Lower blepharoplasty III — Perioperative care and complications
Preoperative assessment, postoperative regimen and management of the two complications you must know how to solve: retroseptal haematoma and ectropion.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Warn the patient about pain and deformity for two weeks: managing expectations prevents calls and distress.
- Suture removal at 7 days.
- Retroseptal haematoma: urgent canthotomy. Not a decision that tolerates delay.
- Established ectropion: canthopexy with a tarsal strip.
Preoperative assessment
| What to record | Why it matters |
|---|---|
| Lid laxity | Decides whether canthopexy is indicated in the same procedure |
| Globe position relative to the rim | Prominent eye with poor bony support → higher retraction risk |
| Dry eye, blepharitis, previous refractive surgery | They condition postoperative tolerance and comfort |
| Anticoagulation and antiplatelet therapy | Bleeding risk in a plane where haemorrhage is the serious complication |
| Standardised photography, static and dynamic | Planning and objective outcome assessment |
| Pre-existing asymmetry shown to the patient | Prevents pre-existing findings being blamed on surgery |
Postoperative regimen
- Analgesia and anti-inflammatoryParacetamol 1 g + dexketoprofen 25 mg + prednisone 30 mg for one week
- First 48 hoursLocal cooling, head elevation, ocular lubrication and avoidance of Valsalva
- Day 7Suture removal
- If TCA peel was performedDesquamation in the first week; petrolatum once daily for two weeks
- Weeks 1-4: mild retractionUsually oedematous. Directed massage and observation
- Beyond three monthsPersistent retraction: reassess, may require a corrective manoeuvre
Retroseptal haematoma: urgent canthotomy
Intense, progressive ocular pain with proptosis or visual loss mandates decompression without delay through canthotomy. The therapeutic window is narrow and delay compromises vision irreversibly, so the decision must not be made contingent on imaging or on waiting for a deferred assessment. The patient must take this instruction home in writing on discharge, with a direct contact number and an explicit instruction to attend the emergency department without waiting.
Established ectropion: canthopexy step by step
- 1. AccessSmall lower blepharoplasty incision with lateral extension
- 2. DissectionTo the lateral orbital rim, at Whitnall’s tubercle, where the upper and lower canthi insert
- 3. Tarsal stripDissect the cartilage strip with mucosa, released from orbicularis and septum
- 4. SutureDouble-armed 5/0 prolene, both ends through the grey line of the most lateral lower lid, 1 mm apart
- 5. FixationPass both needles transconjunctivally to the incision and suture to the tubercle periosteum. Tension to the desired canthopexy
- 6. ClosureExcision of excess tarsus and skin, and skin closure
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.
References
- 1.Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: incidence, management, and preventive measures. Aesthet Surg J. 2011;31(1):21-29.
- 2.Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97(11):2192-2196.
- 3.Gurtner GC, Neligan PC, editors. Plastic Surgery. Volume 2: Aesthetic Surgery. 4th ed. Edinburgh: Elsevier; 2018.
Related specialty: Blepharoplasty