Safety and Complications in Lower Eyelid Blepharoplasty: A Systematic Review

Abstract

Background:

Lower blepharoplasty is one of the most commonly performed aesthetic procedures in the United States. Although lower blepharoplasty techniques have evolved significantly, it remains a considerable surgical challenge, associated with many aesthetic and functional complications. This review aimed to elucidate the safety and complication profiles of lower blepharoplasty.

Methods:

A comprehensive review of the literature was performed using PubMed/MEDLINE, Embase, and Cochrane databases to identify studies that report the complication profiles of lower blepharoplasty techniques.

Results:

A total of 36 articles meeting inclusion criteria and critically evaluating lower blepharoplasty and its associated complications were analyzed and discussed.

Conclusions:

This review reports the overall safety and low complication profile associated with lower blepharoplasty. No major complications resulting in ocular and visual disturbances are reported, and the majority of complications resulting in functional and aesthetic concerns can be resolved with conservative management or revisionary surgery. More rigorous studies are needed to more critically assess and compare the various surgical techniques.

Takeaways

Question: What is the safety profile of lower blepharoplasty, and how do complications vary across different techniques?

Findings: This systematic review examined the complication profiles and safety of various lower blepharoplasty techniques, finding that although the procedures are generally safe with low complication rates, comparing results between techniques was challenging due to varying study designs, methods, and follow-up durations.

Meaning: This systematic review highlights that although lower blepharoplasty techniques are generally safe, effective, and associated with a low complication profile, comparing outcomes across methods is difficult due to variations in study designs and surgical approaches.

INTRODUCTION

In 2022, blepharoplasty was the fifth most commonly performed aesthetic procedure in the United States, with more than 115,000 procedures, representing a notable 13% increase compared with 2019.¹ As the demand for blepharoplasty increases, lower blepharoplasty techniques have evolved rapidly to emphasize more natural and augmented lower eyelids that seamlessly integrate at the lid–cheek junction. This shift has been underpinned by an enhanced understanding of lower eyelid aging, characterized by varying degrees of orbital fat herniation secondary to septal attenuation, an accentuated tear trough deformity, an inverted V-deformity due to eyelid lengthening, and loss of volume and support due to fat atrophy.² With this better understanding of eyelid aging, more traditional blepharoplasty techniques that rely on skin, muscle, and fat resection only are being replaced or enhanced with fat augmentation, repositioning, or conservation, orbicularis retaining ligament release, and septal reset procedures.³ Additionally, the adjunctive use of nonsurgical fillers and lasers is becoming more prominent to further improve periorbital contouring and facial harmony.⁴

Despite the rapid evolution of lower blepharoplasty, it continues to pose a significant surgical challenge with numerous aesthetic and functional short- and long-term complications. Traditional techniques, although successful, have been associated with high complication rates such as hollow appearance, change in eye shape, lower eyelid malposition, and ocular irritation.⁵ Newer techniques and various canthal procedures aim to mitigate these issues while maximizing aesthetic outcomes. Currently, there is no consensus on an optimal technique, as there is a paucity of studies tabulating complications and comparing techniques with sufficient long-term follow-up.

The aim of our study was to provide a comprehensive review of the latest evidence on the complication profiles and safety of various lower blepharoplasty techniques. This study encompasses a thorough analysis of both short-term and long-term complications to build a comprehensive understanding of the potential risks patients may encounter during their postoperative journey.

METHODS

A systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to delineate the evolving approach to lower blepharoplasty and characterize the complication profiles of each surgical technique. A query of PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify all articles published on or before September 12, 2023, discussing lower blepharoplasty. General MeSH terms for lower blepharoplasty were selected to generate a comprehensive article list. (See appendix, Supplemental Digital Content 1, which displays databases queried and syntax used during article search completed on September 12, 2023, https://links.lww.com/PRSGO/E316.)

Included articles contained at least 50 patients with 1-year follow-up and tabulated patient outcomes and complication rates. Exclusion criteria included review articles without patient series, case reports, abstracts, communications, and non-English and non-Spanish language articles. The generated articles were screened by one of the authors (A.R.G.) and eliminated per the selection criteria. Additionally, some articles that did not strictly adhere to the inclusion criteria were included for final review at the discretion of the senior author (R.J.R).

RESULTS

The search parameters resulted in 4230 articles. Initial screening based on title, abstract, and language review yielded 476 articles. Full-text assessment established 36 articles meeting inclusion criteria (Fig. 1). Among these, 34 were observational and 2 were prospective clinical trials. (See appendix, Supplemental Digital Content 2, which displays details of 36 studies that met the selection criteria, https://links.lww.com/PRSGO/E317.) The diversity in study design, surgical methods, and the durations of postoperative follow-up, made it unfeasible to conduct a meta-analysis. As such, articles were categorized based on the various complications reported in the lower blepharoplasty literature.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram showing the total number of articles screened and excluded at each stage; 36 articles included after review.

Lower Eyelid Malposition

The rates of various forms of lower eyelid malposition, including scleral show, lagophthalmos, ectropion, entropion, temporary eyelid laxity, and eyelid retraction, were discussed in 30 articles.^6–35 In some articles, these were further subdivided into transient and permanent as well as those managed conservatively and operatively.

The overarching rate of lower eyelid malposition ranged from 0% to 12%. Eight articles discussed lower eyelid malposition specifically with rates ranging from 0% to 4.8%.^{13,17,19,21,22,25,26,31} Of these, the highest rate was reported with the KS pexy technique, whereby the transcutaneous subciliary approach is used to perform an orbital retaining ligament (ORL) and septal orbicularis oculis release and reset, orbital fat manipulation, eyelid shortening wedge resection with a lateral canthopexy and orbicularis suspension, and skin excision. In this study, 4.8% of patients experienced lower eyelid malposition that was transient (<3 mo) and/or too minor for revisionary surgery. In contrast, 3.2% of patients experienced lower eyelid malposition requiring revisionary surgery.³¹ Scleral show was reported in 11 articles ranging from 0% to 2%.^{7,8,10,14,16,17,24,26,29,32,34} With the 5-step transconjunctival lower blepharoplasty technique, Rohrich et al²⁶ reported a 2% of transient scleral show that improved with conservative management. Additionally, no patient required revisionary surgery for lower eyelid malposition.²⁶ In contrast, Viana et al³² reported 12% and 8% rates of scleral show in their prospective, randomized controlled surgical trial comparing transcutaneous lower blepharoplasty with traditional fat resection versus fat preservation and repositioning along with arcus marginalis release, respectively.

Ectropion was reported in 16 articles with overall rates ranging from 0% to 11.3%.^{6,9,10,12,14–17,19,20,23,24,27,28,34,35} Chan et al⁶ compared the effect of ORL release on the rate of complications and final aesthetic outcomes and noted a higher likelihood of developing ectropion (19.2% versus 3.8%) along with longer duration of swelling and chemosis without any added aesthetic benefit in the ORL release cohort. Additionally, only the patients who developed ectropion after ORL release required revisionary surgery.⁶ Lower eyelid retraction rates were reported in 9 articles, with rates ranging from 0% to 4.3%.^{10,11,14,18,20,23,30,33,35} Lee et al²⁰ compared outcomes between lower eyelid blepharoplasty via a transcutaneous approach with orbicularis oculi muscle and tear trough ligament release along with sub-orbicularis oculi fat (SOOF) and deep nasolabial fat repositioning versus SOOF repositioning without ligament release for severe and mild degrees of periorbital aging, respectively. Eyelid malposition rates were not significantly different between both groups and the overall rate of transient retraction and cicatricial ectropion were 3.4% and 0.9%, respectively. The deep nasolabial fat repositioning cohort exhibited higher rates of satisfaction and lower rates or tear trough and fat bulging recurrence. In contrast, they experienced longer duration of swelling and higher rates of chemosis.²⁰ In their consecutive series of 300 lower eyelid blepharoplasties, Pacella et al²⁴ reported a 0% and 3.3% rate of ectropion and scleral show in their transconjunctival and transcutaneous cohorts, respectively. However, no statistical analysis was performed to elucidate any significance.²⁴

Entropion was reported in 3 articles with rates ranging from 0% to 1.2%.^17,19,28 Transconjunctival septal suturing, which aims to correct medial and middle fat compartment herniation, was reported to have a 1.2% rate of entropion which required revision. Additionally, 7.7% of patients experienced temporary lower lid laxity.²⁸ Finally, lagophthalmos was only reported in 1 article with a rate of 0%.¹⁷

Change in Eye Shape

The rates of eye shape change or the creation of a round eye and canthal distortion and webbing were reported in only 5 articles.^{19,23,26,28,30} Of these articles, Sadove²⁸ reported a 1.2% rate of eye shape change which did not require revisionary surgery. Massry and Hartstein²³ reported a 1.8% rate of canthal webbing in their cohort which did not require revision.

Hematoma, Hemorrhage, and Seroma

In total, 15 articles reported on the rates of hematoma and hemorrhage, with the rates ranging from 0% to 2.2%.^{8–10,12,13,17–20,24,27–29,35,36} Lee et al reported an overall hematoma rate of 2.1% in their series, with the deep nasolabial fat cohort experiencing a slightly higher but not significant 2.8% hematoma rate.²⁰ Pacella et al reported 1.7% and 2.2% rates of subconjunctival hematomas in transconjunctival and transcutaneous blepharoplasties but no statistical analysis was performed to elucidate significance.²⁴ Finally, 3 articles reported a 0% incidence of seromas.^10,19,28

Ecchymosis

Ecchymosis rates ranging from 20% to 96.3% were reported by 3 articles.^6,27,32 Chan et al noted the majority of their patients developed ecchymosis at the same rate and for similar durations following transconjunctival lower blepharoplasty with and without ORL release.⁶ Rohrich et al evaluated the effect of fractionated versus traditional fat grafting to blend the eyelid–cheek junction and noted more patients developed bruising after fractionated fat grafting (23% versus 20%), although this was not statistically significant.²⁷ In their prospective trial, Viana et al noted more patients developed bruising in the fat resection than in the fat preservation and repositioning cohort (76% versus 52%).³²

Edema

Rates of edema, ranging from 0% to 100%, were reported by 7 articles.^{6,12,16,27,29,31,32} The duration of edema was not documented in all articles. Although the majority of patients developed periorbital edema following lower blepharoplasty with and without ORL release, those patients that had ORL release had a longer duration of swelling, with an average of 19 days compared with 14 days in those patients without ORL release.⁶ Rohrich et al noted a trend toward more patients developing postoperative swelling lasting more than 2 weeks in those who underwent fractionated instead of traditional fat grafting, but this was not statistically significant.²⁷ In their series of 500 consecutive patients who underwent augmentation blepharoplasty with microfat grafting, Tonnard et al²⁹ noted a 7% rate of prolonged edema lasting more than 1 month.

Chemosis

Sixteen articles reported on the rates of chemosis, with a range from 0% to 84.6%.^{6,8,10,11,16,18,20,22,25–27,31,32,35,37,38} Prischmann et al tabulated the rate of chemosis and dry eyes and their associated risk factors in a retrospective review of 892 upper and lower blepharoplasties by a single surgeon. The overall rate of chemosis and the rate in those patients that underwent lower blepharoplasty alone was 26.3% and 15.6%, respectively. All cases of chemosis resolved within 180 days, with an average of 26 days and a median of 14 days. Risk factors for developing chemosis included concomitant upper and lower blepharoplasty, patients undergoing skin-muscle flap blepharoplasty, male sex, preoperative eyelid laxity, and preoperative dry eye symptoms. Additionally, canthopexy increased the risk of developing chemosis.³⁷ Chan et al noted a longer duration of chemosis in patients who underwent ORL release with an average of 21 days compared with 3 days in the no release cohort.⁶ Van Slyke et al noted a 27.4% rate of chemosis, with the majority being mild (22.4%) and all cases resolved with conservative treatment.³¹ Lee et al reported a higher rate of chemosis in those patients who underwent deep nasolabial fat transposition and ligament release compared with SOOF repositioning alone.²⁰ In their series of 146 patients undergoing transconjunctival blepharoplasty with chemoexfoliation, Gilbert⁸ noted a 17.1% rate of chemosis.

Dry Eyes

Postoperative dry eye symptoms, which ranged from 0% to 25.6% of patients, were reported by 5 articles.^{11,17,19,31,37} In their large series, Prischmann et al administered a self-reported dry eye questionnaire pre- and postoperatively. They reported an overall rate of 26.5% for the development of dry eye symptom and noted a higher incidence in patients undergoing concomitant upper and lower blepharoplasties and skin-muscle flap blepharoplasty. Additionally, hormone therapy and preoperative scleral show were associated with a higher risk of postoperative dry eye symptoms.³⁷ Hamawy et al¹¹ reported 10.9% and 2% rates of dry eye symptoms lasting longer than 2 weeks and 2 months, respectively, in their retrospective review of 202 consecutive patients who underwent upper and/or lower blepharoplasty. Symptoms resolved with conservative management in 95.5% of patients. Those with persistent symptoms for more than 2 months were referred to an ophthalmologist, and 0.5% of patients required revisionary surgery.¹¹

Aesthetic Complications

Various aesthetic complications were reported in 14 articles, including generalized aesthetic concerns (5.1%), periorbital hollowness and depression (0%–9.8%), unfavorable scarring (0%–12%), inappropriate fat removal (0%–4.9%), malar bags (0%–8.2%), wrinkling (2.1%–69%), need for postoperative touch-ups (3.1%–31%), need for repeated peels (27.4%), granuloma/cyst formation (0%–4%), and need for cyst/granuloma injections (11.1%).^{7–9,12,18,19,23,24,28,30–32,36,39} Additionally, suture issues, including palpability (1.1%–3.8%) and abscess (0–1.8) were reported in 4 articles.^7,19,23,28

Postinflammatory Hyperpigmentation

Postinflammatory hyperpigmentation (PIH) was reported in 3 articles, with rates ranging from 1.8% to 14.4%.^8,18,33 Watson et al³³ noted a 5.1% rate of PIH in their retrospective review of 59 patients who underwent lower blepharoplasty with adjunctive fractionated CO₂ laser resurfacing. These patients had successful resolution with conservative topical management.³³ Gilbert reported a 14.4% rate of PIH in their series of patients undergoing lower blepharoplasty with chemoexfolation. Hyperpigmentation was more common in patients with higher Fitzpatrick skin types.⁸

Infection

The rate of infection was reported in 11 articles, with rates ranging from 0% to 1.6%.^{9,12,16,17,19,24,27,28,31,33,40} Carter et al⁴⁰ analyzed the rates of infection in 1861 patients undergoing blepharoplasty with and without carbon dioxide laser resurfacing and noted the rates to be 0.4% and 0.2% of patients, respectively. None of the infections occurred in patients undergoing lower blepharoplasty alone, and all infections resolved with oral antibiotic treatment without sequelae. As expected, all infections presented with 4–7 days postoperatively. The hospital or clinic setting did not affect the rate of infection development. In patients undergoing blepharoplasty without laser resurfacing, they note that postoperative topical antibiotic prophylaxis alone is sufficient in healthy patients. In those undergoing concomitant laser resurfacing, the rate of infections could be lower with the use of prophylactic oral antibiotics. In those patients with predisposing risk factors for infection, prophylactic antibiotics may be warranted.⁴⁰

Reoperation

Reoperation following lower blepharoplasty, which ranged from 0% to 9%, was reported by 21 articles.^{6,7,9,11–13,17–19,21–26,28–30,35,36,39} The majority of articles reported a revision rate less than 3%. Chan et al noted a 7.5% rate of reoperation for ectropion repair, and these were all in the ORL release group.⁶ In their comparison of fat repositioning versus only segmental fat grafting in conjunction with either transcutaneous or transconjunctival blepharoplasty, Hedén and Fischer¹² noted a 5% reoperation rate in both cohorts, which was not statistically significant. Duan et al ³⁶ noted a 9% rate of reoperation for various indications, including inadequate fat resection, hemorrhage, skin depressions at suture fixation points, and repositioned fat bulging.

Ocular, Visual, and Sensory Disturbances

Nine articles reported on the rates of blindness, diplopia, inferior oblique palsy, muscle paralysis, and sensory disturbances.^{8,12,16,18,19,30,31,35,36} No cases of blindness, diplopia, inferior oblique injury, or muscle paralysis were noted in 5 articles. Duan et al reported a 4.5% rate of transient paralysis secondary to local anesthesia infiltration which self-resolved in all cases.³⁶ Van Slyke et al³¹ reported a 1.6% incidence of V2 paresthesias with the KS pexy technique.

DISCUSSION

The aging process brings about notable changes in the eyelids and periorbital tissues, often a primary concern for those seeking facial rejuvenation. Nonsurgical options, although popular, often fail to meet patient expectations due to a monotherapeutic approach that rarely addresses the complex requirements of periorbital aging that are more accurately addressed with surgery. Although traditional lower eyelid blepharoplasty concentrated on resection of the skin, muscle, and fat through skin or skin-muscle flaps, this, too, did not effectively and aesthetically restore the youthful complex, as it ignored some of the primary issues related to lower periorbital aging. Contemporary lower blepharoplasty approaches emphasize less aggressive fat removal, fat repositioning through transconjunctival or subciliary methods, minimal skin removal, providing lower eyelid support through canthopexy and canthoplasty techniques, and volume augmentation with fat grafting. Understanding periorbital aging components and the associated safety and complication profile is paramount as lower blepharoplasty evolves.

A literature review revealed that blepharoplasty is safe with a low overall complication rate and high patient satisfaction. Major complications resulting in ocular and/or visual disturbances such as blindness, diplopia, and inferior oblique muscle injury/paralysis were not reported in any of the included articles. Furthermore, the rates of hematoma, hemorrhage, and infection are low. More commonly occurring complications resulting in both functional and aesthetic concerns, such as varying degrees of lower eyelid malposition, changes in eye shape, dry eye symptoms, and prolonged chemosis, contribute to the revision rate, with the highest reported as 9%.³⁶ Although infrequently reported, the authors have found that a common aesthetic concern of those seeking additional surgery (most often performed elsewhere) without functional complications is dissatisfaction with “looking different” or generally failing to meet expectations.

Lower blepharoplasty has been combined with adjunctive procedures such as chemoexfoliation and laser therapy to improve final aesthetic results with low complication rates. Gilbert combined a transconjunctival lower blepharoplasty with trichloroacetic acid peels, reporting chemosis (17.7%) and PIH (14.4%), which resolved with conservative management. Additionally, persistent malar bags (8.2%) were common, and they note that patients with prominent preoperative malar bags may be better candidates for other techniques.⁸ Hidalgo¹³ performed transconjunctival lower blepharoplasty with a trichloroacetic acid peel in 62% of patients, with complication rates ranging from 0.4% to 2.4%. Six articles combined lower blepharoplasty with laser resurfacing, revealing low complication rates consistent with nonresurfacing techniques.^{6,10,21,33,39,40}

Although elucidating a surgical technique with the lowest complication and highest patient satisfaction rates would be beneficial, the available literature precludes this due to numerous factors. There is no standardized, widely used periorbital and lower eyelid assessment scale to objectively grade the degree of aging and postoperative results. Many articles lack preoperative assessments or correlation of surgical techniques with degree of aging, making comparisons challenging. Additionally, inter- and intraarticle technique variability along with heterogenous data reporting and follow-up time, further complicate comparisons. Examples of this large variability include the management of SOOF compartments, as there are varying degrees of both resection and repositioning within and between articles. Additionally, incision placement also varies within articles depending on the degree of skin laxity and oftentimes this is not accounted for in the statistical analysis. Finally, different terminologies and timelines for complication and data reporting also preclude meaningful comparison analysis.

Despite numerous articles describing various lower blepharoplasty techniques, there is a paucity of studies with adequate study design, technique comparison, postoperative follow-up, and complication cataloguing. Only 2 of the 36 articles included were prospective studies; the remainder were observational cohort studies. Although more rigorous prospective studies should be performed to further elucidate those techniques with lower complications and higher patient satisfaction rates, the available literature reveals that the various lower blepharoplasty techniques are safe and effective to restore a youthful appearance.

CONCLUSIONS

As lower blepharoplasty continues to evolve, a literature review indicates that lower blepharoplasty is generally safe with low complications and high patient satisfaction. However, comparing the numerous techniques is challenging due to the vast heterogeneity in patient periorbital aging, surgical techniques, and inconsistent terminology and reporting in the literature. Although more rigorous studies are needed, existing evidence suggests the safety and efficacy of diverse lower blepharoplasty techniques in restoring a youthful appearance.

DISCLOSURES

Dr. Rohrich is a research support and consultant in Allergan/AbbVie, Musculoskeletal Transplant Foundation, and Galderma; research support, consultant, and speakers bureau in InMode; consultant in Evolus; research support in Merz, Cytrellis, Rion, and Teoxane; received book royalties from Thieme Publishers and instrument royalties from Eriem Surgical (Micrins); and owner of Medical Seminars of Texas. The other authors have no financial interest to declare in relation to the content of this article.