In general terms, blepharoplasty is a very safe procedure with a very low risk of complications, so it is typically performed successfully by the surgeon with excellent satisfaction from the patients… in most cases!
Of course, the procedure must be performed correctly, with appropriate and customized techniques for each individual patient.
The surgeon’s background in eyelid surgery is very important, and while it is true that surgery is based on the specialist performing it, unless proven otherwise, knowledge of the specific anatomy of eyelid structures is almost exclusively the domain of the ophthalmologist’s academic path.
More and more often, blepharoplasties are being performed by dermatologists, dentists, and maxillofacial surgeons, and it is no surprise that they have higher complication rates than usual!
UPPER EYELIDS
Under normal conditions, the upper eyelids represent an area with a low risk of complications, or so it is typically explained during studies. In reality, the main risk is related to the excessive removal of skin, which would prevent the normal closure of the eyelids, especially during sleep, causing troublesome nocturnal lagophthalmos with dry eyes, redness, and increased photophobia in the morning.
To avoid this complication, I recommend always leaving at least 18 millimeters of eyelid skin between the eyelashes and the eyebrow: this amount of eyelid skin is always able to allow perfect eyelid closure.
Sometimes, excessive excision of the orbicularis oculi muscle (just under the skin) can cause a similar nocturnal lagophthalmos due to the weakening of the muscle responsible for eyelid closure. The removal of skin and orbicularis oculi muscle should always be done based on the functional characteristics of the eye, which can vary greatly from patient to patient.
The tear film must be carefully studied and evaluated, because a subclinical form of dry eye may become clinically symptomatic after even a well-performed blepharoplasty. The upper eyelid also has a very complex anatomy, with at least 8 different layers in a very thin space and with complex functions such as opening, closing, winking, protecting, and lubricating the eye’s surface.
These functions are entrusted to 3 distinct muscles contained within the upper eyelid itself:
- The orbicularis oculi muscle, which is responsible for eye closure.
- The levator muscle.
- The Muller muscle.
The latter two muscles are responsible for automatically and symmetrically opening the eyelid, and they are located just below the orbital septum and the pre-aponeurotic fat (which must be removed during blepharoplasty). Poor surgical dissection technique, a surgical field with poor visibility due to excessive bleeding (which, in turn, is caused by poor technique) can make it difficult to identify these structures and cause direct damage to one of the muscles, resulting in postoperative ptosis, which would require a subsequent and delicate corrective procedure.
The patient will notice ptosis because the eyelid is lower than before the surgery or lower than the opposite eye, leading to an unsatisfactory result. An oculoplastic surgeon can recognize the eyelid’s surgical anatomy with familiarity and avoid such complications. They are also capable of correcting these complications if they occur.
The fusion of the levator muscle with the skin creates the upper eyelid fold, an important structure that allows us to hide scars in the case of a well-performed upper blepharoplasty, making the scar invisible when the eye is open. Respect for symmetry and the position of the fold is crucial to the postoperative result, and an excellent result is made possible by a precise design of the skin to be removed before holding the scalpel.
The loss of the fold, the loss of symmetry, or the extension of the eyelid scar outside of the eyelid fold makes the result aesthetically unsatisfactory. In rare circumstances, it is a surgical choice to reposition the fold on one or both sides, raising it, lowering it, or creating it where it is poorly formed, optimizing symmetry and the final result.
The secret to achieving a natural result in upper blepharoplasty, where patients maintain their appearance from 20 years ago, lies in respecting the position of the eyelid fold. Elevating the fold in a man can be dangerous or desirable, depending on the patient’s request, resulting in a deeper palpebral sulcus, which is typically a feminine characteristic, while a lower fold is more typical of men.
Swelling of the upper eyelid may be related to ptosis of the lacrimal gland, which, no longer supported by its ligament, becomes visible among the fat lobules in the lateral portion during blepharoplasty. Failing to recognize ptosis of the lacrimal gland can be very dangerous and result in the accidental removal of the gland during the removal of eyelid fat, causing severe dry eye.
However, recognizing lacrimal gland ptosis is also necessary to improve the aesthetic result. Repositioning the gland to its anatomical position is very easy during blepharoplasty, and if the gland is not repositioned, the swelling associated with the gland may become more prominent after the procedure, leading to aesthetic dissatisfaction and the need for reoperation.
LOWER EYELIDS
Most of the complications in blepharoplasty involve the lower eyelids since they are more subjected to the force of gravity, and even a small, innocent mistake can affect the result. Lower eyelids also have complex anatomy, based on the presence of ligamentous structures that support them, attaching them to the orbital bone on the sides and the eye in the center. They contain a muscle, the lower eyelid retractors, which, however, has limited contractile function.
In the following images, we see a case of complication following lower blepharoplasty. In the first photo, the right round eye appears (on the left for the viewer). In the second photo, the result after surgical correction.
The position of the lower eyelid margin in relation to the surface of the eye is crucial in determining the perfect balance of tears and ocular lubrication.
A lowering of even just one millimeter, barely visible from an aesthetic perspective, can cause dryness of the lower cornea due to lower eyelid retraction, a complication also known as cicatricial ectropion, with discomfort, a foreign body sensation, redness, and risking the health of the entire eye.
Aesthetic surgery of the lower eyelids should only be performed by experienced surgeons who can recognize and manage this dangerous relationship between the eye, ocular surface, and eyelid and be capable of performing correction or eyelid reinforcement techniques at the same time as blepharoplasty. The appropriate surgical technique for a given patient is the right technique, and never has there been a case in lower eyelid surgery where one technique works for all patients.
Transconjunctival blepharoplasty with moderate fat removal is generally excellent for young patients with no excess skin and does not pose risks for ectropion. SOOF lifting with repositioning of fat is excellent for patients who show early signs of eyelid laxity, prominent dark circles, and slight excess skin.
Therefore, recognizing the appropriate technique and performing it correctly allows the avoidance of complications in most cases. When excessive skin removal occurs, either absolutely or for that particular patient, the most feared and frequent complication in aesthetic eye surgery arises: cicatricial ectropion, with signs and symptoms easily recognizable: round eye, eyelid retraction, redness, incomplete closure.
In short, daily discomfort related to insufficient corneal protection and a highly unsatisfactory aesthetic result. The correction of this complication is quite difficult and, in theory, would require a skin graft taken from another site (in front of or behind the ear): this ‘skin patch,’ although effective in correcting eyelid position, has the disadvantage of being very visible and aesthetically unacceptable to most patients.
To avoid this risk and simultaneously return the lower eyelid to its natural position without leaving visible scars, tarsal substitutes (palatal mucosa grafts, upper eyelid tarsus) can be used as supports on the posterior part of the eyelid (‘posterior spacers’), the part in contact with the eye, so nothing is visible externally, but a rigid support is effective in lifting the eyelid.
This technique is often combined with the release of the lower eyelid retractors and lateral canthoplasty with a ‘lateral tarsal strip’ technique, where the outer corner of the eyelid is elevated and fixed to the periosteum of the lateral orbital rim.
Finally, excessive fat removal can accentuate dark circles and give the patient a more aged appearance; this complication is avoidable with very conservative fat removal or, even better, by releasing the marginal arc and repositioning the fat to fill the ‘tear trough,’ keeping the eyelid youthful and trophic without the bags. Once this complication arises, it can be corrected with a hyaluronic acid filler implant or lipofilling.
