LECZENIE RAN 2023; 20 (4)

Postoperative care

Postoperative care is necessary for the performed procedure to obtain a good effect. It consists of many elements to which the patient must pay attention in the postoperative period. By strictly following the appropriate recommendations, the risk of complications is reduced and the chance of achieving a satisfactory result of the procedure is increased [16].

To minimize the risk of complications, the procedure should be carefully planned. First of all, attention must be paid to the amount of excess skin, fat and the location of the tear glands. Many factors influence the details of the procedure performed. These include racial, ethnic and genetic differences of patients. Changing the appearance of the eyelid too radically is a common mistake that can be avoided at the stage of planning the surgery [1].

During the second and third day after the procedure, it is recommended that cold compresses be applied to the eyelids 3 or 4 times a day. Patients can use gel masks or ice packs, which can be reused after being stored in a refrigerator. It should be remembered that the duration of one-time cooling should not exceed 10 minutes, due to the risk of frostbite. For 3 days after surgery, patients should sleep with the head raised by using more pillows, a reclining chair or an armchair. For 2 weeks after the procedure, the wearing of contact lenses, staying in the sun and using make-up should be avoided. Physical activity is not recommended for the next 3–4 weeks in the case of upper eyelid surgery. Activities that require heavy lifting or bending should especially be avoided. Patients should avoid physical activity for 48 hours after the procedure, and intensive exercise is not recommended for 2 weeks in the case of lower eyelid surgery. From 3 days after the intervention, patients can use warm compresses, which allows a gentle cleansing of the surgical wound without damaging the operated area. During the first week after surgery, it is recommended that an antibiotic ointment be applied 3 to 4 times a day on the postoperative wound. Some patients have some degree of dry eye due to swelling and ecchymosis of the eyelids. In these cases, the eye should be lubricated with artificial tears, a lubricating gel at night and antibiotic ointment along the incision up to 4 times a day after peroxide cleansing. Removal of sutures is recommended on the 7th day after surgery, if reabsorbable material has not been used in the case of upper eyelid surgery and the period is from 5 to 7 days in the case of lower eyelid surgery, Then the application of corticosteroid ointment allows the wound to heal better. The ointment should be used 3 times a day during the initial period. Patients should be advised to avoid rubbing the eyelid because it may cause wound dehiscence [16].

Risk factors for postoperative wound dehiscence include infections, minor trauma, and the patient’s uncoordinated movements during sleep. It is necessary to choose the right type of sutures to reduce the risk of wound dehiscence. Prolene 6-0 skin sutures are preferred for upper eyelid surgery. Silk and absorbable sutures give less satisfactory results in the plastic surgery of the upper eyelids. Prolene is useful for precise wound closure. The use of Prolene sutures and their complete removal at the appropriate time reduces the risk of granulomas. Minor wound dehiscence can be treated with topical and oral antibiotics. The postoperative area must be carefully monitored because complete wound dehiscence requires rapid debridement and repair. This avoids lower eyelid retraction and scarring. It should be remembered that medications such as aspirin, ibuprofen, and naproxen can increase bleeding, and may have a negative influence on wound healing [1].

If the incision line is red and thick after 4 weeks, a cream containing vitamin E, massage, or topical steroids can be used. Occasionally, epithelial inclusion cysts appear instead of scar hypertrophy. It is important to pay attention to this, because the epithelial inclusion cyst must be removed. Pyogenic granulomas occasionally develop in the incision area, treatment of which consists of applying topical steroids or excision of the pathological lesion [1, 16].

The frequency of complications is largely influenced by the technique of the procedure. Authors in the literature more often choose CO2 laser blepharoplasty. More procedures for the lower eyelids are performed via a transconjunctival approach than an external approach [1].

It has been shown that the use of silicone ointments after blepharoplasty improves the appearance of postoperative scars. This method is safe and effective, but it requires the patient to be systematic in its use [17].

The wound healing process after blepharoplasty lasts from 6 to 8 weeks, but the period of postoperative scar reduction can take up to 12 months. It is extremely important that post-treatment scars are located in the natural folds of the skin, which makes them less visible and has a significant impact on the final effect of the procedure. In the case of lower eyelid surgery, the best location for the incisions is just below the lash line. Thanks to its rich vascularization, the skin of the eyelids heals extremely quickly.

Complications 

Every surgical intervention carries a potential risk of complications. Complications after blepharoplasty are quite rare and if they do occur, they are usually mild rapidly treatable. It should be noted that with the increasing number of blepharoplasty procedures performed, the risk of complications increases. The surgeon performing the procedure should inform the patient about the potential risks associated with the operation and ask what their expectations are in relation to the postoperative effect. It is important that the patient is aware of their decision and knows that blepharoplasty, although a simple procedure, may be associated with later complications [1, 18].

The most common side effects after blepharoplasty are superficial petechiae and hematomas. They may arise during the preparation of the patient for surgery, e.g. when administering local anesthesia; intraoperatively when there is bleeding into the orbicularis oculi muscle or postoperatively due to weakening of the structure of the blood vessels [2]. To minimize the formation of superficial petechiae and hematomas, patients are advised to avoid the use of anticoagulants, blood pressure should be controlled in hypertensive patients, excessive physical exertion should be avoided, and the surgical site should be protected from trauma [1]. Superficial petechiae and hematomas usually resolve shortly after surgery and do not require re-surgical intervention [1, 6].

Another complication that occurs after blepharoplasty is dehiscence of the postoperative wound. Factors contributing to this include: postoperative injuries, infections and patients who sleep restlessly and damage the surgical site while sleeping. It is important to properly select and apply sutures supplying the wound after the procedure. The patient should avoid pressure on the operated eyelid (e.g. during sleep) and injuries in this place. In the event of a minor wound dehiscence, topical or oral antibiotic treatment is possible, and at the time of significant dehiscence, it is necessary to clean and suture the wound again [1].

Wound infections after blepharoplasty are quite rare. This is due to the good vascularization of this area of the face and the recommended use of antibiotic ointments. The most common pathogens causing postoperative wound infections are bacteria living on the skin of patients but also Streptococcus and Mycobacterium. One of the most serious infections that can be a complication of blepharoplasty is orbital cellulitis. It manifests as by severe pain, swelling, movement disorders of the eye muscles and may lead to loss of vision. Intravenous broad-spectrum antibiotic therapy is implemented to treat infections. When it does not bring therapeutic effects and the patient’s symptoms worsen, surgical treatment should be initiated as soon as possible [6].

In the initial phase of recovery after blepharoplasty, patients often suffer from symptoms of dry eye syndrome, such as foreign body sensation, burning or photophobia. According to research, this problem is faced by 8% to even 21% of operated patients [2, 6]. To eliminate the adverse symptoms of dry eye syndrome, patients are advised to use artificial tear preparations or corneal moistening drops. Before performing blepharoplasty, the surgeon should assess the patient for lacrimation disorders and perform the Schirmer test. This will determine whether the patient is predisposed to adverse symptoms. Symptoms associated with dry eye syndrome after blepharoplasty surgery may persist for approximately 3 months in patients [6, 19].

Complications after blepharoplasty are also oculomotor disorders, lymphatic edema, eyelid ptosis (blepharoptosis), and ectropion – eyelid retraction and lagophthalmos, i.e. the inability to completely close the eyelids. These are changes caused by incorrect healing of the postoperative wound, its scarring, abnormalities of the eyelid folds, incorrect resection of the skin during the procedure [18]. Patients may also report esthetic complications such as eyelid asymmetry, medial membrane formation, and eyelid skin pigmentation anomalies [2].

The most serious complication after blepharoplasty is intraorbital hemorrhage and, consequently, ischemic optic neuropathy, which in extreme cases leads to partial or complete loss of vision. According to studies, the incidence of orbital hemorrhage with vision loss is 1 in 2,000 to 1 in 25,000 operated patients [1]. This complication most often occurs in the immediate postoperative period [2]. The symptoms that should prompt the physician to prompt diagnosis and treatment include reduced eyeball mobility, exophthalmos, dilated pupil, sudden and severe pain, and deterioration of vision. In this case, the patient should be immediately qualified for surgical treatment (lateral canthotomy) to evacuate the hematoma and decrease the intraocular pressure. It is also recommended that an osmotic diuretic and steroid therapy be used [1, 2, 19].

In current medical practice, the preferred technique in most cases is the transconjunctival approach, which is accompanied by fewer complications compared to the percutaneous approach. In addition to the advantage of avoiding scarring, this method is said to be simpler and much faster than the conventional percutaneous approach. We avoid cutting through the orbicularis muscle, which preserves its innervation, reduces postoperative swelling and retraction, and avoids the formation of a scar. This method also reduces the risk of postoperative lower eyelid retraction. In the percutaneous approach, swelling of the orbicularis oculi muscle caused by bleeding may affect visual acuity; in the case of the transconjunctival approach, we avoid this complication, as well as the occurrence of lagophthalmos and ectropion and eyelid asymmetry, which are common side effects of the classic percutaneous approach [20].