ex hypersecretion of tears and/or a malposition of the inferior punctum. Patients who have been identi ed as having a preoperative predisposition to a dry eye problem should undergo a more conservative upper lid blepharoplasty with careful attention to avoid an overresection of skin. A more conservative approach to any orbicularis resection should also be undertaken. Persistent symptomatic lagophthalmos following an overresection of upper lid skin will require a skin graft. The skin graft is placed above the skin crease. If necessary, a bucket-handle ap of orbicularis muscle may have to be brought inferiorly to provide an adequate blood supply for the graft. A subtle vertical positioning of the inferior punctum may result in epiphora. This is seen on careful slit lamp examination. This may occur some years after surgery as the lower eyelid tarsoligamentous support becomes more lax. Care should be taken to avoid any skin resection from the medial half of the lower lid during the course of a transcutaneous lower lid blepharoplasty, except in exceptional circumstances, to avoid a cicatricial punctal ectropion. A punctal ectropion associated with tarsoligamentous laxity will respond to a medial spindle procedure. A lateral suture canthopexy may also be required. Conjunctivochalasis, a redundant fold of inferior bulbar conjunctiva lying over the inferior punctum, may obstruct tear ow. This is another subtle abnormality requiring careful slit lamp examination. This will usually respond to a conservative resection of the redundant conjunctiva.

Diplopia
Diplopia is a rare complication following lower eyelid blepharoplasty. This is usually due to inadvertent surgical trauma to the inferior oblique muscle but can also occur due to damage to the inferior rectus.7 A good knowledge of eyelid and orbital anatomy, a meticulous surgical dissection, and an avoidance of the excessive use of cautery should prevent such a complication. Great care must also be taken to ensure that the inferior oblique muscle is not damaged with the passage of sutures when performing a septal reset or a fat-repositioning procedure. Diplopia due to a permanent ocular motility disturbance caused by intraoperative damage to an extraocular muscle is much rarer than diplopia due to decompensation of a preexisting ocular muscle imbalance following surgery. For this reason, it is imperative to perform a detailed preoperative ophthalmic examination to diagnose the problem and to protect the surgeon from unfair blame postoperatively.

Blepharoptosis
A blepharoptosis may occur if the levator muscle, the levator aponeurosis, the horns of the levator muscle complex, or Whitnalls ligament is damaged during the course of an upper lid blepharoplasty. These structures can only be damaged directly if the orbital septum has been opened to reposition or debulk fat or to reform the skin crease by incorporating the levator aponeurosis in the skin closure. These structures should be carefully identi ed and avoided. A blepharoptosis can also occur following excessive postoperative upper lid edema or bleeding leading to an aponeurotic dehiscence.
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Lagophthalmos
An incomplete re ex blink following an upper lid blepharoplasty is always seen when a portion of orbicularis muscle is

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removed as part of the procedure. This is usually a temporary denervation phenomenon, which recovers spontaneously in 2 to 6 weeks. It is also seen following overly aggressive lateral canthal dissection when a lower lid blepharoplasty is combined with a SOOF-lift or a midface-lift due to damage to branches of the facial nerve. Frank lagophthalmos following an upper eyelid blepharoplasty (Fig. 9) is avoided by ensuring a conservative skin resection in the upper eyelids. An overzealous resection of upper lid skin may require a skin graft if exposure symptoms do not respond to conservative treatment.

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Sensory loss in the distribution of the infraorbital or zygomaticofacial nerves is usually temporary. Care should be taken when cauterizing branches of the infraorbital artery over the inferior orbital margin during the course of an extended lower lid blepharoplasty with fat repositioning.

Any preexisting ptosis should be addressed at the time of an upper eyelid blepharoplasty by means of anterior approach levator aponeurosis advancement or by means of a posterior approach to Mller muscle resection or levator advancement. This should ideally be performed under local anesthesia, with or without sedation, to facilitate an intraoperative adjustment of the height and contour of the upper eyelid(s) with the bene t of the patients cooperation.

Fat Necrosis
Fat necrosis following a blepharoplasty is rare and manifests as small, painful, indurated nodules. Massage can hasten their resolution. Injection of steroids into the lesions is effective but carries the risk of subcutaneous fat atrophy and hypopigmentation.

Conjunctival Chemosis
Conjunctival chemosis, which is more commonly seen following a transconjunctival blepharoplasty, usually resolves after 10 to 14 days following the liberal use of topical lubricants. On very rare occasions it may last for some weeks or even months postoperatively. It is more likely to be severe in older patients who have preexisting conjunctivochalasis. It also complicates overly aggressive lateral canthal dissection. Conjunctival chemosis that fails to resolve spontaneously can be treated surgically by opening the conjunctiva and applying a pressure dressing. Rarely a temporary lateral suture tarsorrhaphy is required. The use of topical steroids is very rarely indicated and as a general rule they should be avoided.

Infection
Elective facial surgery is associated with a low infection rate. The incidence of infection following blepharoplasty surgery is estimated at 0.2%, increasing to 0.4% if laser resurfacing of the skin is performed.8 Treatment follows recommendations for all soft tissue infections, namely, systemic antibiotics with removal of any foreign material, including permanent sutures if these are involved. Samples should be taken for culture and microscopy to identify causative organisms because occasionally unusual organisms resistant to empirical therapy are the cause.9

Corneal Abrasion
All precautions must be taken to prevent a corneal abrasion, which can be extremely painful and debilitating. Most corneal abrasions heal rapidly without any long-term sequelae but in some patients a recurrent corneal erosion syndrome can occur. Diabetic patients and patients with corneal dystrophies (which may have been previously undiagnosed) are at particular risk of a recurrent corneal abrasion syndrome. A recurrent corneal erosion syndrome requires long-term topical lubricants and a bedtime ointment or more aggressive treatment with the use of a bandage contact lens, corneal stromal puncture, or therapeutic phototherapeutic keratectomy. Care should be taken when placing eyelid and conjunctival traction sutures to avoid causing a corneal abrasion. Great care should be taken when using cautery or cutting diathermy during the course of a blepharoplasty. A corneal protector shield in conjunction with a lubricant ointment should be used. If an abrasion does occur, the patient must be treated with frequent topical antibiotics and should undergo frequent review with slit lamp examinations until the abrasion has completely healed. A topical lubricant ointment should be prescribed at night for a minimum period of 6 weeks to help to prevent a recurrent corneal erosion syndrome.

Cosmetic Problems
Rounding of the Lateral Canthus
Rounding of the lateral canthus is a deforming appearance that occurs following the resection of skin and orbicularis oculi muscle as a triangle laterally together with loss of lateral canthal support (Fig. 10). This can be managed by reshaping the lateral canthal angle using aps augmented with lateral canthal resuspension. The procedure involves splitting the lateral canthal web into anterior and posterior lamellae, then creating a skin ap based on the lower eyelid and a conjunctival ap based on the upper eyelid. These aps are then

Facial Nerve Trauma

Injury to branches of the facial nerve, particularly the zygomatic branch to the inferior orbicularis, is a potential hazard of dissecting below the orbicularis oculi muscle. This can lead to a loss of tone in the muscle with loss of lower eyelid symmetry, lower eyelid ectropion, or lagophthalmos. Subperiosteal dissection or dissection within the suborbicularis oculi muscle fat plane minimizes the risk of this complication.
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Fig. 10 Lateral canthal rounding following upper and lower blepharoplasty.

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Fig. 12 A patient after upper blepharoplasty with an abnormally high skin crease and consequent large upper eyelid skin show.

Visible Scarring
folded over to create newly formed lateral eyelid margins. The procedure can be augmented with a lateral canthopexy and/ or a midface-lift (Saha K and Joshi N, personal communication) (Figs. 10, 11). Inappropriate skin incision placement in the lower lidthis should be strictly subciliary, avoiding damage to the lash follicles from cautery. It is better performed with a cutting diathermy needle rather than with one sweep of a blade, which can be dif cult to keep on track in lax skin.

Hollowing of the Eyelids

Hollowing of the eyelids can occur if too much orbital fat is removed, particularly in older patients with very thin eyelid skin. In the lower eyelids care should be taken to resect the fat ush with the inferior orbital margin and to avoid pulling the fat anteriorly. Usually, only a minimal volume of fat needs to be resected except in those with steatoblepharon or fat hypertrophy such as patients with thyroid eye disease. Fat repositioning is often preferable to signi cant fat resection. In some patients fat resection and fat repositioning can be combined. In addition, resected fat can be cut into small pearls and placed as free grafts in the lateral tear trough area in suitable patients. In patients who are left with cosmetically unacceptable hollowing of the eyelids, fat pearl grafting can be undertaken. The fat is usually harvested from the periumbilical area via a small skin incision shaped as a smile, divided into small pearls and placed into the upper eyelid preaponeurotic space via a skin crease incision and into the lower eyelid via a transconjunctival incision.

A Bulky Upper Eyelid

Care needs to be taken to resect orbicularis muscle below the superior aspect of the skin incision in patients in whom more than a few millimeters of skin is resected. This conservative, graded excision of orbicularis oculi allows a smooth transition across the wound without unduly compromising eyelid closure.

Poor Lateral Canthal Scarring

Upper and transcutaneous lower eyelid blepharoplasty techniques should result in minimal visible scarring. The upper eyelid incision should fall in the natural skin crease; however, if extended further laterally, care should be taken to place the scar in a laughter line, necessitating marking the patient preoperatively before any local anesthetic is injected. If the incision seems to warrant extension laterally, consideration should be given to whether a browlift would produce a better result. The transcutaneous lower eyelid blepharoplasty incision often extends beyond the lateral canthus, again necessitating careful preoperative marking prior to local anesthetic injection to ensure a natural laughter line is followed.

Upper Lid Skin Crease Defects

The appearance of the upper eyelid skin creases has a profound effect on the cosmetic outcome of an upper eyelid blepharoplasty. The skin crease is usually higher in a female patient and well de ned in contrast to a male patient, in whom it is usually lower and more subtle. There are also clear racial variations that must be recognized. Complications are avoided by careful preoperative planning and meticulous marking of the skin crease incisions. Postoperatively, it is easier to raise a skin crease that is unsatisfactory than it is to lower it. Preaponeurotic fat pad advancement has been suggested to be useful in creating a low skin crease in

Fig. 13 The patient from Fig. 12 after lowering of the upper eyelid skin crease using fat pearls harvested from the periumbilical region.
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Fig. 11 The same patient as Fig. 10 following eyelid lengthening.

Japanese patients,10 and this technique can be extended to patients with an abnormally high skin crease following blepharoplasty. If such fat is not available, the use of fat pearl grafting can be considered (Figs. 12, 13).

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3 Qureshi F, Leatherbarrow B. Expanding indications for orbital

Postoperative scarring has been shown to bene t from topical silicone dressings. In the periocular region, gels are the practical choice and can be started as early as 5 days postoperatively.11

decompression surgery. BOPSS 2012

4 Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of

Conclusion
Blepharoplasty surgery is most commonly performed for cosmetic indications. It is of paramount importance not to compromise function with the operation. A technically adequate operation can be associated with a dissatis ed patient if the preoperative discussion and assessment is de cient. Awareness of the potential complications, careful planning, immaculate surgical technique, and the ability to recognize and manage complications promptly are all necessary for safe blepharoplasty surgery.
6

9 10

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drome: association of upper-eyelid dermatochalasis and tearing. Arch Ophthalmol 2012;130:10071012 2 Maf TR, Chang S, Friedland JA. Traditional lower blepharoplasty: is additional support necessary? A 30 year review. Plast Reconstr Surg 2011;(Mar):10

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postblepharoplasty orbital hemorrhage and associated visual loss. Ophthal Plast Reconstr Surg 2004;20:426432 Patel BCK, Patipa M, Anderson RL, McLeish W. Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg 1997;99: 12511260 Ferri M, Oestreicher JH. Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting. Orbit 2002;21: 281288 Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg 1998;102:12191225 Carter SR, Stewart JM, Khan J, et al. Infection after blepharoplasty with and without carbon dioxide laser resurfacing. Ophthalmology 2003;110:14301432 Moorthy RS, Rao NA. Atypical mycobacterial wound infection after blepharoplasty. Br J Ophthalmol 1995;79:93 Kakizaki H, Ichinose A, Iwaki M. Preaponeurotic fat advancement for prevention of unexpected higher eyelid crease in upper eyelid lengthening surgery. Orbit 31:200302 Puri N, Talwar A. The ef cacy of silicone gel for the treatment of hypertrophic scars and keloids. J Cutan Aesthet Surg 2009;2: 104106