Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our health archives for her posts—calling on the expertise of medical specialists—on topics from angiography to vulvar melanoma.)

This week, she has asked Dr. Leila Rafla-Demetrious, an Assistant Professor of Ophthalmology at New York–Presbyterian Hospital, Weill Cornell Medical College, to discuss the benefits—and hazards—of cosmetic surgery on the eyelid.

 

Dear Dr. Pat:

I had my eyes done by a plastic surgeon.  I just wanted the droopy upper lids cut back, since they were hideous and wrinkly.  I am just 50 but this eyelid condition is genetic.  The surgeon told me that I needed both “upper and lower” work.  I now have dry eyes and the inside of my lower eyelid on one eye is pulled down.  Not only does this look weird, but it is uncomfortable. I have constant tearing and a feeling of local irritation at this spot.

I still would have wanted my upper eyelids cosmetically repaired, but I certainly wouldn’t agree to surgery on the lower lids.  Is there anything that can be done about this? Why did the dry eye condition appear after surgery?  

Jean

 

Dr. Leila Rafla-Demetrious Responds:

Dear Jean:

I’m sorry to hear about your problem, though this is a well-known complaint after lid surgery. Blepharoplasty, which involves the removal of excess tissue from the upper and/or lower lids, is a common cosmetic procedure, but not without its risks and complications.

Your problem, lagophthalmos, is one in which the eyes cannot close properly. It happens fairly often, at least transiently, after upper-lid ptosis repair (a procedure in which the lid is surgically elevated), though less so after blepharoplasty. The postoperative gap (see figure below) not only prevents the lids from meeting fully in closure, but also leads to exposure problems, causing the cornea and surrounding tissues to dry out. This in turn causes dry spots on the eye, leading to a foreign-body sensation and initiating the tearing reflex; this can be extremely annoying, and—more important—cause blurred vision.

Fortunately, this issue tends to be short-lived, resolving once post-operative swelling has gone down and the lids have settled into their new state. In the interim, the treatment for the tearing is, ironically, frequent lubrication to keep the tissues moist, thus limiting the tearing reflex. This takes the form of preservative-free tears during the day and an artificial-tear ointment into the eye at bedtime. If the situation does not improve itself even when all the swelling has gone down, or in 10 to 12 weeks, further surgical intervention may be warranted.

eye lidslagophthalmos

As I mentioned, lid malposition and lagophthalmos is a fairly common “minor” problem after eyelid surgery, but there are others to note and consider prior to making a decision about eyelid surgery. To better understand these, I spoke with my colleague, Benjamin Levine, an assistant professor of ophthalmology at Weill Cornell Medical College, who specializes in oculoplastic surgery. Dr. Levine performs many blepharoplasties, among other cosmetic and reconstructive procedures, and he and I reviewed some of the other potential complications of such procedures, both minor and major.

Minor, usually transient, issues include prolonged postoperative edema (swelling) or bruising of the lids; lid numbness; worsening of pre-existing dry eyes; and blurred vision. This last can be due to both dryness and a swollen/tightened lid pressing on the cornea. All of these “minor” complications tend to be self-limiting, and usually resolve without further surgical intervention.

Major complications, which, thankfully, are rare, include infection; hematoma (accumulation of blood); double vision (due to inadvertent injury to eye muscles controlling movement); and permanent visual loss (due to severe hemorrhage around the eye).

Dr Levine emphasized that while all these risks are rare, they are to be taken into consideration when debating eyelid surgery, and should be discussed with your surgeon. Your surgeon should also review expectations, and what eyelid surgery can and cannot do in enhancing one’s appearance.  At the same time, it would be wise to consider the clinical training of your surgeon. A simple blepharoplasty, in which tissue is removed but the lid height remains the same, is a part of most plastic surgeons’ repertoires. However, ptosis repair, in which the surgeon alters the actual position of the eyelid as it rests on the eye, is generally best left in the hands of someone trained in ophthalmic plastics. These surgeons have extensive knowledge of the anatomy of the vital tissues around the eye, and can make detailed assessments of the nature of the ptosis, thereby more accurately planning its repair.

 

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