Lower blepharoplasty III — Perioperative care and complications

Preoperative assessment

The first 48 hours: what is normal and what is not

The patient must leave the consultation able to tell expected recovery from a warning sign, because that is what determines whether they call in time. It is normal for swelling to increase until day two or three, for bruising to track down towards the cheek under gravity and change colour, and for there to be tightness, slightly blurred vision from the ointment and mild chemosisConjunctival oedema, which swells and can protrude beyond the lid margin. It is not normal, and requires immediate contact, to have pain that increases rather than settles, proptosis, visual loss or a lid that feels tense on palpation. Progressive pain with visual loss is retrobulbar haematoma and admits no delay. Immediately after surgery: local cold, head elevation and ocular lubrication, with Valsalva manoeuvresStraining against a closed glottis — coughing, lifting, straining at stool — which abruptly raise orbital venous pressure expressly forbidden.

Postoperative regimen

1. Analgesia and anti-inflammatory→Paracetamol 1 g + dexketoprofen 25 mg + prednisone 30 mg for one week
2. First 48 hours→Local cooling, head elevation, ocular lubrication and avoidance of Valsalva
3. Day 7→Suture removal
4. If TCA peel was performed→Desquamation in the first week; petrolatum once daily for two weeks
5. Weeks 1-4: mild retraction→Usually oedematous. Directed massage and observation
6. Beyond three months→Persistent retraction: reassess, may require a corrective manoeuvre

Postoperative eye pain: what to do

Canthotomy and cantholysis: how it is done

Lateral canthotomy with cantholysis takes minutes and is done wherever the patient is, without transfer to theatre. Local anaesthetic is infiltrated at the lateral canthus, a mosquito clamp is applied for a few seconds to limit bleeding, and scissors divide from the canthus towards the lateral orbital rim, some 10 mm. That only opens skin: what decompresses is the cantholysis. With the scissors angled downward and slightly outward, the inferior crus of the lateral canthal tendonLower limb of the lid’s lateral anchorage; dividing it frees the lid and allows the orbital contents to expand is palpated and divided, and the lower lid must come free. If it does not separate easily from the globe, the cantholysis is incomplete and must be completed. Then reassess intraocular pressure, visual acuity and pupillary reflex. Canthal repair is done later and electively: the immediate goal is not appearance, it is vision.

Retraction and ectropion: identify the type before treating

Not every retraction is an ectropion, and three pictures must be separated because treatment differs entirely. Oedema-related retraction appears in the first weeks, improves with upward massage and resolves on its own: here the correct action is to wait. Laxity ectropion occurs in a lid that was already lax before surgery and has been decompensated by it; it is corrected by tightening, with canthopexyRepositioning the lateral canthal tendon without dividing it or a tarsal stripLid shortening: the tendon is divided, a strip of tarsus prepared and fixed to the rim periosteum. And cicatricial ectropion is a problem of length, not tension: the anterior lamella is short and, however much it is tightened laterally, the lid will keep pulling down; here skin must be added, by graft or flap. The distinguishing test is simple: if pushing the cheek upward returns the lid to position, the problem is tension; if it does not rise, skin is missing.

Scleral show at four weeks

Established ectropion: canthopexy step by step

1. 1. Access→Small lower blepharoplasty incision with lateral extension
2. 2. Dissection→To the lateral orbital rim, at Whitnall’s tubercle, where the upper and lower canthi insert
3. 3. Tarsal strip→Dissect the cartilage strip with mucosa, released from orbicularis and septum
4. 4. Suture→Double-armed 5/0 prolene, both ends through the grey line of the most lateral lower lid, 1 mm apart
5. 5. Fixation→Pass both needles transconjunctivally to the incision and suture to the tubercle periosteum. Tension to the desired canthopexy
6. 6. Closure→Excision of excess tarsus and skin, and skin closure

Less frequent complications

Chemosis is common after the transconjunctival route and almost always transient: lubrication, topical steroid and, if marked, gentle patching for a few days. Diplopia on upgaze should raise the question of the inferior oblique; most cases are oedema-related and settle within weeks, but diplopia persisting beyond two or three months warrants ophthalmological assessment. Granulomas along the conjunctival suture line respond to topical steroid and rarely need excision. And asymmetry is the commonest late complaint: it almost always reproduces asymmetry that was already there, which is why preoperative photography discussed with the patient is worth more than any subsequent explanation.

Informed consent

Beyond general risks, three points specific to this procedure should be stated in writing: the possibility of residual asymmetry, the eventuality of a revision, and ectropion and lid retraction as specific lower-lid complications. Documenting that pre-existing asymmetry was shown to the patient before surgery prevents a good share of later misunderstandings. The warning about pain and deformity during the first two weeks should also be recorded, as this is the phase in which patients tolerate the normal course least well.