Blepharoplasty complications

Complications covered

• Complications fall into three overlapping groups: cosmetic, functional, and symptomatic (PMID 22723228).
• Complication timing follows a pattern: corneal abrasion and retrobulbar hemorrhage in week 1; lid malposition, exposure, and tearing in weeks 1-6; contour change, asymmetry, and scarring later (PMID 20195127).
• An extensive 1994 review catalogued prevention, diagnosis, and management of complications ranging from transient ocular dryness to severe visual loss (PMID 8160107).
• Blindness after blepharoplasty is rare but has been reported repeatedly since the 1970s (PMID 432313), (PMID 1200102), (PMID 3814893), (PMID 3940099), (PMID 7338008); a 1986 review of about 60 cases found retrobulbar hemorrhage was a feature of most, with the final event usually retinal or optic nerve ischemia (PMID 3516289).
• Diplopia after blepharoplasty most often follows injury to the inferior oblique or inferior rectus muscle during fat removal, a risk recognized since a 1989 photo essay on avoiding inferior oblique injury (PMID 2783072), (PMID 9734448), (PMID 12360075).
• Dry eye is reviewed for its incidence, clinical manifestations, mechanisms, and prevention (PMID 32309188), with guidance for reducing its incidence published as early as 2004 (PMID 19336196).
• Lagophthalmos (incomplete lid closure) was 8-fold more frequent with orbicularis muscle excision than skin-only excision in a meta-analysis of 12 randomized trials, without improving satisfaction (PMID 40152471).
• Orbital compartment syndrome, a surgical emergency from rising pressure behind the eye, has been reported after blepharoplasty and requires emergency lateral canthotomy (PMID 41191880).

How each complication is recognized and managed

• Retrobulbar hemorrhage presents with pain, proptosis, and falling vision, usually within the first 24 hours. A systematic review of 93 cases found full recovery in 51%, partial recovery in 27%, and blindness in 22%; surgical decompression and shorter time to treatment each predicted better outcomes (P=0.024, P=0.003) (PMID 29239798).
• Removing postoperative bandages and checking vision and proptosis every 10 minutes for the first 2 hours was proposed after an early reported case of temporary blindness from retrobulbar hemorrhage (PMID 1200102).
• Bilateral sequential retrobulbar hemorrhage causing transient bilateral blindness was reversed by immediate decompression in one reported case (PMID 3940099).
• Delayed periocular hemorrhage, occurring more than 48 hours after surgery, was linked to uncontrolled hypertension in 2 reported cases presenting 5 and 8 days after upper blepharoplasty (PMID 25797846).
• Diplopia after transconjunctival blepharoplasty in a series of 6 patients involved the inferior rectus and inferior oblique muscles equally (4 of 6 cases); 2 needed strabismus surgery and 4 improved with observation alone (PMID 9734448).
• Cadaver dissection located the inferior oblique muscle origin 5.14 ± 1.21 mm posterior to the orbital rim, to guide surgeons avoiding it during fat excision (PMID 12360075).
• A survey of oculoplastic surgeons found 23.2% had at least one case of diplopia lasting more than a week after lower blepharoplasty; the inferior oblique was involved in 61% of cases and diplopia resolved completely in 73% (PMID 33246110).
• Thermal injury to the inferior rectus muscle from a carbon dioxide laser during transconjunctival fat removal left 8 prism diopters of residual hypertropia at 6 months in one reported case, treated with rectus muscle transposition (PMID 39360962).
• A systematic review of 16 studies on suspension techniques (Frost sutures, periosteal anchoring, barbed sutures, forehead hitch) to prevent ectropion found the techniques generally effective, though one trial found no benefit from Frost sutures and overall evidence quality was low (PMID 40907566).

Results and evidence

• A survey of 720 American and British aesthetic surgeons covering 752,816 blepharoplasties recorded 39 cases of visual loss: overall incidence 0.0052% (1 in 20,000), permanent loss 0.0033% (1 in 30,000), temporary loss 0.0019% (1 in 50,000); hypertension was the most common risk factor (PMID 21239669).
• CosmetAssure data on 6,126 aesthetic eye surgery patients found major complications in 0.4%, most commonly hematoma at 0.2% (PMID 29369102).
• The TOPS database recorded 29,797 blepharoplasties among 214,504 aesthetic surgery patients from 2008-2019; pooled across procedures, hematoma occurred in 0.7%, superficial wound complications in 0.9%, and reoperation in 0.80% (PMID 36728533).
• A 20-year literature review of 10,698 lower blepharoplasty patients across 49 studies found pooled reoperation of 0.77%, scleral show of 0.37%, lid malposition of 0.25%, and ectropion of 0.24% (PMID 30084870).
• A systematic review of 36 articles on lower blepharoplasty safety reported no major complications causing ocular or visual disturbance, with most functional and aesthetic problems resolving with conservative management or revision surgery (PMID 40995580).
• A systematic review and meta-analysis of upper blepharoplasty techniques across 20 studies found few complications reported overall and no significant differences between techniques in intraocular pressure, corneal thickness, or dry eye measures (PMID 37430010).

Risks and complications

• Muscle excision during upper blepharoplasty raised the odds of lagophthalmos nearly 8-fold (OR 7.98) compared with skin-only excision in pooled randomized data (PMID 40152471).
• Dry eye symptoms and chemosis were reported in 26.5% and 26.3% of 892 cases respectively in a 10-year single-surgeon series; intraoperative canthopexy significantly increased chemosis risk (P=0.009), and postoperative lagophthalmos significantly increased dry eye risk (P<0.001) (PMID 23329270).
• Male sex, preoperative eyelid laxity, and preoperative dry eye symptoms were each associated with more chemosis; concurrent upper and lower blepharoplasty and a skin-muscle flap technique raised dry eye and chemosis rates further (P<0.001, P=0.001) in the same series (PMID 23329270).
• Adding ptosis correction to upper blepharoplasty raised revision from 3.8% to 9.2% in a 278-patient series (PMID 38315110).
• Older age and sustaining the hemorrhage from trauma rather than surgery each predicted a worse visual outcome after retrobulbar hematoma (P=0.029, P=0.023) (PMID 29239798).
• Incision tool (scalpel, radiofrequency, or CO2 laser) and suture material did not change the final scar in a 2026 evidence review; silicone-based products did reduce hypertrophic scarring (PMID 41193896).
• A silicone-based scar cream cut the need for intralesional triamcinolone or 5-fluorouracil injection for hypertrophic or cicatricial scarring after upper blepharoplasty from 43.9% to 22.9% of 272 eyelids (P<0.05) (PMID 31141848).

Recovery

• Symptoms of retrobulbar hemorrhage typically appear within the first 24 hours after surgery, with two reported peaks: intraoperative to 1 hour after surgery, and 6-12 hours after surgery (PMID 21239669).
• Lower-lid retraction requiring secondary surgery developed in 15% of 111 patients in one review, with orbicularis suspension sutures reducing the risk (PMID 1892615).
• Cosmetic blepharoplasty was one of several identified causes of symptomatic nocturnal lagophthalmos in a series of 40 patients, alongside alcohol use and facial palsy; all were relieved with non-surgical treatment (PMID 2076287).
• Iatrogenic dry eye disease after oculoplastic procedures including blepharoplasty is described as a distinct, under-recognized clinical entity requiring systematic preoperative ocular-surface assessment (PMID 42343584).

Combined procedures

• Blepharoplasty combined with a brow lift showed the same major complication rate (0.4%) as blepharoplasty alone among 6,126 CosmetAssure patients (PMID 29369102).
• Blepharoplasty was the most common procedure added to facelift in a 13,346-patient facelift database, and combined procedures raised the overall odds of an adverse event (5.1% overall) (PMID 32459769).
• Forehead lift, midface lift, canthopexy, and canthoplasty performed alongside blepharoplasty were each analyzed for their effect on dry eye and chemosis in the 892-case series; canthopexy specifically raised chemosis risk (PMID 23329270).

Current questions

• Database studies report low complication rates (under 1% for most events) (PMID 36728533), while a single-surgeon series using patient-reported symptoms found dry eye and chemosis in over a quarter of patients (PMID 23329270); the gap likely reflects what is measured rather than what occurs.
• Evidence for ectropion-prevention suspension techniques remains low-quality despite 16 studies reviewed, and comparative trials are still needed (PMID 40907566).
• Iatrogenic dry eye disease is described as an expanding, multidisciplinary problem that extends beyond blepharoplasty to other periocular and refractive procedures (PMID 42343584).
• Persistent diplopia after lower blepharoplasty may be more common than the published literature suggests, based on a survey in which 23.2% of oculoplastic surgeons reported at least one case (PMID 33246110).

Terms

• Retrobulbar hemorrhage: bleeding behind the eye that can compress the optic nerve and cause vision loss (PMID 15599241).
• Orbital compartment syndrome: dangerously high pressure within the orbit, an emergency treated with lateral canthotomy (PMID 41191880).
• Lagophthalmos: incomplete closure of the eyelids (PMID 40152471).
• Ectropion: outward turning of the eyelid margin, away from the eye (PMID 1892615).
• Chemosis: swelling of the conjunctiva, the clear membrane over the white of the eye (PMID 23329270).
• Inferior oblique muscle: an eye-movement muscle that lies in the path of lower lid fat removal and can be injured, causing diplopia (PMID 12360075).
• Diplopia: double vision, which after blepharoplasty usually comes from extraocular muscle injury (PMID 9734448).
• CosmetAssure / TOPS: insurance-claim and outcomes databases used to track complication rates across many surgeons' patients (PMID 29369102), (PMID 36728533).
• Scleral show: visible white of the eye below the iris, from lower lid malposition (PMID 30084870).

Papers