• unrealistic expectations
• poor choice or execution of the procedure by an inexperienced surgeon
• asymmetric creases
• undercorrection
• Unrealistic expectations is, obviously, a difficult problem to undue once surgery has been performed. The only effective "treatment" is a careful and honest discussion between the patient and surgeon about what can and cannot be achieved by blepharoplasty. It goes without saying that it is far preferable for such a conversation to take place before rather than after surgery.
• Poor execution by an inexperienced surgeon can create uneven results and excessive scarring. The best approach is referral to a more experienced eyelid surgeon, who may need to retrace most (if not all) of the steps of the operation and undertake revision as needed.
• Asymmetric creases, in which the creases of the two upper eyelids are unmatched in height or shape, is not a rare outcome. Sometimes the problem in unrelated to blepharoplasty, per se, but rather caused by a separate pre-existing (but possibly unrecognized) problem that existed even before the operation, such as brow droop or ptosis. In these cases, a patient may elect to have these additional deficiencies corrected with the appropriate additional surgical procedure or simply ignore the imbalance if it is mild. Keep in mind that small eyelid asymmetries are more the rule rather than the exception, whether or not a person has undergone blepharoplasty. While attempts to lower a high crease are often unsuccessful, the opposite (or lower) crease may be raised slightly by the removal of a small amount of additional skin (see next paragraph) accompanied by deep fixation.
• The most common reason for patient dissatisfaction is overly conservative removal of upper eyelid skin. It is important to emphasize that the main goal of blepharoplasty is to improve the appearance without creating a stark "surgical" look. Such healthy conservatism will invariably leave an occasional patient slightly undercorrected. Fortunately, this condition is easily remedied by the further small excision of excess tissue. Most commonly, only skin needs to be removed and healing is rapid.
If excessive fat has been removed from the upper eyelid, the resulting hollowness may be helped by orbital fat grafting.
The most common complications causing true functional impairment include:
• ptosis, or the creation of a droopy upper eyelid
• lagophthalmos, or tissue shortage preventing adequate closure
• Ptosis may be caused by direct surgical injury to levator muscle or aponeurosis (the elevating muscle and tendon) or by a tethering of levator action by the placement of sutures. Surgical injury (most commonly, cutting or stretching of the tendon) requires further surgical exploration and repair by a specialist in eyelid reconstructive surgery. Tethering, on the other hand, is most commonly caused by a restriction of levator action from sutures placed to accomplish deep fixation. In the majority of such cases, the ptosis resolves fully without additional surgery over a matter of two to four weeks.
• Lagophthalmos, or inadequate eyelid closure due to excessive skin removal or internal scarring, is a serious problem that risks compromising the health of the eye surface. While very mild cases may respond to massage, more advanced cases require the grafting of more skin from a distant donor site (most commonly, from the area behind the ear). Results are generally unsatisfactory and cosmetically disappointing.
• The most uncommon but feared complication of upper (and lower) blepharoplasty a permanent catastrophic loss of vision caused by the build up of blood in the tissues of the socket behind the eyeball. "Retrobulbar hemorrhage" can occur suddenly and is most commonly heralded by the onset of very significant pain and a graying of the vision. For management to be successful, treatment must be initiated without delay. Stitches are removed to open the wounds and release any trapped blood. The eyelid tendons may be disinserted to take undue pressure off the eyeball by allowing it to bulge forward. As a last result, orbital decompression (removal of socket bone separating the orbit from the sinus cavities) may help.
• Excessive bleeding that remains localized within the eyelid and does not extend into the deeper socket may form a large clot that discolors and distorts the eyelid. While such "hematomas" do not usually threaten the vision, the wound may need to opened in order to stop any continued bleeding or to evacuate the clot (which promotes healing).
