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5 Complications Involving Locoregional Flap Reconstruction of Facial Defects
37
15. Gassner HG, Brissett AE, Otley CC, et al. Botulinum toxin
to improve facial wound healing: A prospective, blind-
ed, placebo-controlled study. Mayo Clin Proc 2006;81(8):
1023–1028
16. Grabb WC, Myers MB. Skin Flaps. Boston: Little, Brown & Com-
pany; 1975
17. Becker FF. Facial Reconstruction with Local and Regional Flaps.
New York: Thieme-Stratton; 1985
18. Jackson IT. Local Flaps in Head and Neck Reconstruction. St.
Louis: Mosby Year Book; 1985
19. Stauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclope-
dia of Flaps. Boston: Little, Brown, & Company; 1990
20. Thomas JR, Holt GR, Eds. Facial Scars: Incision, Revision and
Camoufl age. St. Louis: Mosby Year Book; 1989
21. Tromovitch TA, Stegman S, Glogau RG. Flaps and Grafts in Der-
matologic Surgery. St. Louis: Mosby Year Book; 1989:74
22. Dzubow LM. Facial Flaps: Biomechanics and Regional Applica-
tion. Norwalk, CT: Appleton and Lange; 1990
23. Loeb R. Technique for preservation of the temporal branches
of the facial nerve during face-lift operations. Br J Plast Surg
1970;23(4):390–394
24. Robbins TH. The protection of the frontal branch of the fa-
cial nerve in face-lift surgery. Br J Plast Surg 1981;34(1):
95–96
25. Bernstein L, Nelson RH. Surgical anatomy of the extra-
parotid distribution of the facial nerve. Arch Otolaryngol
1984;110(3):177–183
26. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle fl aps.
Br J Plast Surg 1964;28:63
27. Conley JJ, Price JC. The midline vertical forehead fl ap. Otolar-
yngol Head Neck Surg 1981;89(1):38–44
28. Conley JJ, Donovan DT. A new technique for total reconstruc-
tion of the lower lip in a patient with malignant melanoma.
Otolaryngol Head Neck Surg 1986;94(3):393–397
29. Thomas JR, Griner N, Cook TA. The precise midline forehead
fl ap as a musculocutaneous fl ap. Arch Otolaryngol Head Neck
Surg 1988;114(1):79–84
30. Ohtsuka H. Nasolabial skin fl aps to the cheek. In: Strauch B,
Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia of
Flaps. Boston: Little, Brown, & Company, 1990, pp 348–351.
31. Burget GC. The axial paramedian forehead fl ap. In: Strauch
B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia of
Flaps. Boston: Little, Brown, & Company; 1990:204–215
32. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin
Flaps. New York: Churchill Livingstone; 1986:113–130
33. Larrabee WF Jr, Holloway GA Jr, Sutton D. Wound tension and
blood fl ow in skin fl aps. Ann Otol Rhinol Laryngol 1984;93(2
Pt 1):112–115
34. Myers MB, Combs B, Cohen G. Wound tension and wound
sloughs—A negative correlation. Am J Surg 1965;109:
711–714
35. Angel MF, Narayanan K, Swartz WM, et al. The etiologic role of
free radicals in hematoma-induced fl ap necrosis. Plast Recon-
str Surg 1986;77(5):795–803
36. Angel MF, Mellow CG, Knight KR, O’Brien BM. The eff ect of
deferoxamine on tolerance to secondary ischaemia caused by
venous obstruction. Br J Plast Surg 1989;42(4):422–424
37. Knight KR, MacPhadyen K, Lepore DA, Kuwata N, Eadie PA,
O’Brien BM. Enhancement of ischaemic rabbit skin fl ap sur-
vival with the antioxidant and free-radical scavenger N-acet-
ylcysteine. Clin Sci (Lond) 1991;81(1):31–36
References
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1987;2:243–267
2. Daniel RK. The anatomic and hemodynamic characteristics
of the cutaneous circulation and their infl uence on skin fl ap
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Little, Brown & Company; 1975:111–134
3. Daniel RK. Letter: Toward an anatomical and hemodynamic
classifi cation of skin fl aps. Plast Reconstr Surg 1975;56(3):
330–332
4.
Daniel RK, Williams HB. The free transfer of skin fl aps by mi-
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Pearl RM, Johnson D. The vascular supply to the skin: an ana-
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6.
Milton SH. Pedicled skin-fl aps: the fallacy of the length: width
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Borges AF. Elective Incisions and Scar Revision. Boston: Little,
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Borges AF, Alexander JE. Relaxed skin tension lines, Z-plas-
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9.
Burget GC, Menick FJ. The subunit principle in nasal recon-
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10. Menick FJ. Aesthetic refi nements in use of forehead for nasal
reconstruction: the paramedian forehead fl ap. Clin Plast Surg
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11. Burgess LP, Morin GV, Rand M, Vossoughi J, Hollinger JO.
Wound healing. Relationship of wound closing tension to scar
width in rats. Arch Otolaryngol Head Neck Surg 1990;116(7):
798–802
12. Gassner HG, Sherris DA. Chemoimmobilization: improving
predictability in the treatment of facial scars. Plast Reconstr
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13. Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds
with botulinum toxin A improves cosmetic outcome in pri-
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sion 1954–1955
14. Sherris DA, Gassner HG. Botulinum toxin to minimize facial
scarring. Facial Plast Surg 2002;18(1):35–39
PEARLS OF WISDOM
Evaluate your patients for factors that will predispose them to
poor wound healing, like a history of smoking, a history of ke-
loid or hypertrophic scar formation, the presence of diabetes
mellitus, and previous irradiation of the site.
Decision before incision: Plan your fl ap reconstructions care-
fully, taking into account the defect size and location, patient
expectations, and placement of incisions related to RSTLs and
anatomic units.
Treat hematomas, fl ap ischemia, and infections without delay.
Follow patients until their wounds are fully healed and treat
delayed healing problems expeditiously and aggressively.

Complications in Facial Plastic Surgery
38
53. Patterson TJS, Berry RJ, Hopewell JW, et al. The eff ect of x-radiation
on the survival of experimental skin fl aps. In: Grabb WC, Myers
MB, eds. Skin Flaps. Boston: Little, Brown, & Company; 1975:39
54. Tromovitch TA, Stegman S, Glogau RG. Flaps and Grafts in Der-
matologic Surgery. St. Louis: Mosby Year Book; 1989:74
55. Zitelli JA. Secondary intention healing: an alternative to surgi-
cal repair. Clin Dermatol 1984;2(3):92–106
56. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg
1985;12(3):463–480
57. Becker GD, Adams LA, Levin BC. Nonsurgical repair of perina-
sal skin defects. Plast Reconstr Surg 1991;88(5):768–776, dis-
cussion 777–778
58. Davis RE, Wachholz JH, Jassir D, Perlyn CA, Agrama MH. Com-
parison of topical anti-ischemic agents in the salvage of fail-
ing random-pattern skin fl aps in rats. Arch Facial Plast Surg
1999;1(1):27–32
59. Fairbanks DF. Antimicrobial Therapy in Otolaryngology—Head
and Neck Surgery. Alexandria, VA: American Academy of Oto-
laryngology—Head and Neck Surgery; 1991
60. Sebben JE. Prophylactic antibiotics in cutaneous surgery. J
Dermatol Surg Oncol 1985;11(9):901–906
61. Burke JF. The eff ective period of preventive antibiotic ac-
tion in experimental incisions and dermal lesions. Surgery
1961;50:161–168
62. DiPiro JT, Record KE, Schanzenbach KS, Bivins BA. Antimi-
crobial prophylaxis in surgery: Part 1. Am J Hosp Pharm
1981;38(3):320–334
63. Simmons BP. Guideline for the prevention of surgical wound
infections. Infect Control 1982;2:188–196
64. Fisher HW. Surgery on patients receiving anticoagulants. J
Dermatol Surg Oncol 1977;3(2):210–212
65. Hicks PD Jr, Stromberg BV. Hemostasis in plastic surgical pa-
tients. Clin Plast Surg 1985;12(1):17–23
66. Sherris DA, Larrabee WF Jr, Murakami CS. Management of scar
contractures, hypertrophic scars, and keloids. Otolaryngol Clin
North Am 1995;28(5):1057–1068
67. Brissett AE, Sherris DA. Scar contractures, hypertrophic scars,
and keloids. Facial Plast Surg 2001;17(4):263–272
68. Paquet P, Hermanns JF, Piérard GE. Eff ect of the 585 nm fl ash-
lamp-pumped pulsed dye laser for the treatment of keloids.
Dermatol Surg 2001;27(2):171–174
69. Webster RC, Benjamin BJ, Smith RC. Treatment of “trap door
deformity.” Laryngoscope 1978;88(4):707–712
70. Holt GR. Treatment of the trapdoor scars. In: Thomas JR, Holt
GR, eds. Facial Scars: Incisions, Revision and Camoufl age. St.
Louis: Mosby Year Book; 1989:271
38. Knight KR, Angel MF, Lepore DA, et al. Secondary ischaemia
in rabbit skin fl aps: the roles played by thromboxane and free
radicals. Clin Sci (Lond) 1991;80(3):235–240
39. Knight KR, Mellow CG, Abbey PA, et al. Interaction be-
tween thromboxane and free radical mechanisms in ex-
perimental ischaemic rabbit skin fl aps. Res Exp Med (Berl)
1990;190(6):423–433
40. Mosely LH, Finseth F, Goody M. Nicotine and its eff ect on
wound healing. Plast Reconstr Surg 1978;61(4):570–575
41. Reus WF, Robson MC, Zachary L, Heggers JP. Acute eff ects of
tobacco smoking on blood fl ow in the cutaneous micro-circu-
lation. Br J Plast Surg 1984;37(2):213–215
42. Webster RC, Kazda G, Hamdan US, Fuleihan NS, Smith RC. Ciga-
rette smoking and face lift: conservative versus wide under-
mining. Plast Reconstr Surg 1986;77(4):596–604
43. Reinisch JF. The role of arteriovenous anastomoses in skin
fl aps. In: Grabb WC, Meyers MB, eds. Skin Flaps. Boston: Little,
Brown & Company; 1975:81–92
44. Angel MF, Ramasastry SS, Swartz WM, Basford RE, Futrell
JW. Free radicals: basic concepts concerning their chemistry,
pathophysiology, and relevance to plastic surgery. Plast Re-
constr Surg 1987;79(6):990–997
45. Angel MF, Haddad JJ Jr, Abramson M. A free radical scavenger
reduces hematoma-induced fl ap necrosis in Fischer rats. Oto-
laryngol Head Neck Surg 1987;96(1):96–98
46. Angel MF, Ramasastry SS, Swartz WM, et al. The critical re-
lationship between free radicals and degrees of ischemia:
evidence for tissue intolerance of marginal perfusion. Plast
Reconstr Surg 1988;81(2):233–239
47. McFarlane RM, Heagy FC, Radin S, Aust JC, Wermuth RE. A
study of the delay phenomenon in experimental pedicle fl aps.
Plast Reconstr Surg 1965;35:245–262
48. Meyer MB, Cherry G. Augmentation of tissue survival by de-
lay: An experimental study in rabbits. Plast Reconstr Surg
1969;39:397–401
49. Cherry GW, Austad E, Pasyk K, McClatchey K, Rohrich RJ. In-
creased survival and vascularity of random-pattern skin fl aps
elevated in controlled, expanded skin. Plast Reconstr Surg
1983;72(5):680–687
50. Baker SR. Fundamentals of expanded tissue. Head Neck
1991;13(4):327–333
51. Miller SH, Rudolph R. Healing in the irradiated wound. Clin
Plast Surg 1990;17(3):503–508
52. Stearner SP, Sanderson MH. Mechanisms of acute injury in the
gamma-irradiated chicken: eff ects of a protracted or a split-
dose exposure on the fi ne structure of the microvasculature.
Radiat Res 1972;49(2):328–350

Contemporary skin resurfacing procedures—chemo-
exfoliation, laser resurfacing, and dermabrasion—have
been in continual evolution since their inception over
65 years ago and in general represent safe and effi ca-
cious techniques for the rejuvenation of aging skin. Like
all surgical procedures, resurfacing has associated com-
plications (Table 6.1). Most complications, however, are
avoidable if the physician thoroughly understands this
family of treatments, including the pharmacokinetics
of diff erent wounding agents on various skin types, the
histology of depth wounding, normal wound healing,
and laser physics. Each modality has a particular mech-
anism to injure skin and the physician must know how
an agent or technique can be used to produce the favor-
able results desired.
By convention, resurfacing procedures are divided by
depth of injury into superfi cial, medium, and deep. The
depth of wounding determines the level of destruction
and thus the degree of rejuvenation, as well as length of
time for wound healing and risk of complications. While
superfi cial wounding will heal within 24 to 48 hours
with little risk of problems, medium and deep resur-
facing may take considerably longer, and can produce
many of the complications to be discussed. In general,
resurfacing below the mid-reticular dermis causes de-
structive necrosis and scarring and should not be per-
formed. Much has been published regarding resurfacing
and is available in the literature for physicians to devel-
op a better understanding of its principles and proce-
dures.1,2 When resurfacing devices or peel solutions are
overused, inappropriately used, or mismatched with a
skin type, unintended injuries and complications may
occur.3 Such injuries are the focus of this chapter.

◆Timing of Adverse Events
Resurfacing complications can be divided by the timing
of their occurrence. Intraoperative problems inadver-
tently occur during the procedure, and for dermabra-
sion, an example would be overly aggressive use of the
mechanical abrader, creating a wound too deep to heal
without a scar. There are documented cases of the wi-
rebrush dermabrader piercing through skin or ripping
a lip or eyelid due to lack of surgical control or sudden
movement of the patient. One must also be careful not
to overuse a freezing agent, which can cause a freeze-
burn injury that will create textural scarring or pigmen-
tary alteration.
Intraoperative laser complications include laser-
induced fi res and laser energy deposition outside the
operative fi eld. Proper laser safety precautions should
always be mandated, such as keeping wet towel drapes
around the operative fi eld and keeping O2 sources and
combustible products out of range. The surgeon must
give the procedure his full attention so that there are
not unwanted laser impacts. Laser-impermeable scleral
shields should be used for all facial CO2 or erbium re-
surfacing cases, especially when performed around the
periorbital area. Chemical peel solutions—whether TCA
or phenol—are caustic and can cause signifi cant prob-
lems if they are inadvertently dripped into the eye or
sensitive cutaneous surfaces. The surgeon should per-
39
6
Challenges in Skin Resurfacing
Gary D. Monheit and Randolph B. Capone
Table 6.1
Complications Seen with All Types of Resurfacing
Dyspigmentation
Scarring
Infection
Prolonged erythema or pruritus
Contact dermatitis
Textural changes
Milia
Acne
Cold sensitivity
Worsened doctor-patient relationship

Complications in Facial Plastic Surgery
40

◆ Chemoexfoliation: The Workhorse of
Resurfacing Procedures
The most common resurfacing procedure performed un-
der the direction of a physician is chemical peeling. Gen-
erally, light chemical peels have fewer complications than
any of the others. These peels are “lunch time” procedures
designed to exfoliate the upper epidermis with minimal
dermal infl ammation. Healing is usually uncomplicated,
occurring in 1 to 3 days. Untoward problems can occur
with overcoating low-dose trichloracetic acid (TCA), leav-
ing glycolic acid in place for prolonged periods without
proper neutralization, or over-aggressive degreasing of
the skin prior to the peel.7 These can result in edema, pro-
longed erythema, excessive pain, prolonged exfoliation,
and delayed healing. Hyperpigmentation and scarring
can occur. Practitioners should be especially concerned
with sensitive-skinned patients, such as those with
atopy, or patients using regular exfoliating programs or
retinoids or other skin-care programs that may thin the
stratum corneum. Most of these problems are reversible
with skin protection, bland emollients and appropriate
treatment, such as topical corticosteroids and bleaching
agents. In well-trained hands, unmet expectation is the
prime risk associated with light chemical peels.
If medium or deep resurfacing is chosen as the proce-
dure to solve a patient’s skin problem, the physician must
discuss the patient’s expected down time, temporary side
eff ects such as erythema, pruritus, and skin sensitivity, as
well as care instructions for for 7–14 days of healing. Do-
ing so will likely yield a favorable result with a happy pa-
tient. Not doing so can produce complications—reversible
or irreversible—and an unhappy patient. Medium and
deep resurfacing create full-thickness destruction of the
epidermis along with partial necrosis and infl ammation
of varying levels of dermis. With medium depth chemical
peeling, aggressive overcoating with 35% of TCA or com-
bination TCA peels can drive a medium peel into a much
deeper destructive procedure and potentially cause scar-
ring (Fig. 6.1).7 The most common complication, though,
is hyperpigmentation, which can last up to 3 months,
depending on skin type and postoperative care. Medium
and deep chemical peels along with deep resurfacing
procedures, such as CO2 resurfacing or dermabrasion,
must be considered more serious surgical procedures
and deserve the appropriate preoperative consultation
and informed consent with a thorough understanding of
the postoperative care and sequelae.

◆Dyspigmentation
Alterations in pigmentation after resurfacing proce-
dures can be either desirable or constitute a complica-
tion. Desirable pigmentary changes include lightening
sonally check the acid and strength before applying and
never pass the application over the patient’s central face
or eyes. Accidents of this sort have resulted in disastrous
corneal damage and cutaneous scars. Over all, howev-
er, scarring after all resurfacing procedures—chemical
peeling, laser resurfacing, and dermabrasion—has a re-
ported incidence of less than 1%.
Once a resurfacing procedure is completed, the recov-
ery and regrowth of new skin should occur in a controlled
environment in which noxious external factors—trauma,
allergy, and infection—should be minimized to prevent
serious complications. The fi nal common pathway for
a resurfacing complication is scarring. This dreaded re-
sult can be avoided by careful observation and follow-up
during the recovery period, as well as early intervention
to reguide the skin to normal healing.4

◆ Patient Expectations Associated with
Resurfacing
The most common risk of skin resurfacing is patient dis-
satisfaction with the procedure. While it is not a com-
plication in the strictest of terms, many authors view
this undesirable outcome as such. This can be avoided
by carefully analyzing the patient’s perceived problem
and deciding how to realistically treat it with a particu-
lar type of procedure.5 It is best to give a patient a mir-
ror and allow them to show you the specifi c problem
that bothers them. Their concern may be fi ne wrinkles,
abnormal color, or inappropriate texture (all eff ectively
treated with erbium laser or medium-depth chemical
peeling), or volume defects that require fi llers rather
than resurfacing. The physician must address the proce-
dure most applicable to achieve the results desired. Re-
petitive light chemical peels or microdermabrasion can
correct pigmentary change but not signifi cant rhytids,
which may require a deeper resurfacing procedure. One
must then look at patient-specifi c risks for particular
complications, such as hypo- or hyperpigmentation, or
the potential for scarring in previously irradiated skin or
in the penumbra of a course of isotretinoin.6
It is also important for the physician to distinguish a
true complication from an expected side eff ect of re-
surfacing and educate the patient appropriately. For
example, most ablative resurfacing procedures have
expected side eff ects of transient erythema, fl ushing,
increased skin temperature, pruritus, edema, milia for-
mation, and acne. These are consequences of the new
skin formation and should be addressed (as with pa-
tient expectations) before the procedure so their ap-
pearance will not alarm the patient. Patient reassurance
is usually all that is necessary since these problems will
resolve spontaneously. Overtreatment of these side ef-
fects alone can lead to overtreatment complications.

6 Challenges in Skin Resurfacing
41
uneven dyschromias or correcting conditions such as
melasma or age-related hyperpigmentation. Unintend-
ed pigmentation changes, such as streaks or irregular
lines of demarcation, can occur from uneven degreasing,
inhomogeneous chemical application, or inappropriate
choice of wounding agent. TCA 50%, for example, has
fallen out of favor as a resurfacing treatment because of
its increased complication profi le, including dyspigmen-
tation and scarring. Post-peel pigmentary inhomogene-
ity typically occurs around the eyes, mouth, or jawline
margin adjacent to the untreated neck. Such irregulari-
ties are not specifi c to chemical resurfacing, but also
occur as a result of uneven laser resurfacing or derm-
abrasion. With all modalities of resurfacing, care must
be taken to ensure an even and homogeneous treatment.
Dyspigmentation can occur after any depth chemical
peel, but deeper peel procedures harbor risk of greater
problems. In general, patients with light complexions
(Fitzpatrick skin types I–II) have lower risks for this
complication, while Fitzpatrick IV–VI skin must be ap-
proached with caution due to the elevated risk of hyper-
pigmentation. Patients taking photosensitizing drugs
or hormone replacement therapy (estrogen) are also at
greater risk for pigmentary complications from resur-
facing procedures (Table 6.2), and therefore it is unwise
Fig. 6.1 Excess skin wounding from overcoating with Jessner’s
solution.
Table 6.2
Common Photosensitizing Medications
Antibiotics
• fl uoroquinolones (ciprofl oxacin, levofl oxacin, gatifl oxacin)
• tetracyclines (tetracycline, doxycycline, minocycline)
• sulfonamides (sulfamethoxazole, trimethoprim,
cotrimoxazole)
Antihistamines
• diphenhydramine
Antimalarials
• quinine
• chloroquine
• hydroxychloroquine
Chemotherapeutic agents
• 5-fl uorouracil
• vinblastine
• dacarbazine
Cardiac agents
• amiodarone
• nifedipine
• quinidine
• diltiazem
Diuretics
• furosemide
• hydrochlorothiazide
Diabetic agents
• sulfonylureas (chlorpropamide, glyburide)
Analgesics
• nonsteroidal anti-infl ammatory drugs (naproxen,
piroxicam)
Skin medications
• 5-aminolevulinic acid (Levulan, DUSA Pharmaceuticals,
Wilmington MA)
Acne medications
• isotretinoin (Accutane, Hoff man-LaRoche, Palo Alto CA)
Antipsoriatic agents
• acitretin (Soriatane, GlaxoSmithKline)
Psychiatric drugs
• phenothiazines (chlorpromazine)
• tricyclic antidepressants (desipramine, imipramine)

Complications in Facial Plastic Surgery
42
and its melanin will temporarily lighten the skin but
color will return as migrating melanocytes from pilo-
sebaceous complexes re-pigment the new skin. This is
especially apparent in types IV through VI skin.10 There-
fore, reactive hyperpigmentation is a greater risk in
darker skin types than is prolonged hypopigmentation.
Protracted (even permanent) hypopigmentation can
be the result of deep peeling or aggressive resurfacing in
darker skin types. This is especially true with CO2 laser
and occluded phenol peels which may destroy the re-
serve of melanocytes in pilosebaceous apparatus need-
ed to resurface the epidermis. A “melanotoxic” eff ect of
the deeply penetrating phenol on melanocytes has been
purported, but this perhaps is a direct result of deep-
depth injury, since it is also seen after ablative laser re-
surfacing, overly aggressive dermabrasion or laser hair
removal, and deep chemical peeling without phenol. In
addition to hypopigmentation, the skin can assume an
atrophic or ‘plastic’ appearance with deep peeling due
to destruction of the papillary dermis.11 Although this
was an acceptable side eff ect of deep phenol peeling in
past decades, it is no longer tolerated by patients today
and resurfacing at this depth should be avoided.

◆Scarring
The most feared complication associated with all resur-
facing procedures is scarring. Factors that lead to this
unfortunate result are myriad and at times additive.
Contributing factors are classifi ed as intrinsic, preopera-
tive, or postoperative as outlined in Table 6.4. The re-
to proceed until these medications have been stopped
completely and the risk profi le has decreased suffi cient-
ly (12 months after Accutane, for example).
Reactive dyschromia (postinfl ammatory hyperpig-
mentation, PIH) occurs by postoperative weeks 3 or 4,
but may appear earlier. PIH usually responds to topi-
cal therapy (Table 6.3) and is therefore viewed as a less
troublesome complication than hypopigmentation. PIH
is more common after superfi cial and medium-depth
peels, whereas hypopigmentation typically is a risk af-
ter deep peels (e.g., Baker-Gordon) and laser resurfacing.
PIH is often initiated by minimal sun exposure during the
erythematic phase of healing, and broad spectrum sun-
screen protection and/or sun avoidance is imperative af-
ter resurfacing procedures for 3–6 months. Fortunately,
PIH usually responds well to lightening agents, tretinoin,
and corticosteroids as outlined above.8 Treatment for hy-
perpigmentation should begin in susceptible skin types
directly after re-epithelialization is complete and contin-
ue for 4 to 6 weeks. It is also helpful to pretreat suscep-
tible skin types IV to VI with hydroquinone 6 to 8 weeks
prior to peeling as a preventive measure. Skin lightening
agents are then resumed after re-epithelialization.
It should be emphasized that factors promoting hy-
perpigmentation after resurfacing procedures include
birth control pills and exogenous estrogens, photosensi-
tizing drugs, steroids, and excessive sun or tanning bed
exposure prior to and after peeling (Fig. 6.2). If post-
peel hyperpigmentation does not respond to topical
treatments alone, repeated light chemical peels can be
a helpful adjunct. Selective lasers such as Q-switch YAG
532 and intense pulse-light sources can also be helpful
in treating resistant post-peel or resurfacing pigmenta-
tion or resurfacing pigmentary problems.9
Hypopigmentation can be a normal event in resur-
facing to a degree. The removal of photodamaged, dys-
chromic epidermis evens a “muddy complexion” and
brightens skin. Thus, in fair-complected skin, a medium
depth chemical peel will restore a lighter color, pre-sun
damaged complexion. In both superfi cial- and medium-
depth chemoexfoliation, the removal of the epidermis
Fig. 6.2 Diff use facial hyperpigmentation after full face laser
resurfacing.
Table 6.3
Treatment of Postinfl ammatory Hyperpigmentation (PIH)
1. hydroquinone 4 to 8%—inhibits melanogenesis
2. retinoic acid—enhances pigment exfoliation
3. mild corticosteroids—reduce infl ammation
4. non-infl ammatory, light chemical peeling:
a. salicylic acid—20%
b. glycolic acid—30 to 40%

6 Challenges in Skin Resurfacing
43
sultant scars themselves can be divided into 3 variants
based on extent of wound injury: textural, atrophic/
hypopigmented, and contractile. Textural scarring oc-
curs with the ablation of superfi cial skin structure and
is characterized by a “grainy” skin texture (Fig. 6.3A).
Enlarged pores are also common in textural scarring af-
ter resurfacing due to infl ammation of the high papil-
lary dermis with widening of the pore exit to the skin
surface. Dermal atrophy and hypopigmentation with
irregular contours can be seen with wounds extend-
ing through the upper/mid-dermis, while contractile
(or pulling) scars are seen after full-thickness dermal
injuries with deep dermal scarring. Contractile scars
create the worst deformities and include such problems
as lower eyelid ectropion, lip deformities, and nasal alar
distortions (Fig. 6.3B).
Early identifi cation and intervention can help pre-
vent scarring complications, and knowledge of the nor-
mal timetable of each healing phase is imperative to
detect an impaired healing process. Early evidence for
the development of scarring can be erythema or pru-
ritus, though these are typical in the fi broplasia phase
of wound healing. When they persist for a prolonged
time or appear in a particularly aggressive fashion, it
should be a red fl ag to the physician. Prolonged erythe-
ma should be treated with mild topical steroids and/or
systemic steroids to reduce the infl ammation trigger-
ing the problem. Pruritus can be a part of this problem
and the symptoms should be treated with antihista-
mines, as scratching the delicate new skin can lead to
skin breakdown and scarring. Mild topical steroids and
bland emollients will protect the newly formed skin
and control symptoms.
Skin breakdown is also an abnormality that needs the
physician’s attention. The wound should be cultured
immediately to rule out the presence of a post-proce-
dure infection. Non-epithelialized areas may be covered
with a biologic dressing [e.g., Flexzan (Bertek Pharma-
ceuticals) or Vigilon (Bard Medical)], and changed daily.
Antibiotic, antifungal, or antiviral agents should be used
where appropriate.
Other causative factors leading patients down the
scarring pathway can include trauma (chemical or me-
chanical irritations) or contact allergy. These external
factors should be eliminated with fastidious post-pro-
cedural patient education. Patients should be instructed
to use only bland emollients (Vaseline, Aquaphor) and
non-caustic cleansers. Early use of irritating makeup or
glycolic acid-containing skin products, for example, can
induce this erythematous phase and thus all topicals,
including sunscreens, bleaches, and retinoids, should be
discontinued until the skin is fully healed and no longer
infl amed.
If the aff ected areas of erythema begin to thicken,
intralesional injections of corticosteroids (Kenalog, tri-
amcinolone acetonide) may be injected throughout the
area and repeated weekly if needed. Care must be taken,
Table 6.4
Factors Associated with Scarring after Deep Resurfacing
I. Intrinsic causes
A. Hereditary skin type
1. Discoid lupus erythematosus
2. Scleroderma
3. Atopic
4. Ehler-Danlos syndrome
5. Keloid tendency
B. Compromised skin healing
1. Irradiated skin (absence of pilosebaceous apparatus)
2. Poikilodermatous atrophy
3. Undermined skin before surgery
4. Isotretinoin therapy within last six months
5. Poor health and nutritional status
6. Active infection or open wounds, excoriations, and
infl ammatory acne
7. Infl ammation from active skin disease or retinoid
dermatitis
II. Operative causes
A. Overtreatment creating a wound beyond the mid reticu-
lar dermis
1. Repeated overcoating with 25–40% of TCA
2. Use of 50% or above TCA
3. Overly aggressive use of phenol
B. Aggressive treatment of scar-prone areas on the face—
forehead, malar prominence, eyelids, jaw line
C. Aggressive treatment of nonfacial skin, especially neck,
chest, shoulders
III. Postoperative causes
A. Infection
1. Bacterial—Staphylococcus, Pseudomonas, E. coli
2. Fungal—Candida
3. Viral—Herpes simplex
B. Trauma: Irritants, allergens, physical factors that wound
skin, and picking or scratching
C. Idiopathic prolonged wound healing
D. Idiopathic prolonged erythema

Complications in Facial Plastic Surgery
44
ing Streptococcus, Staphylococcus, and Pseudomonas
species (Fig. 6.4A–D). Regular, gentle debridement of
exudate, necrotic tissue, and ointment using a 0.25%
acetic acid solution [1 tablespoon (15 cc) of white vin-
egar in 1 pint (473 cc) of sterile water] is necessary to
encourage the normal phases of wound healing—granu-
lation, epithelialization, and fi broplasia. Systemic anti-
biotics are usually not necessary in open healing with
good debridement, because bacterial infection is rare if
good hygiene, postoperative soaks, and careful observa-
tion are enforced.12 It is important for the physician to
see the patient regularly during the postoperative pe-
riod to catch the signs of early bacterial infection. Any
suspicious exudate should be cultured, and the patient
should be placed on the appropriate antibiotic. If an in-
fection is neglected and left untreated, it will lead to de-
layed wound healing and scarring.
however, not to induce steroid atrophy or telangiectasia
formation; thus it may be more judicious to use a short
course of systemic steroids. This can be delivered as 40
mg of intramuscular triamcinolone acetonide or 60 mg
of oral prednisone tapered gradually over 2 to 3 weeks.
If left unchecked, scar formation can follow diff erent
pathways, dependent on the dermal level of injury, the
region of the face or body cavity and the injury and the
nature of the skin; i.e., eyelid versus neck versus jaw
line. Resurfacing by laser or deep peel of the lower eye-
lid skin induces signifi cant collagen contraction which
can produce scleral show or even ectropion in suscep-
tible patients. If the patient has a poor Snap Test, the re-
surfacing procedure should be very conservative. These
patients should be seen regularly because ectropion can
occur 1 to 2 weeks after re-epithelialization—when the
physician feels all is well. Intervention with intralesion-
al steroid therapy, silicone sheeting, and even mechani-
cal debridement of early adhesions can be productive in
preventing and correcting early ectropion.

◆Infection (Table 6.5)
During wound healing, compromised skin is undoubt-
edly susceptible to infection. Factors contributing to
bacterial or yeast infection are inadequate debridement
of necrotic tissue and occlusive ointments such as pet-
rolatum and moisturizers. The mineral and vegetable
fats used for occlusive healing can serve as a culture
medium, promoting the growth of pathogens, includ-
Table 6.5
Infections after Resurfacing
Bacterial pyoderma
Herpes simplex virus
Epstein-Barr virus keratitis
Candidiasis
Toxic shock syndrome
Fig. 6.3 (A) Textural scarring and prolonged
erythema after resurfacing. (B) Posttreatment
ectropion after lower lid resurfacing. Used with
permission from Sabini P. Facial Plast Surg Clin N
Am 12 (2004) Figure 3, p. 359.
A
B

6 Challenges in Skin Resurfacing
45
Herpes simplex outbreaks can be triggered by the
resurfacing procedure itself. A careful history of prior
herpes simplex virus I or II outbreaks will reveal those
patients who require prophylactic therapy. Because
many patients do not know if they have had HSV and
are carriers, all patients having medium-depth and
deeper resurfacing procedures should receive prophy-
lactic therapy, such as Valcyclovir, 500 mg twice a day
for 10 days, starting 4 days prior to the procedure. If HSV
infection occurs during the postoperative phase, the ve-
sicular infection can spread over the entire peeled area
and has the potential for devastating sequelae and scar-
It has been noted that some patients develop Candida
infections after occlusive healing without debridement
while on systemic antibiotics. They have been reported
more frequently after dermabrasion and CO2 laser re-
surfacing, because the nonviable epidermis after a peel
has been thought to be somewhat protective. Yeast over-
growth should be treated aggressively with soaks and
debridement, plus oral ketoconazole and fl uconazole.13
Daily dressing changes and debridement performed by
the physician or a trained staff member are advisable
during the fi rst three to fi ve days after a resurfacing
procedure.
Fig. 6.4 (A–D) Staphylococcal infection and
subsequent healing after deep chemical peel.
A
B
C
D

Complications in Facial Plastic Surgery
46
parenteral antiviral agents, and ophthalmologic
consultation.
Toxic shock syndrome has also been described after fa-
cial resurfacing.16 Toxic shock is a severe toxin-mediated
condition that aff ects multiple organ systems, with pre-
dominant signs being sudden fever, rash, desquamation,
and hypotension. It occurs in both males and females and
is not related to the menstrual period. The resurfaced area
does not usually appear infected as with other types of
infections seen after a peel. Early recognition and prompt
therapy are the hallmarks of successful intervention. Pa-
tients need symptomatic therapy, with aggressive admin-
istration of fl uids and IV antistaphylococcal antibiotics.
ring (Fig. 6.5A–C). Vesicles are rare on denuded skin,
but the sudden onset of pain in the midst of uneventful
wound healing is the classic sign of HSV infection and
mandates skin swab culture and prompt initiation of
antiviral therapy (Valcyclovir, 500 mg TID or QID)14 and
prolonged skin care.
Epstein-Barr virus keratitis can manifest with vi-
sion changes, fever, and arthralgias; it is a rare com-
plication seen after chemoexfoliation with a solution
containing croton oil. EBV reactivation and replication
can be induced by croton oil in up to 10% of other-
wise healthy EBV seropositive patients.15 The condi-
tion can be treated with steroid-containing eye drops,
Fig. 6.5 (A) Herpes simplex (HSV) infection 8
days after full face dermabrasion. Patient pre-
sented with pain, fever, malaise, and lymph-
adenopathy. (B) HSV infection presenting with
vesicular eruption and pain in the left cheek
after resurfacing. (C) HSV infection after laser
resurfacing in a patient with no prior history
of herpes labialis. Used with permission from
Hirsch R. Facial Plast Surg Clin N Am 12 (2004)
Figure 2, p. 319.
A
B
C

6 Challenges in Skin Resurfacing
47
Therapy directed at persistent erythema should em-
phasize protection of the skin from noxious and irri-
tating agents, as well as the use of corticosteroids and
anti-infl ammatory agents—topical and/or systemic—to
halt any emerging cicatricial process. If the erythema-
tous area begins to feel fi rm and indurated, it is a sign
that scar formation is beginning. If scarring is treated
early, it can be prevented and corrected. In many cases,
the early fi broplasia stage exhibited by induration and
erythema can be reversed, preventing the fi nal results
of scar formation and deformity. If, however, prevention
fails and a scar forms, the various treatment options—
intralesional corticosteroids, topical corticosteroids
under occlusion, silicone sheeting, and pulse dye laser
treatment—must be considered.

◆Conclusion
Although cosmetic resurfacing procedures, like all surgi-
cal procedures, have associated complications and the
potential for adverse sequelae, these can be minimized
with a strong knowledge base, careful technique, close
patient observation, and appropriate intervention when
necessary. Proper physician training for this family of
procedures should encompass optimal patient selec-
tion, conservative and safe performance of the appro-
priate resurfacing method, and knowledge of untoward
sequelae and their treatment. A skilled physician with
such knowledge and experience will make skin resur-
facings—whether with chemicals, lasers, or dermabra-
sion—the safe, effi cacious, and successful treatments
they are meant to be.

◆Delayed Wound Healing
It is important to recognize delayed wound healing after
a resurfacing procedure has been performed. Patients
may present with painful open erosions with friable
granulation tissue well beyond the time epithelializa-
tion should be completed. The symptoms of delayed
healing can occur during the second or third weeks after
a resurfacing procedure and continue for weeks. Rare-
ly they can surface four to six weeks after full healing.
Prolonged granulation phase is a stimulus for scarring
and should be treated aggressively to complete epitheli-
alization and healing. Empiric antimicrobial therapy to
cover the possibility of an underlying bacterial, yeast,
or herpetic infection should be instituted until culture
results are available. The treatment of choice is close
follow-up with daily dressing changes, using a commer-
cial biosynthetic membrane such as Vigilon (C.R. Bard,
Inc., Covington, GA).17 The protection and coverage of
the granulating wound allow the tissues to progress to
normal healing.

◆Persistent Erythema
All patients undergoing a resurfacing procedure will
have some degree of erythema for a variable period of
time. The degree and extent of redness are dependent
on the depth of injury and procedure type. Laser resur-
facing generally has a more prolonged period of ery-
thema than does chemical peeling. Although superfi cial
peels are erythematous for two to three days, medium
depth peels are normally erythematous for two to three
weeks, deep peels for four to six weeks, and CO2 resur-
facing for up to 12 weeks. Erythema that lasts beyond
the normal duration is defi ned as persistent erythema
and should signal the physician that there is a potential
problem. Persistent erythema is often accompanied by
prolonged pruritus, burning or stinging sensations, and
irregularities in skin texture. It may represent sensitiv-
ity to topical agents such as an allergy to antibiotic oint-
ment or irritation from lanolin, makeup, moisturizer,
SPF, or early usage of a retinoid. It may also be an indi-
cation of intrinsically sensitive skin, such as atopic der-
matitis, seborrheic dermatitis, or rosacea. The surgeon
should attempt to identify and correct any underlying
factors that may be contributing to the problem. This is
most important because persistent erythema may in-
dicate the impending development of scar formation.18
It should be recognized that neglect of these symptoms
and signs is now considered failure to meet the standard
of good medical care.
PEARLS OF WISDOM
Always maintain an eyewash station and have it readily avail-
able before starting any chemical peel.
Mineral oil, not water, should be used as a fl ushing medium if
phenol inadvertently splashes in a patient’s eye.
For all resurfacing modalites, always take additional care to
blend the transition from the face to the neck to prevent
unsightly demarcation.
Dermabrasion is not an appropriate resurfacing technique for
eyelid rejuvenation.
The use of newer resurfacing modalities, such as fractionally
ablative CO2 resurfacing, can be enticing, but the risk-benefi t
profi le of emerging technologies often lags.

Complications in Facial Plastic Surgery
48
10. Ho C, Nguyen Q, Lowe NJ, Griffi n ME, Lask G. Laser resur-
facing in pigmented skin. Dermatol Surg 1995;21(12):
1035–1037
11. Hetter GP. An examination of the phenol-croton oil peel:
part IV. Face peel results with diff erent concentrations
of phenol and croton oil. Plast Reconstr Surg 2000;105:
1061–1083
12. Coleman K, Coleman W. Complications in Skin Resurfacing.
Philadelphia: Wilkins and Wilkins; 1998:244–268
13. Giandoni MB, Grabski WJ. Cutaneous candidiasis as a cause
of delayed surgical wound healing. J Am Acad Dermatol
1994;30(6):981–984
14. Monheit GD. Facial resurfacing may trigger the herpes simplex
virus. Cosmetic Dermatol 1995;8:9–16
15. Brody HJ. Chemical Peeling and Resurfacing. St. Louis: Mosby;
1997:161–193
16. LoVerme WE, Drapkin MS, Courtiss EH, Wilson RM. Toxic
shock syndrome after chemical face peel. Plast Reconstr Surg
1987;80(1):115–118
17. Alt TH. Avoiding complications in dermabrasion and chemical
peeling. In Skin Allergy News; 1990:2
18. Maloney BP, Millman B, Monheit G, McCollough EG. The etiol-
ogy of prolonged erythema after chemical peel. Dermatol Surg
1998;24(3):337–341
References
1. Matarasso SL, Glogau RG. Chemical face peels. Dermatol Clin
1991;9(1):131–150
2. Coleman WP, Lawrence N, eds. Skin Resurfacing. Philadelphia:
Williams and Wilkins; 1998:42–66
3. Brody HJ. Complications of chemical peeling. J Dermatol Surg
Oncol 1989;15(9):1010–1019
4. Demas PN, Bridenstine JB. Diagnosis and treatment of postop-
erative complications after skin resurfacing. J Oral Maxillofac
Surg 1999;57(7):837–841
5. Duff y DM. Cosmetic surgery and informed consent. Dermatol
Surg 1993;5:369–370
6. Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. Atypi-
cal keloids after dermabrasion of patients taking isotretinoin.
J Am Acad Dermatol 1986;15(2 Pt 1):280–285
7. Monheit GD. The Jessner’s—TCA peel. Facial Plast Surg Clin
North Am 1994;2:21–22
8. Brody HJ. Complications of chemical resurfacing. Dermatol
Clin 2001;19(3):427–438, vii–viii
9. Monheit GD, Zeituni MC. Skin resurfacing for photoaging;
Laser resurfacing vs. chemical peeling. Cosmetic Dermatol
1997;10:11–22

Upper eyelid blepharoplasty can have a dramatic restor-
ative aff ect on the eyes and the face as a whole. Howev-
er, care must be taken during this delicate operation to
prevent its many possible complications. As experience
with upper eyelid blepharoplasty has grown over the last
century, so has the list of complications. This chapter dis-
cusses avoidance and management of complications that
may be encountered before, during, and after this surgery.

◆Preoperative Complications
The treatment of complications begins with careful pre-
operative assessment of the patient. Certain preexisting
conditions are more likely to result in complications or
disappointing outcomes. The initial encounter with the
patient provides an opportunity to identify and avoid
the sources of potential future complications. These
conditions do not necessarily prohibit upper eyelid sur-
gery but may need to be addressed before surgery.
Psychiatric History
Determining the patient’s desires, motivations, and ex-
pectations of blepharoplasty is an essential component
of the initial consultation. Properly motivated patients
have a healthy self-esteem and seek restorative changes.
The surgeon must determine exactly what bothers the
patients about their eyes and whether these conditions
can be corrected with surgery. If inappropriate desires,
motivations, or expectations exist preoperatively, the
procedure is likely to fail to satisfy the patient.
A brief psychiatric assessment should be part of every
cosmetic preoperative evaluation. Cosmetic surgery pa-
tients may have concomitant psychiatric disorders, but
this rarely precludes surgery. Body dysmorphic disorder
(BDD) is a preoccupation with an imagined or slight de-
fect in appearance that leads to excessive concern and
signifi cant impairment in social, occupational, or oth-
er areas of functioning.1 In one prospective study, the
prevalence of BDD in patients seeking cosmetic eyelid
rejuvenation was 13%.2 The authors found that cosmet-
ic surgery patients are no more dissatisfi ed, critical, or
preoccupied with their overall appearance than a na-
tionwide sample of Americans. This contrasts with the
common portrayal of cosmetic surgery patients as ex-
cessively vain. Most patients seek blepharoplasty to re-
store their eyes to a previous state and are likely to cope
with the postoperative change in appearance. However,
patients desiring to dramatically change the shape of the
eye must be approached with caution, and a preopera-
tive psychiatric consultation may be indicated.3
Past Medical History
When obtaining a past medical history, the surgeon
should pay close attention to past bleeding problems
and the use of anticoagulant or herbal medications.
Those with bleeding disorders or who use anticoagulant
medications have an increased risk of bleeding compli-
cations following blepharoplasty. Many commonly used
herbal medications, such as echinacea, ephedra, gar-
lic, ginkgo, ginseng, kava, St. John’s wort, and valerian,
pose a perioperative bleeding risk.4 In particular, garlic,5
ginkgo,6 and ginseng7 have been shown to decrease co-
agulation parameters. The authors request their blepha-
roplasty patients stop taking all herbal medications 10
days before surgery.
During the initial consultation, the surgeon must also
inquire about disorders that may lead to poor healing.
Diabetes, malnutrition, and immunosuppression con-
stitute relative contraindications for elective surgery.
A discussion regarding wound healing preoperatively
will help avoid litigation should poor healing lead to a
complication postoperatively. A careful medical history
allows the surgeon to fi lter out candidates whose pre-
operative health may produce complications and poor
outcomes.
49
7
Complications of
Upper Eyelid Blepharoplasty
Tom D. Wang and Andrew A. Winkler

Complications in Facial Plastic Surgery
50
eyelid movement.12 The outermost layer of the tear fi lm
is a hydrophobic oil layer produced by the meibomian
glands and accessory sebaceous glands (the palpebral
glands of Zeiss and Moll) that reduces evaporation of
the tear fi lm. When this layer is disrupted, evaporative
losses may increase 10 to 20 times.13 The middle layer
is aqueous and has the largest volume. It is produced by
basal secretion from numerous accessory glands (lacri-
mal exocrine glands of Kraus and Wolfring) plus a stim-
ulated secretion from the lacrimal gland. Basal aqueous
secretion decreases with age, leading to a loss in tear
volume.11 The deep layer of the tear fi lm is a mucous
barrier produced by goblet cells of the conjunctiva. The
secretion of mucin by the goblet cells of the conjunctiva
increases in response to infl ammation.
Keratoconjunctivitis sicca is the term used to de-
scribe eye irritation caused by decreased tear produc-
tion or increased tear fi lm evaporation. There are many
pathophysiologic causes of dry eye, but the most com-
mon one is a reduction of the aqueous portion of the
tear fi lm. Many systemic disorders are associated with
keratoconjunctivitis sicca, including systemic lupus ery-
thematosus, scleroderma, Wegener’s granulomatosis,
hyperthyroid states, and rheumatoid arthritis. It is im-
portant to identify preoperatively those patients who
are likely to develop dry eye symptoms. In one study of
blepharoplasty, those more likely to develop postopera-
tive keratoconjunctivitis sicca included men, postmeno-
pausal females, and patients with hypertension.14
The tear defi ciency is diagnosed through inquiring
about dry eye symptoms and confi rming abnormal tear
fi lm production. One may be clued into the presence of
a dry eye by observing the corneal surface in preopera-
tive photographs: it should appear glass-like. If the light
refl ex appears rough, as if there is debris on the cornea,
further workup should be sought. On exam, an abnor-
mal tear fi lm is recognized by rapid tear evaporation and
increased mucus on the eyelid margins.
Schirmer testing is perhaps the most useful and easily
performed test to establish the diagnosis of keratocon-
junctivitis sicca in the preoperative setting.14 The eye is
fi rst topically anesthetized to prevent eliciting refl ex se-
cretion and the patient is placed in a moderately illumi-
nated room facing away from direct light. Filter paper 35
mm long × 5 mm wide is partially folded at one end and
the folded end is placed on the lateral one-third of the
lower lid conjunctiva. The patient is then asked to fi xate
on an object above the direct line of gaze for 5 minutes.
Hyposecretion is defi ned by less than 10 mm of wetting.
Normal wetting is between 10 and 30 mm.15 Unfortunate-
ly, the results of the Schirmer test in a given patient may
vary greatly and it is necessary to perform several tests for
each patient. Those who consistently fall below 10 mm of
wetting should be suspected of having dry eye syndrome
and warrant a complete ophthalmologic workup.
Physical Examination
A meticulous physical examination can identify many
potential causes of blepharoplasty complications. While
patients commonly present with a desire to remove re-
dundant eyelid skin, close examination often reveals that
skin redundancy is caused at least in part by descent of
the eyebrows. To make this assessment, it is helpful to
understand the anatomic position of the eyebrows in
youth. The youthful brow in women lies just above the
supraorbital rim and is a gentle arc.8,9 In men, the brow is
fl atter and lies at the level of the supraorbital rim.10 The
surgeon evaluates the contribution of the brow to eyelid
skin redundancy by manually elevating the eyebrows to
these positions in the offi ce. This often leads to a dra-
matic decrease in the amount of skin laxity. If the brow
position is corrected to the level of the orbital rim, much,
if not all, of the skin redundancy is often reduced. After
the contribution of the eyebrows to eyelid skin redun-
dancy has been determined, the surgical steps to correct
the problem can more accurately be suggested. Excision
of the upper eyelid skin without addressing preexisting
eyebrow ptosis results in further brow descent and pre-
vents the desired opening of the eyes.
Dry Eye Syndrome
Symptoms of soreness, burning, foreign body sensa-
tion, or mucoid discharge should raise red fl ags dur-
ing an assessment of blepharoplasty patients (Fig. 7.1).
Blepharoplasty surgery in those with tear defi ciency
can aggravate subclinical symptoms into full-blown
dry eye syndrome.11 An understanding of the tear fi lm
allows the physician to diff erentiate the causes of dry
eye syndrome. The tear fi lm is a trilaminar fl uid barrier
that bathes the exposed cornea. It contains antibacterial
agents, oxygenates the corneal epithelium, maintains a
smooth refractive surface, and provides lubrication for
Fig. 7.1 Clinical appearance of a dry eye.

7 Complications of Upper Eyelid Blepharoplasty
51
sonable expectations of the outcome. One of the most
common errors in preoperative planning is not taking
into account the patient’s ethnicity. The surgeon must
respect the patient’s desires for maintaining ethnic
traits in the appearance of the upper eyelid
Patients are often unaware of asymmetries in their
eyelids, and taking standard preoperative blepharoplas-
ty photographs is an important practice. These photo-
graphs are reviewed with the patient to demonstrate the
small degrees of asymmetry between the upper eyelids.
The most important landmark in upper eyelid blepha-
roplasty is the upper lid crease. When inherent asym-
metry exists, attempts to create symmetry between the
upper eyelid creases may change the shape and over-
all appearance of the eyes. It is imperative to identify
asymmetries and discuss them with the patient preop-
eratively to avoid a situation where the patient believes
the preexisting condition was caused by the surgery.20
Preexisting Upper Eyelid Ptosis
Patients seeking blepharoplasty are often unaware of
preexisting upper eyelid ptosis. Blepharoptosis is clas-
sifi ed by the extent of superior limbus coverage by the
lid margin. It is defi ned as mild (2 mm or less), moderate
(2–4 mm), or severe (4 mm or more).21 Beard classifi ed
acquired ptosis by etiology into neurogenic, myogenic,
traumatic, and mechanical categories.22 The levator apo-
neurosis, which normally inserts on the anterior tarsal
surface, can become disinserted or dehiscent. Eyelid
trauma, ocular surgery, recurrent lid edema of any etiol-
ogy (i.e., allergic, infl ammatory), and idiopathic atrophy
of the levator aponeurosis may all lead to upper eyelid
ptosis. In the elderly population, acquired ptosis is most
often due to senile atrophy of the levator aponeurosis,
which is often accompanied by varying amounts of der-
matochalasis. Excess skin exaggerates the degree of pto-
sis and leads the patient to seek surgical correction.
In evaluating a patient with eyelid ptosis, the surgeon
should inquire about a history of eyelid trauma, recur-
rent lid edema or infl ammation, previous eyelid surgery,
or congenital ptosis. The surgeon must also document
the onset, duration, and progression of the ptosis. Re-
viewing old photos of the patient can be useful to illus-
trate the progress of ptosis. The position of the eyelid
relative to the superior limbus in primary gaze should
be noted. The superior eyelid margin is normally po-
sitioned 1 mm below the superior limbus. If the eyelid
falls below this level, the upper eyelid is ptotic.23 The de-
gree of levator aponeurosis function can be documented
with a millimeter ruler in front of the eye. Using one or
two fi ngers of pressure over the brow to prevent use of
the frontalis muscle, the patient is asked to look down
and then upward. The amount of excursion of the eyelid
margin is due to levator function. Movement of 4 mm
Hypothyroidism
Hypothyroidism causes soft-tissue changes throughout
the body, including the periorbital soft tissues. In one
study, 2.6% of patients seeking a consultation for bleph-
aroplasty were found to have undiagnosed hypothyroid-
ism.16 These patients will attribute the skin changes of
their eyelids to aging and excessive fatigue. When ex-
amined, they will have characteristic skin laxity and
periorbital edema leading to a puff y appearance. Swell-
ing of the periorbital tissues is due to local deposition
of mucopolysaccharides. These patients should undergo
further evaluation, because the orbital changes general-
ly resolve with adequate treatment of the hypothyroid-
ism.17 Although iodine defi ciency is the most common
cause of hypothyroidism worldwide, Hashimoto’s thy-
roiditis, which is caused by anti-thyroid peroxidase
(anti-TPO) antibodies, is the most common cause in the
United States. If patients suspected of having hypothy-
roidism have an elevated TSH level on initial screening, a
total serum T4 should then be evaluated. Once the diag-
nosis is made, the patient’s primary care physician may
institute treatment.
Lacrimal Gland Prolapse
Occasionally, prolapse of the lacrimal gland is encoun-
tered on initial examination. This must not be mistaken
for fat prolapse and should be evaluated to exclude a
malignant, infl ammatory, or thyroid hormone-related
pathology of the lacrimal gland. Patients with undi-
agnosed lacrimal gland lymphoma, adenocarcinoma,
and metastatic cancer have all presented requesting
cosmetic eyelid surgery. The lacrimal gland lies in the
superotemporal quadrant of the orbit and is separated
into the orbital and palpebral lobes. These lobes are
divided by the lateral horn of the levator aponeuro-
sis, through which run the lacrimal ductules. Lacrimal
gland prolapse can be diagnosed by everting the upper
eyelid and asking the patient to look down. This will ac-
centuate prolapse of the palpebral portion of the lacri-
mal gland. Comparison between sides and during globe
ballottement should also be performed. Repositioning
of the lacrimal gland, if necessary, may be performed
to elicit a satisfying cosmetic result in upper blepha-
roplasty. Suturing techniques as well as removal of the
orbital fat that surrounds the lacrimal gland have been
described.18,19
Surgical Planning
Poor postoperative results can often be attributed to
poor preoperative surgical planning. It is important for
both the patient and the surgeon to reach a congruent
understanding of the goals for surgery and to share rea-

Complications in Facial Plastic Surgery
52
sual acuity preoperatively, because patients are often
unaware of poor vision in one eye. If they fi rst notice
decreased vision postoperatively, they may attribute
this inappropriately to the surgical procedure. For this
reason, before the operation the surgeon should test the
patient’s vision, then discuss and document any visual
acuity issues with the patient.

◆Intraoperative Complications
Corneal Abrasion
Corneal abrasion commonly occurs following blepha-
roplasty, though its true incidence is unknown. Corneal
eye shields off er excellent protection against unforeseen
events and accidents. If they are used, eye shields must
be generously lubricated on the concave surface with a
petrolatum-based agent to minimize the risk of abra-
sion. During surgery, cotton-tipped applicators should
be used instead of gauze sponges to avoid inadvertent
injury to the cornea. Only the surgeon or the assistant
should instrument around the surgical fi eld, and extra-
neous movements should be minimized.
Throughout the procedure and at its end, balanced
saline solution should be used frequently to wash out
bits of suture and other debris.29 The fi rst complaint of
patients who have sustained a corneal abrasion is eye
pain. If an abrasion is suspected, it is prudent to obtain
an ophthalmologic consultation for a fl uorescein dye
and a slit lamp exam. Patients with poor Bell’s phenom-
enon are at risk for postoperative corneal abrasion in the
setting of a transient lagophthalmos. For such patients,
the use of eye drops and ointment, especially at night,
helps to avoid injury.
Chlorhexidine concentrations of 2% and 4% have
been shown to be toxic to corneal epithelium. In a rab-
bit study, MacRae et al. found that a single drop caused
sloughing of the entire corneal epithelium in three
hours.30 In contrast, povidine iodine solution (without
detergent) caused no de-epithelialization or increase in
corneal thickness compared to the saline control. Aff ect-
ed corneas returned to normal within one week. Should
accidental spillage into the eye occur, immediately irri-
gate the eye with balanced salt solution and consider an
ophthalmologic consultation.
Corneal Thermal Injury
Thermal injury to the cornea during cosmetic blepha-
roplasty from electrocautery has been reported.31 The
resultant contraction of stromal collagen can cause sig-
nifi cant astigmatism. Patients under general anesthesia
may sustain greater damage to the corneal epithelium
because of a lack of Bell’s phenomenon and other protec-
tive refl exes. Treatment of corneal thermal injury begins
with antimicrobial prophylaxis with broad-spectrum
or less is classifi ed as poor function, 6 mm is fair, and
8 mm is considered good levator function.24 In some
cases, preexisting ptosis may actually be exaggerated
by tightening of the eyelid skin.25 If upper eyelid ptosis
is asymmetric, the surgeon should consider Herring’s
phenomenon. Herring’s law states that there is equal
and symmetric innervation to the frontalis muscle. If
asymmetric ptosis is corrected, the stimulus to raise
the eyebrows via contraction of the frontalis muscle
decreases bilaterally, which then unmasks ptosis on the
less aff ected side.
Myasthenia gravis is an autoimmune phenomenon
mainly aff ecting young women that causes upper eye-
lid ptosis. Ptosis that gets worse as the day progresses is
the hallmark of this condition. While the Tensilon test
is the standard method for diagnosis, a simple method
of testing for myasthenia in the offi ce is to place a few
drops of phenylephrine in the eye. Immediate improve-
ment of the ptosis suggests the presence of underlying
myasthenia. This fi nding should prompt a referral to a
neurologist for further treatment and work-up.
A high upper eyelid crease suggests the most com-
mon cause of upper eyelid ptosis, levator aponeurosis
dehiscence. Levator aponeurosis dehiscence can have
several causes, including senile aging and intraoperative
stretching. It is important, therefore, for the surgeon to
be careful to avoid manipulation of an atrophic levator
aponeurosis.26 In patients with levator aponeurosis de-
hiscence, the eyelid crease must be marked inferior to
the existing crease and the ptosis repaired by advance-
ment of the levator aponeurosis in a superior direction.
The eyelid crease may then be reformed at the desired
level, taking small bites of the orbicularis muscle when
closing the skin.27
Orbital Tumors
Asymmetric swelling of the upper eyelids should prompt
further attention. Palpation of the upper eyelids may
quickly identify a lacrimal gland mass. As the previous
discussion indicated, potential tumors in this location
include glandular tumors, lymphomas, and metastatic
tumors from other sites. In addition, unilateral eyelid
edema can be the presenting symptom of retroorbital
tumors that impair lymphatic fl ow from the eyelid.
Preexisting Visual Complaints
A visual acuity examination is warranted in blepharo-
plasty patients with new visual obstructive complaints.
In those who wear prescription eyeglasses, the surgeon
should obtain recent documentation of visual acuity
from the patients’ ophthalmologist. In a national survey,
surgeons were asked what percentage of their blepha-
roplasty patients received an eye examination. Overall,
only 50% of the patients undergoing eyelid surgery had
an eye examination.28 It is important to document vi-

7 Complications of Upper Eyelid Blepharoplasty
53
blood pressure, which promotes continued bleeding
into the orbital space and increased pressure. Some
authors dispute this hypothesis, citing visual evoked
response data that is more consistent with optic nerve
injury rather than retinal ischemia.38,39 In the opposing
theory, pressure becomes great enough to occlude the
vasa nervorum of the optic nerve and cause permanent
visual impairment.
Retrobulbar hemorrhage generally occurs during the
fi rst few hours after surgery, but it has been reported
days after surgery.40 The characteristic fi ndings include
stone-hard proptosis, chemosis, mydriasis, increased in-
traocular pressure, and severe eye pain.35 Acute retrobul-
bar hemorrhage is common in ophthalmologic surgery
and occurs in perhaps 0.03–0.05% of all blepharoplas-
ties.41 The rate of blindness following blepharoplasty
surgery is probably underreported but is estimated to
be 0.04%.28 When loss of vision accompanies retrobul-
bar hemorrhage, it is almost always transient.37 In 2004,
members of the American Society of Ophthalmic Plastic
and Reconstructive Surgery were surveyed to ascertain
the incidence of postoperative retrobulbar hemorrhage
and blindness.41 Among 269,433 cosmetic eyelid cases,
there were 149 orbital hemorrhages (0.055%). Only 12 of
these (0.0045%) were associated with permanent visual
loss. Though visual loss is more likely to be a complica-
tion of lower eyelid blepharoplasty, there have also been
reports of blindness after upper blepharoplasty alone.39
Treatment of retrobulbar hemorrhage is generally
conservative and includes ice packs and monitoring of
the retinal circulation by an ophthalmologist.39 In these
cases, changes in visual acuity should determine the
course of action, not intraocular pressure alone. Uncom-
plicated cases may be managed by medications, which
include intravenous osmotic agents, acetazolamide,
and β-blocker eye drops. However, retrobulbar hema-
toma associated with visual changes requires aggressive
antibiotic drops and pain management using cyclople-
gic agents and analgesics. After re-epithelialization,
topical steroids are used to limit infl ammation and scar-
ring. If signifi cant astigmatism persists, some patients
may benefi t from corrective astigmatic keratotomy.
Transient Ophthalmoplegia/Mydriasis
Transient mydriasis and ophthalmoplegia is common
following blepharoplasty.32 This condition is caused by
the eff ects of local anesthetic on the short ciliary nerves
and the oculomotor nerve. As such, it is a benign, self-
limiting condition that must not be confused with the
mydriasis caused by retrobulbar hematoma (see below).
Recognition of the cause of these fi ndings prevents un-
necessary treatment.
In the patient with a shallow anterior chamber any
condition that causes pupillary dilation may precipi-
tate acute glaucoma.33 The stress of surgery plus the
sympathetic action of vasoconstrictive agents in local
anesthetics can lead to closure of the anterior chamber
drainage angle. In susceptible patients, this precipi-
tates acute glaucoma. Patients with elevated intraocular
pressure should undergo a slit lamp examination before
surgery. Acute angle closure glaucoma is successfully
treated with instillation of pilocarpine drops.

◆Immediate Postoperative Complications
Bleeding
Of all immediate postoperative complications, bleeding
is potentially the most devastating. There are numer-
ous causes of postoperative bleeding, including needle
injection trauma, rough handling of orbital fat, and pa-
tient-related factors, such as coagulopathies or Valsalva
maneuvers while coming out of anesthesia.34 Every pa-
tient will have some degree of periorbital ecchymosis
following upper lid blepharoplasty, so this should not
necessarily raise concern (Fig. 7.2). On the other hand,
retrobulbar bleeding is a feared complication that can
lead to one of the most devastating complications of
blepharoplasty: blindness. Retrobulbar bleeding can
lead to a compartment syndrome within the bony or-
bital boundaries. Though the exact mechanism is un-
known, two theories exist to explain this phenomenon.
One theory focuses on occlusion of the central retinal
artery, which can occur through the following sequence
of events.35–37 As retroorbital hemorrhage proceeds,
blood dissects into the orbital fat, muscles, and other
structures. Pressure then builds in the rigid confi nes
of the bony orbit. As intraorbital pressure reaches that
of the systolic blood pressure, bleeding from the con-
tributing artery halts. However, blood fl ow also ceases
in the central retinal artery. The body responds to in-
creased intraocular pressure by increasing the systolic
Fig. 7.2 Periorbital ecchymosis and edema are common after
upper eyelid blepharoplasty, as is demonstrated in this patient
two days after surgery.

Complications in Facial Plastic Surgery
54
edema and postoperative changes. Chemosis generally
resolves by fi ve months, and its resolution does not ap-
pear to be hastened by any specifi c treatment.46,47

◆Late Postoperative Complications
Infection
Like any procedure that penetrates the skin barrier, up-
per lid blepharoplasty carries with it a risk of infection,
albeit quite low. There have, however, been reports of
very serious infections stemming from cosmetic upper
blepharoplasty, and the surgeon should be cognizant of
them. Necrotizing fasciitis, a life-threatening soft-tissue
infection caused by group A α-hemolytic Streptococcus,
has been reported following blepharoplasty.48–50 Necro-
tizing fasciitis typically occurs in the setting of trauma,
immunosuppression, malnutrition, and other condi-
tions that cause poor wound healing.51 The characteris-
tic fi ndings are those of a tense dusky-gray eyelid with
violaceous bullae and necrosis across fascial planes.
Proper and rapid identifi cation of necrotizing fasciitis
is crucial, as immediate intravenous antibiotics and de-
bridement of necrotic tissue are essential to achieving
a positive outcome. Ancillary treatment modalities in-
clude hyperbaric oxygen therapy and intravenous gam-
ma globulin therapy.
Orbital abscess has also been reported following up-
per eyelid blepharoplasty.52 An orbital abscess will typi-
cally present on the fi fth to seventh postoperative day,
and Staphylococcus aureus is the most common bacte-
rium isolated. Typical fi ndings include lid infl ammation,
diplopia, and proptosis. Computed tomography or ultra-
sound can be useful in making the diagnosis. As in other
areas of the body, treatment includes surgical drainage
of the abscess cavity and administration of intravenous
antibiotics.
Visual Complaints/Astigmatism
The risk of astigmatism after eyelid surgery or from eye-
lid tumors such as hemangiomas has been well docu-
mented.53–55 Studies have indicated that astigmatism and
blurred vision may occur following upper eyelid blepha-
roplasty as well.56 Removal of skin repositions the eye-
lid and alters its relationship to the cornea. This in turn
leads to changes in corneal curvature, which may aff ect
the patient’s refraction. In one study, the average refrac-
tive error at one month and three months after surgery
was 0.62 diopters (D) and 0.45 D, respectively.56 This
study also revealed that one month after blepharoplasty
16% of patients showed astigmatic changes greater than
1.00 D. Surgeons should therefore inform patients that
changes in their refractive status may occur. However,
visual changes of less than 0.50 D are perceived only by
those whose activities require a higher standard of vi-
and immediate treatment. Frequent monitoring of vi-
sion establishes the necessity for a surgical procedure.
If there are any signs that vision has deteriorated, the
orbit should be surgically decompressed via lateral can-
thotomy and cantholysis, and the wound explored.40,42
Blepharoptosis
Eyelid ptosis is a relatively common complication of up-
per eyelid blepharoplasty, though it is rarely permanent.
There are several potential etiologies of this complica-
tion, including local anesthesia, postoperative edema,
direct injury, and levator-septal adhesion. Deep penetra-
tion of local anesthesia can cause blockade of the sym-
pathetic innervation of the levator superioris muscle.
This blockade produces a ptosis lasting an hour or two
after surgery, depending on the agent used. Postopera-
tive swelling, which causes a temporary ptosis, occurs in
nearly every patient undergoing upper eyelid blepharo-
plasty.43 The patients can be quite concerned about this
swelling, but they can be reassured that it will resolve
over the next several days. Cool compresses can help to
hasten the resolution of edema.
The levator aponeurosis can be injured directly dur-
ing surgery, resulting in blepharoptosis. This generally
occurs from inadvertent sharp dissection during skin-
muscle excision or during excision of orbital fat.44,45 At
the lower half of the skin-muscle excision, the levator is
merging with the septum and orbicularis muscle and is
more vulnerable to injury. To prevent injury at this loca-
tion, the surgeon should perform the septal excision su-
periorly, where the preaponeurotic fat pad is thick and
protects against direct levator injury.44 As well, pulling
on the upper lid orbital fat pulls the aponeurosis into
the wound, where it is vulnerable to surgical damage.
Gentle ballottement of the globe with careful and con-
servative fat excision will help to prevent injury to the
levator complex.
Ptosis may also occur if the orbital septum is inadver-
tently sutured to the levator apparatus during closure.45
This will occur only if the orbital septum is attached to
the levator superior to the original insertion of the sep-
tum. In eff ect, this causes a reduction of the mechanical
advantage of the levator, resulting in ptosis.
Chemosis
Chemosis is common in the immediate postoperative
period following upper lid blepharoplasty. It is seldom
of concern to the patient, but in rare cases it can persist
for several weeks. The cause of chemosis following cos-
metic upper eyelid blepharoplasty is unknown. Eyelid
lymph vessels consist of a superfi cial system that drains
the skin of the lids and the orbicularis oculi muscle, along
with a deep system that drains the tarsal and conjuncti-
val region. Chemosis is probably caused by interruption
or compression of lymphatic outfl ow secondary to local

7 Complications of Upper Eyelid Blepharoplasty
55
persistent, they may be easily treated by unroofi ng the
thin epithelium with a #11 blade scalpel tip or a fi ne
needle.29
Other incisional complications include dyspigmented
scars, hypertrophic scars, or visible suture tracks (Figs.
7.4, 7.5). These can be diffi cult to predict and to man-
age once present. Strict adherence to meticulous suture
technique (wound edge apposition, not constriction)
and timely suture removal (fi ve to six days) can help
limit these issues. Silicone sheeting can be used with-
out problems on the upper eyelids, but the use of topical
steroids and hydroquinone is not advisable.

◆Conclusion
If the surgeon performs a careful analysis of the pro-
spective upper blepharoplasty patient and responsibly
discusses postoperative expectations, it can prevent
many complications. In addtion, careful technique with
a mastery of eyelid surgical anatomy will help to prevent
complications during the procedure. In the postopera-
tive setting, prevention or treatment of infections and
anticipation of the vagaries of healing maximize patient
satisfaction with upper eyelid blepharoplasty. A properly
performed blepharoplasty is a satisfying procedure that
results in a very high percentage of grateful patients.
sual acuity. These patients should know that they may
require a change in their lens prescription to account for
refractive change after blepharoplasty.
Lagophthalmos
A small degree of scleral show, especially during sleep,
is an expected outcome in the acute postoperative set-
ting following blepharoplasty. Scleral show is often ac-
centuated by concurrent brow lift, but it will gradually
improve over the fi rst few postoperative weeks. Lag-
ophthalmos occurs when scleral show persists longer
than two to three weeks. Upper eyelid lagophthalmos is
caused by excessive skin removal or by fi brosis of the or-
bital septum. Patients who develop lagophthalmos com-
plain of eye pain and fl uctuating vision, which results
from corneal exposure and keratopathy. Corneal infec-
tions can develop, and the patient may even experience
permanent vision loss.57,58
Full-thickness upper eyelid skin grafting may be used
to replace insuffi cient skin, and often it is the only cure
for a shortened upper eyelid anterior lamella. Skin graft-
ing is the only surgical procedure that directly addresses
earlier excessive removal of skin.58
Eyelid Skin Abnormalities
Epicanthal folds can occur if the line of skin excision in
the nasal portion of the upper lid is carried too far into
the thicker skin of the nasal sidewall near the canthal
angle. The resulting contracture of the scar creates a
tight band across the canthus that can be quite conspic-
uous postoperatively. In mild cases, massage and time
may resolve the epicanthal fold formation. A V-to-Y re-
laxation incision can be performed to restore the con-
tour of the upper lid crease and medial canthal region.
Lateral epicanthal folds can also occur if the incision is
carried past the level of the lateral canthus. Separating
the upper and lower blepharoplasty incisions by at least
5 mm will help to prevent this complication.59
Hypesthesia occurs in most patients following bleph-
aroplasty, but it is seldom a complaint in the postop-
erative period. Recovery of eyelid sensation occurs over
two to six months, although in rare cases this change is
permanent.60
Milia
Milia are epidermal inclusion cysts that result from the
entrapment of glandular ducts or epithelial debris in
the operative wound (Fig. 7.3). The formation of milia
along the fresh scar is frequently seen in the upper eye-
lid, and less frequently in the lower lid. The rate of milia
formation is approximately 2% with wound closure us-
ing either a permanent subcuticular or fast-absorbing
gut skin suture.61 Milia often resolve spontaneously, so
they do not require immediate treatment. However, if
Fig. 7.3 Milia result from entrapment of epithelial tissue in
the wound closure.
Fig. 7.4 Hypertrophic upper blepharoplasty scar.

Complications in Facial Plastic Surgery
56
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PEARLS OF WISDOM
Complications in upper eyelid blepharoplasty can occur in all
phases of patient care: preoperatively, intraoperatively and
postoperatively.
Patients undergoing blepharoplasty should halt all herbal
medications 10 days before the procedure because they
increase the risk of bleeding complications.
Brow ptosis commonly occurs concomitantly with upper eyelid
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Nose Throat J 1986;65(1):6–18
30. MacRae SM, Brown B, Edelhauser HF. The corneal toxic-
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31. Chou B, Boxer Wachler BS. Astigmatism after corneal thermal
injury. J Cataract Refract Surg 2001;27(5):784–786
32. Perlman JP, Conn H. Transient internal ophthalmoplegia dur-
ing blepharoplasty. A report of three cases. Ophthal Plast Re-
constr Surg 1991;7(2):141–143
33. Gayton JL, Ledford JK. Angle closure glaucoma following a
combined blepharoplasty and ectropion repair. Ophthal Plast
Reconstr Surg 1992;8(3):176–177
34. Mahaff ey PJ, Wallace AF. Blindness following cosmetic blepha-
roplasty—a review. Br J Plast Surg 1986;39(2):213–221
35. Hartley JH Jr, Lester JC, Schatten WE. Acute retrobulbar hemor-
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36. Kelly PW, May DR. Central retinal artery occlusion follow-
ing cosmetic blepharoplasty. Br J Ophthalmol 1980;64(12):
918–922
37. Moser MH, DiPirro E, McCoy FJ. Sudden blindness following
blepharoplasty. Report of seven cases. Plast Reconstr Surg
1973;51(4):364–370
38. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness
following blepharoplasty: two case reports, and a discussion
of management. Ophthalmic Surg 1990;21(2):85–89
39. Heinze JB, Hueston JT. Blindness after blepharoplasty: mech-
anism and early reversal. Plast Reconstr Surg 1978;61(3):
347–354
40. Cruz AA, Andó A, Monteiro CA, Elias J Jr. Delayed retrobulbar
hematoma after blepharoplasty. Ophthal Plast Reconstr Surg
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41. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Inci-
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426–432

58
Complications are an inevitable part of surgery, and eye-
lid surgery is no exception. Despite the best eff orts during
preparation, events may not unfold as planned, and un-
anticipated complications unavoidably occur. A thorough
knowledge of potential complications in order of likeli-
hood and importance is paramount for achieving the best
possible outcome, not simply to minimize the occurrence
of these events but also to provide the best evaluation
and management of such events should they arise.
A meticulous preoperative evaluation is important,
including an appropriate ocular examination and an as-
sessment of the patient’s expectations. The practitioner
should assess and document any factors that may aff ect
surgical outcome, such as previous surgery, orbicularis
and facial nerve function, lagophthalmos, tear fi lm in-
stability, prominent eye confi guration, and preexisting
chemosis or edema. If possible, the use of anticoagula-
tion should be discontinued to decrease the risk of in-
traoperative and postoperative bleeding.

◆Diplopia
Diplopia after blepharoplasty may be a consequence of
edema, and it often resolves with time.1 Diplopia may
also occur from extraocular muscle injury from anes-
thesia, intramuscular hemorrhage and edema, and cica-
tricial changes within the muscle or adjacent connective
tissues.1–3 Management of postblepharoplasty diplopia
should be conservative, with the use of corticosteroids
as appropriate. In rare cases the diplopia may be perma-
nent and require muscle surgery to reduce the symp-
toms of double vision.

◆Hematoma
Postoperative hemorrhage can occur with blepharo-
plasty, with sequelae ranging from annoyance to loss
of vision. The bleeding is most often from the vessels
associated with the orbicularis.4 Only in rares cases are
the deep orbital vessels the source of postoperative
bleeding.

◆Superfi cial Hematoma
Following cutaneous lower blepharoplasty, bleeding can
lift the fl ap from the underlying septum and orbital fat.
This presents as a superfi cial hemorrhage or organized
hematoma. It can be diff erentiated from orbital hem-
orrhage by the absence of proptosis, decreased extra-
ocular motility, bloody chemosis, and deep orbital pain.
Hemorrhage below the skin fl ap results in increased
postoperative infl ammation. If there is substantial in-
fl ammation in the plane of the orbicularis and orbital
septum, the risk of postoperative fi brosis and of eyelid
retraction is increased.
Treatment of superfi cial hematoma is primarily con-
servative. The use of orticosteroids should be consid-
ered to break the cycle of infl ammation and decrease
the risk of lower eyelid retraction. After fi ve to seven
days, eyelid massage with lower eyelid stretch elevation
can be employed, and for early chemosis with lower
eyelid retraction in the fi rst week, temporary tarsor-
rhaphy with eyelid suspension sutures to the eyebrow
should be considered.
A substantial localized hematoma that is organizing
should be drained, consistent with surgical principles of
any facial fl ap surgery (Fig. 8.1).

◆ Deep Orbital Hemorrhage and
Vision Loss
The deep orbital hemorrhage is the most worrisome
postoperative complication of blepharoplasty: arterial
pressure can build up in the closed compartment of
8
Complications of
Lower Eyelid Blepharoplasty
Robert A. Goldberg

8 Complications of Lower Eyelid Blepharoplasty
59

◆Dry Eye and Chemosis
Dry eye symptoms are common after blepharoplasty,
and chemosis occurs in a signifi cant percentage of pa-
tients with dry eye after blepharoplasty.6–8 Risk factors
include previous history of dry eye or ocular surface
disorders, previous LASIK refractive surgery, and me-
chanical factors predisposing the patient to poor blink
function (prominent eye, lower eyelid laxity, orbicular-
is weakness, neurologic or myogenic conditions aff ect-
ing blinking or eye movements, or Graves’ orbitopathy).
In this setting, the term dry eye is a misnomer, because
these patients usually have adequate tear production.
In fact, their eyes are often wet or tearing because of
refl ex tear production in response to irritation. The
mechanism of surface irritation and dry eye symptoms
following blepharoplasty relates to dysfunction of the
tear-spreading or “windshield wiper” function of the
eyelid. Loss of the squeegee eff ect of the normal blink
leads to disruption of the smooth tear fi lm, abnor-
mal evaporation of tears, symptoms of blurred vision
(related to loss of the smooth tear fi lm surface), and
foreign body sensation or burning pain. The resulting
infl ammation, potentially combined with generalized
postoperative swelling, leads to conjunctival swelling
or chemosis. When the conjunctiva becomes chemotic,
it creates an additional mechanical impediment to the
ability of the eyelid to create a smooth tear fi lm. A vi-
cious cycle of increasing chemosis can occur, leading
to mechanical disruption and drying out of the ocular
surface (Fig. 8.2).
the orbit.5 If the orbital pressure rises above the capil-
lary fi lling pressure of the posterior ciliary arteries (or
less likely, the central retinal artery), there is potential
for ischemia of the optic nerve and retina, which can
lead to loss of vision. Treatment of orbital hemorrhage
is emergent. Permanent ischemic damage can occur in
90 minutes or perhaps even less. The symptoms of or-
bital hemorrhage include severe deep orbital pressure,
pain, and nausea; fi rm orbit with proptosis; limitation
of extraocular movement; hemorrhagic chemosis; and
decreased or lost vision with unresponsive pupils (af-
ferent pupillary defect). When orbital hemorrhage is
causing ischemic optic or retinal changes, urgent treat-
ment to decrease the orbital pressure and restore cap-
illary perfusion is required. Opening the wound and
releasing any clots is the fi rst-line treatment and is al-
most always eff ective; it may be necessary to spread
gently within the orbital tissues to release any locu-
lated hemorrhage. Lateral cantholysis with complete
release of the lateral canthal tendon is the next step
in the ladder of treatment. In rare cases, bony orbit-
al decompression could be considered. Pericentesis
(removing fl uid from the anterior chamber) should
be considered only as a last resort. Pain and anxiety
should be treated. Hypertension should be treated, al-
though an abrupt severe reduction in blood pressure
could theoretically compromise arterial fi lling pres-
sure. Medical treatment of the orbital pressure, includ-
ing steroids, osmotics such as mannitol, and diuretics
such as acetazolamide, can be started, but their use
should not delay the implementation of surgical reduc-
tion of orbital pressure. Because of the importance of
early treatment, both the patient and the staff should
understand the signifi cance and urgency of the symp-
toms of orbital hemorrhage.
Fig. 8.1 A superfi cial hematoma usually resolves spontane-
ously, but an organized hematoma should be drained. Used
with permission from Regents of the University of California,
Copyright 2009.
Fig. 8.2 Conjunctival chemosis relates to general edema and
also to abnormal eyelid tone with failure of mechanical pro-
tection. Used with permission from Regents of the University
of California, Copyright 2009.

Complications in Facial Plastic Surgery
60

◆Lower Eyelid Retraction
Lower eyelid retraction following blepharoplasty is a
diffi cult problem. I am not aware of good data to assess
the incidence of this complication accurately, but cer-
tainly it is the most frequent postsurgical referral in an
urban ophthalmic plastic surgery practice: I see three to
fi ve new patients every week for consultation regarding
management of eyelid malposition, contour problems,
or ocular surface problems after blepharoplasty or mid-
face surgery. These patients may be angry, frustrated, or
despondent; in my experience, eyelid complications are
a particularly diffi cult type of aesthetic surgery compli-
cation, because they not only change the appearance
of the critically important periorbital aesthetic unit of
the face but also create ophthalmic symptoms that can
range from annoying to vision threatening.
In approachs to the patient with lower eyelid retrac-
tion after blepharoplasty, accurate diagnosis is the
prelude to appropriate treatment. Every case must be
individualized. The unique anatomy and physiology of
every case will dictate a treatment plan that may draw
from a wide spectrum of medical and surgical treat-
ment options. There are many variations, but I suggest
that the etiology of lower eyelid retraction following
blepharoplasty can be divided into seven main catego-
ries, each of which should be assessed when the patient
is evaluated:
1. Orbicularis paralysis
2. Anterior lamellar tightness
3. Middle lamellar tightness
4. Volume collapse
5. Relationship of the globe to its bony support
6. Horizontal laxity
7. Psychological stability and realistic expectations
In this section, I will review each of these mechanisms
with particular attention to diagnosis and management.
In managing the individual patient, the practitioner
should assess the contribution of each of the various
factors and then design an individualized treatment
plan that treats each factor in proportion to its partici-
pation in the problem.
Orbicularis Paralysis
The physiology of the orbicularis oculi is one of Nature’s
wonders. Acting on the supple, independently function-
ing eyelid lamella, the delicate concentric rings of the
orbicularis provide the blink refl ex that spreads the cor-
neal tear fi lm to allow clear vision, drive the tear pump
that drains tears out of the eye into the nasal lacrimal
outfl ow system, and provide static tonic support for the
lower eyelid. Although there is typically a fair amount
of reserve strength, subtle weaknesses the orbicularis
oculi can substantially aff ect eyelid position and func-
Treatment of dry eye after blepharoplasty is ac-
complished in stepladder fashion. Prevention is im-
portant: appropriate lubrication of the ocular surface
during and immediately after surgery is critical. Cor-
neal shields protect the cornea from inadvertent in-
jury, and their use is reasonable. However, because
the shields can also irritate the cornea, some sur-
geons prefer to avoid their use. Protective shields
should be used with copious lubrication. Neither
soap nor betacaine should collect under the shield,
and care should be taken to avoid inadvertently leav-
ing the shield in after surgery. If dry eye develops,
the first step in treatment is lubrication of the ocular
surface with artificial teardrops and nocturnal oint-
ment. Steroid eyedrops and ointments may provide
some therapeutic anti-inflammatory effect, and oral
steroids should be considered. (Be alert to the pos-
sibility of an allergic reaction to topical eye drops or
ointments, which can exacerbate the inflammation
and confound the diagnosis.) Humidifiers or plastic
wrap dressings can be used at bedtime to maintain
a moist ocular surface. More severe cases might re-
quire closing the eyelids, for example with a carefully
applied patch or suture tarsorrhaphy.

◆Wound Granulomata
The diff erential diagnosis of wound granulomata in-
cludes foreign body (including sutures), ointment
granuloma related to the oily vehicle retained inside
the tissues, and atypical infection (including myco-
bacteria).8,9 Postoperative granulomata can be initial-
ly managed conservatively, for example with steroids
or 5-FU injections, but persistent or atypical granulo-
mata should be cultured for mycobacteria (Fig. 8.3).
Fig. 8.3 Eyelid granulomas appearing two weeks after blepha-
roplasty surgery; I&D with culture revealed atypical mycobac-
teria. (Used with permission from Regents of the University of
California, Copyright 2009.)

8 Complications of Lower Eyelid Blepharoplasty
61
persistent orbicularis weakness, static horizontal slings
and upper eyelid gold weights can sometimes be useful,
but frankly no treatment is great or long lasting. Perhaps
most importantly, if signifi cant orbicularis paralysis is
recognized, any further surgical interventions must be
meticulously constructed to avoid further weakening of
the muscle or interruption of the nerve supply.
Volume Collapse
In traditional blepharoplasty, skin, muscle, and fat are
removed in various combinations. In the case of puff y or
full eyelids, this can improve the patient’s appearance.
However, volume in the eyelid is important aesthetically
and functionally, and volume collapse can not only cre-
ate the aesthetic problem of a hollow, surgical appear-
ing eyelid but also lead to functional problems.
If we remember the answer to the brain teaser that
involves letting air out of the tires of the truck so that it
could fi t beneath the overpass, we will understand the
role that a full infl ated lower eyelid has in supporting
the lower eyelid margin. Defl ation of the eyelid, just like
defl ation of the truck tire, leads to lowering of the eyelid
margin.
Volume of the eyelid aff ects function in another way.
The eyelid is composed of multiple delicate lamellae
that need to slide against each other and function in-
dependently for proper eyelid mechanics. When fat is
removed, this buff er function can be lost, so that the
eyelid lamellae no longer function independently. In the
upper eyelid, this can lead to tethered ptosis or lagoph-
tion, especially in the face of postsurgical tightness or
unfavorable globe to bony orbit relationship. I often note
subtle or occasionally substantial orbicularis weakness
in patients after blepharoplasty eyelid retraction. I be-
lieve that the orbicularis can be easily denervated by
eyelid or midface procedures that cut across the lateral
innervation. This is particularly true in patients who re-
ceive multiple operations: I presume that each surgical
insult causes temporary weakness, with return of func-
tion in the months following surgery, but there would
also be some degree of permanent loss of function that
can accumulate with multiple operations.
Orbicularis paralysis is diagnosed by careful study
of eyelid closure. Advanced paralysis is easily identi-
fi ed (but, in my experience, often overlooked). When
the patient forcefully closes the eyelids, the examiner
notes failure of the orbicularis muscle to bunch up, and
the eyelid is easily distracted away from the globe by
the examiner’s fi nger (Fig. 8.4). More subtle orbicularis
weakness can be identifi ed by careful observation and
palpation of the eyelid margin during forced closure.
Sometimes the eyelid will evert on forced closure (Fig.
8.5). This type of “fi sh mouthing” is more common if
there is some degree of coexisting horizontal laxity.
There is no great treatment for orbicularis paralysis.
Fortunately, in a postsurgical setting the muscle func-
tion tends to regenerate, but this process can take many
months. Therefore, in cases of orbicularis paralysis, time
is on the patient’s side, and often a conservative ap-
proach will reward the surgeon and patient with sponta-
neous improvement as the muscle function returns. For
Fig. 8.4 Orbicularis weakness: The eyelid is easily distracted
from the globe during attempted closure. Used with permis-
sion from Regents of the University of California, Copyright
2009.
Fig. 8.5 Orbicularis weakness: The upper eyelid margin spon-
taneously everts during forced closure, suggesting weakness
of the pretarsal orbicularis combined with static horizontal
laxity. Used with permission from Regents of the University of
California, Copyright 2009.

Complications in Facial Plastic Surgery
62
thalmos. In the lower eyelid, it can lead to retraction and
lagophthalmos, related to loss of excursion of the eyelid
relative to the orbital rim and lower eyelid retractors.
Volume collapse is recognized clinically by noting a
hollow or long eyelid (Fig. 8.6). By digitally elevating the
lower eyelid, the examiner can sometimes sense the col-
lapse of the various eyelid lamellae, so that the eyelid is
rigid (cardboard eyelid). In the extreme situation, vol-
ume collapse is indistinguishable from shortening of the
anterior and posterior lamellae, with the full-thickness
eyelid plastered down to the orbital rim.
Treatment of volume collapse is diffi cult because we
do not have technology to recreate the delicate lamellar
layers of the eyelid. However, tissue grafts, carefully and
delicately inserted, can sometimes allow improvement.
Injected fat is diffi cult to use eff ectively in my experi-
ence; I have had better success using small pearls of free
fat, placed in the plane of the lower eyelid retractors with
minimal incisions (Fig. 8.7A–D). An alternative to sur-
gery is the use of injectable synthetic fi llers, such as hy-
aluronic acid gel. Although these are temporary, they can
produce improvement of the eyelid hollowing that can
last six months or more, the procedure is repeatable, and
patients are often receptive to the idea of minimally inva-
sive procedures that can be repeated over time (Fig. 8.6).
Fig. 8.6 Top: Volume collapse of the lower eyelid, recognized as
a long eyelid with orbital hollowing. Bottom: Following hyaluron-
ic acid gel fi lling of the retractor plane, improvement in eyelid
support and volume is demonstrated. Used with permission
from Regents of the University of California, Copyright 2009.
Horizontal Laxity
In the older patient population, horizontal eyelid laxity
can play a role in lower eyelid retraction (Fig. 8.8). The di-
agnosis is straightforward: the snap test (distracting the
eyelid from the globe and noting the rapidity with which
it snaps back into position) and the distraction test (grasp-
ing the eyelashes and pulling the eyelid away from the
globe) identifying abnormally lax eyelids. The normal eye-
lid should snap back, without blink, in a few seconds, and
should not distract from the globe more than 5 to 7 mm.
If horizontal eyelid laxity is the primary cause of
lower eyelid retraction, then horizontal eyelid shorten-
ing by tightening the lateral canthus should be curative.
Unfortunately, after the patient has had blepharoplasty,
it is rare in my experience that horizontal laxity is the
primary culprit. Instead, vertical inadequacy, volume
collapse, and orbicularis paralysis are usually contribut-
ing factors. For that reason, horizontal shortening alone
typically provides only partial or minimal improvement
and can even make things worse if the surgery further
damages the function of the orbicularis. Tightening the
“clothesline” when there are lots of clothes hanging on it
will predictably fail: the lateral canthal tendon will not
heal under excessive surgical tension, and the vertical
forces will win the war (Fig. 8.9).
To help provide additional elevating power to the
horizontal shortening, some surgeons place the canthal
angle superiorly on the lateral orbital rim. There is some
virtue to the physics of this, because the artifi cially ele-
vated canthal tendon will drag the lower eyelid upward,
reducing scleral show inferiorly. However, the resulting
canthal dystopia is not only functionally suboptimal for
the upper and lower eyelid function but distressingly
disfi guring to the sophisticated patient, especially if it is
asymmetric (Fig. 8.10).
If canthoplasty is to be performed, it should be conser-
vative (over-tightening simply creates a wound under ten-
sion that will not heal properly) and should spare tissue
(removing the tarsus leads in the long run to phimosis;
Fig. 8.11). The approach should be designed to minimize
extensive cutting across the orbicularis and its nerve sup-
ply: often there is already some orbicularis paralysis that
reduces the available reserve function, and even subtle
additional loss of orbicularis function can be signifi cant. I
most often use an upper eyelid crease incision, which al-
lows access to the common tendon at the lateral rim; the
retinaculum can be released as needed, and the cut end
of the tendon can be re-attached to the arcus marginalis
using sutures placed directly into the tendon, through the
gray line with a double-armed suture (Fig. 8.12).
Anterior Lamellar Shortening
The lower eyelid anterior lamella consists of the skin
and the orbicularis. Vertical inadequacy of the ante-
rior lamella can be diagnosed with the forced upward

8 Complications of Lower Eyelid Blepharoplasty
63
Fig. 8.7 (A–D) After en-glove lysis of the contracted middle lamellar scar, a dermis strip or pearl fat grafts are placed across the
plane of the lower retractors, and the eyelid sutured to the eyebrow on stretch for seven to ten days. Used with permission from
Regents of the University of California, Copyright 2009.
Fig. 8.8 The normal eyelid is like a clothesline with few
clothes. Used with permission from Regents of the University
of California, Copyright 2009.
Fig. 8.9 The tight postoperative eyelid has active vertical force,
like a clothesline with many clothes. Used with permission from
Regents of the University of California, Copyright 2009.
A
B
C
D

Complications in Facial Plastic Surgery
64
phimosis is destined to fail if the tissues are tight and
the wound is being closed under tension.
Treatment of anterior lamellar vertical inadequacy
traditionally involves skin grafting. Skin grafting is not
ideal in the aesthetic patient after blepharoplasty: al-
though the skin graft, with luck, can heal fairly well, it
is rarely invisible. Importantly, when there is some or-
bicularis paralysis, the skin graft can further decrease
the function of the orbicularis, both because the muscle
must be exposed and manipulated to place the graft,
and also because the graft itself will always be stiff er
than the original supple skin that it replaces, decreasing
the eff ective functioning of the orbicularis.
Supplying anterior lamella by elevating the midface is
the preferred technique for addressing anterior lamellar
inadequacy in a patient after blepharoplasty. Numerous
approaches have been described; I prefer the subperios-
teal approach, using incisions that minimize additional
trauma to the orbicularis (such as the temporal endo-
scopic approach) (Fig. 8.14). Unfortunately, severe sun
damage with tissue laxity, atonicity related to the zygo-
matic nerve damage, or a bony disadvantage related to
relatively small maxilla are factors that will decrease the
success and longevity of midface lifting. The anticipa-
tion that repeat procedures might be necessary should
be additional stimulus to the surgeon to identify mini-
mally invasive approaches.
Middle Lamellar Shortening
Vertical inadequacy of the middle lamella, like anterior
lamellar shortening, is diagnosed by the forced upward
traction test: if the eyelid does not come up when ante-
rior lamella is supplied, then a middle lamellar tether
is present. Middle lamellar tethering occurs when the
orbital septum is shortened, and it is strongly infl u-
enced by volume collapse, with loss of the orbital fat
traction test. The examiner digitally elevates the eyelid;
normally, it should not take much force to lift the lower
eyelid to the superior corneal limbus. If resistance is en-
countered, then the next step is to determine whether
the vertical inadequacy is in the anterior lamella or in
the middle lamella. By supplying cheek tissue, either by
manually elevating the cheek or by asking the patient
to smile and allowing the patient’s orbicularis to do the
work, the examiner can repeat the test can determine
if the result normalizes (suggesting an anterior lamellar
problem) or if the eyelid is still tethered (suggesting a
middle lamellar tightness).
Rounding of the lateral canthal angle is often evidence
of anterior lamellar inadequacy, with an inferolateral
vector (Fig. 8.13). Tightening the canthus against an ac-
tive cicatrix in an eff ort to improve the rounding and
Fig. 8.10 Canthal dystopia with unnatural superior displace-
ment to the right more than the left side, following cantho-
plasty with vertical placement. Used with permission from
Regents of the University of California, Copyright 2009.
Fig. 8.11 Horizontal phimosis right side, following multiple
canthoplasties with tarsal removal. Phimosis relates to inad-
equate lateral tarsus, so that no amount of lateral tightening
will open the canthal angle. This patient also demonstrates
segmental orbicularis paralysis. Used with permission from
Regents of the University of California, Copyright 2009.
Fig. 8.12 Confi guration of lateral canthal reattachment
performed through a small upper eyelid crease incision, using
a suture externalized through a stab incision in the gray line of
the eyelid margin. Used with permission from Regents of the
University of California, Copyright 2009.

8 Complications of Lower Eyelid Blepharoplasty
65
buff er between the septum, retractors, and orbital rim.
Therefore, cutting through the septum and removing or-
bital fat, as performed in the standard transcutaneous
blepharoplasty, is a common mechanism for production
of middle lamellar tether.
It is very rare for the actual posterior lamella or con-
junctiva to play a role in vertical inadequacy. The con-
junctiva is quite redundant as it sweeps across the
inferior fornix and onto the bulbar surface. Therefore,
procedures that lengthen the posterior lamella, such as
mucosal or hard palate grafts, will not by themselves
address middle lamellar tether. Instead, the middle la-
mellar scar tissue has to be released (preferably with
as little collateral damage as possible) and then both
the anatomy and the biology of the situation optimal-
ly arranged to reduce the risk of further scar forma-
tion. Spacer grafts, such as hard palate mucosa or ear
cartilage, may vertically stent the eyelid and decrease
the early tendency for the scar to recur, but I have seen
many cases in which these grafts enmeshed in recurrent
scar tissue, with no improvement in retraction. Adding a
volume buff er such as cheek fat or free fat may improve
the situation by reinfl ating the eyelid and providing a
buff er between the tissue planes. Unfortunately, despite
nonspecifi c anti-infl ammatories such as steroids, or
anti-metabolites such as 5-FU or mitomycin C, we have
no uniformly predictable tools to aff ect the biology of
wound healing. In diffi cult cases that receive multiple
operations, the biologic tendency for scar tissue to recur
is what defeats us.
Relationship of the Globe to Its Bony Support
The mechanics of the lower eyelid are dependent on the
relationship of the globe to its bony support. When the
inferior-lateral orbital rim is relatively posterior to the
cornea, for example related to development (congenital
prominent eye), proptosis (for example Graves orbitopa-
thy) or aging, then the lower eyelid is at a mechanical
disadvantage to cover the cornea. These patients of-
ten demonstrate inferior scleral show even before any
blepharoplasty is performed. The youthful eyelid that
has not been operated on has enough reserve vertical
elasticity and orbicularis support to protect the cornea
and provide a tear pump even when the globe is rela-
tively prominent. However, when disadvantaged by a
relatively prominent globe, the eyelid has less reserve.
As a result, subtle loss of orbicularis function or stiff -
ening of the vertical elasticity will more easily create
symptomatic eyelid retraction and tear fi lm problems.
There is no easy treatment for lower eyelid retraction
in the patient with prominent eyes. Recognizing this
confi guration preoperatively and designing conserva-
tive surgery are the take-home lesson. One option for
treating lower eyelid retraction in the prominent globe
patient is to address the relative proptosis via orbital sur-
gery. Orbital decompression, using minimally invasive
Fig. 8.13 Anterior lamella shortening with rounding of the
lateral canthal angle related to inferolateral vector shorten-
ing. Used with permission from Regents of the University of
California, Copyright 2009.
Fig. 8.14 Patient shown before and seven months after endo-
scopic subperiosteal midface lift, hidden temporal incision in
the hair, designed to support the midface and provide anterior
lamella to the lower eyelid. Used with permission from Re-
gents of the University of California, Copyright 2009.

Complications in Facial Plastic Surgery
66
scratched your cornea, you understand this) but also re-
garding emotional discomfort. In my experience, these
patients are often depressed, anxious, angry, and fright-
ened. Obviously, support from the physician and staff is
a critical fi rst step in rebuilding the confi dence, trust,
and optimism that will allow the patient to heal over
time. There should be a low threshold for obtaining con-
sultation from professional therapists. The better the
the management of the emotional state of the patient,
the more likely it will be that the patient will accept the
incremental improvements that we can achieve through
stage treatment as positive forward steps.
Lower eyelid retraction following blepharoplasty is a
diffi cult problem. Because of the complex physiology of
the lower eyelids and the substantial variations of nor-
mal anatomy, an individualized approach to diagnosis
and treatment is required. Analyzing the contributions
of orbicularis paralysis, anterior and middle lamellar
tightness, volume collapse, relationship of the globe
to its bony support, and horizontal laxity will lead to
a customized diagnosis and individualized treatment
plan. Surgeries should be carefully designed to mini-
mize the risk of additional collateral damage to the re-
maining normal tissues. These patients not only have
delicate and fragile eyelid anatomy and physiology, but
also have a delicate emotional state: a supportive envi-
ronment and appropriate use of professional counseling
are important.
Patient expectations have to be managed: it is not re-
alistic to expect to cure these patients. Fortunately, by
employing a thoughtful, problem-oriented, customized,
stepwise approach, the surgeon can usually achieve
functional and aesthetic improvement in eyelid retrac-
tion after blepharoplasty.

◆Conclusion
Annoying complications of blepharoplasty are com-
mon; fortunately, ocular surface irritation, early pa-
ralysis, swelling and chemosis, wound granulomas,
and early asymmetries usually respond to conservative
management.
The nightmare complication of blepharoplasty is
blindness, produced by orbital hemorrhage. The symp-
toms and signs of increased orbital pressure (and their
urgency) should be familiar both to the patients and
their families and to the physician’s staff . When in-
creased orbital pressure that threatens vision is diag-
nosed, rapid treatment might save the patient’s vision.
Lower eyelid retraction is the most common serious
complication of lower blepharoplasty. It causes include
vertical shortening of tissues, volume collapse, and or-
bicularis weakness. Conservative surgery decreases the
risk. Treatment is complex and should be customized
to the individual patient’s anatomic and physiologic
features.
techniques, can be appropriately considered in selected
cases. Removing fat from behind the globe reduces pro-
ptosis and provides a potential source of fat grafting to
address any coexistent volume collapse of the eyelid,
but with increased risk compared with removal of ante-
rior fat (traditional blepharoplasty), including increased
risk of double vision (Fig. 8.15).
Psychological Factors
Psychological factors play an important role in aes-
thetic surgical practice, as any experienced practitioner
knows well. An unhappy patient after blepharoplasty
with functional and aesthetic eyelid problems is par-
ticularly vulnerable. For reasons that psychologists and
psychiatrists could presumably elucidate better than
I, the eyes seemed to be a particularly sensitive areas
not only regarding physical discomfort (if you have ever
Fig. 8.15 Patient with relatively prominent globe, seen
before and after intraconal fat harvest (which reduced the
proptosis by 2 mm) and en-glove lowe r eyelid lysis with
placement of the harvested intraconal fat as a free graft.
Used with permission from Regents of the University of Cali-
fornia, Copyright 2009.

8 Complications of Lower Eyelid Blepharoplasty
67
References
1. Harley RD, Nelson LB, Flanagan JC, Calhoun JH. Ocular motility
disturbances following cosmetic blepharoplasty. Arch Oph-
thalmol 1986;104(4):542–544
2. Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplo-
pia following transconjunctival blepharoplasty. Plast Reconstr
Surg 1998;102(4):1219–1225
3. Syniuta LA, Goldberg RA, Thacker NM, Rosenbaum AL. Ac-
quired strabismus following cosmetic blepharoplasty. Plast
Reconstr Surg 2003;111(6):2053–2059
4. Sutcliff e T, Baylis HI, Fett D. Bleeding in cosmetic blepharo-
plasty: an anatomical approach. Ophthal Plast Reconstr Surg
1985;1(2):107–113
5. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness
following blepharoplasty: two case reports, and a discussion
of management. Ophthalmic Surg 1990;21(2):85–89
6. Hamawy AH, Farkas JP, Fagien S, Rohrich RJ. Preventing and
managing dry eyes after periorbital surgery: a retrospective
review. Plast Reconstr Surg 2009;123(1):353–359
7. Weinfeld AB, Burke R, Codner MA. The comprehensive man-
agement of chemosis following cosmetic lower blepharoplas-
ty. Plast Reconstr Surg 2008;122(2):579–586
8. Enzer YR, Shorr N. Medical and surgical management of
chemosis after blepharoplasty. Ophthal Plast Reconstr Surg
1994;10(1):57–63
9. Douglas RS, Cook T, Shorr N. Lumps and bumps: late postsur-
gical infl ammatory and infectious lesions. Plast Reconstr Surg
2003;112(7):1923–1928
PEARLS OF WISDOM
The doctor, the patient, and the staff should know the symp-
toms and signifi cance of orbital hemorrhage (pain, fi rm swell-
ing, decreased vision, nausea).
Chemosis relates to dysfunctional blink and windshield wiper
mechanism of the lower eyelid; lubrication and topical anti-
infl ammatory medications can help break the cycle until eyelid
function returns.
Lower eyelid retraction has multiple potential causes, and
treatment must be individualized.
Prominent eye confi guration is a strong risk factor for compli-
cations and should be identifi ed preoperatively.
Eyelid anatomy and physiology are delicate and easily disrupt-
ed; blepharoplasty surgery should be conservatively designed
and meticulously performed to avoid over-resection and to
minimize collateral tissue damage

68
Surgical rejuvenation of the aging brow is straightfor-
ward in principle, with primary goals being upward
repositioning of the lateral brow/upper eyelid complex
and reduction in brow depressor muscle activity. When
the procedure is undertaken on a suitable patient, the
combination of anatomically appropriate dissection and
bitemporal fi xation should be free from complications,
easy to undergo, appear natural, improve the aesthetics
of the upper face, and be pleasing to the patient (Fig.
9.1A–D).
The operation itself is one of the safer cosmetic surgi-
cal procedures, typically devoid of the devastating com-
plications that can be seen with other facial surgeries.
Even so, there is no dispute over the importance of a
well-performed browlift and its signifi cant contribution
to the overall appearance of the rejuvenated patient.1 In
this chapter, both the potential pitfalls of contemporary
endoscopic browlifting and straightforward mitigation
strategies are reviewed.

◆A Brief History
Modern browlifting, like many facial surgery proce-
dures, can trace its roots to a time of human confl ict
when combat-related deformities were abundant, with
the fi rst description of an aesthetic foreheadplasty in
1919 by Rene Passot.2 Early emphasis was placed upon
horizontal skin excisions to improve forehead furrows
and lateral brow hooding, but repositioning techniques
quickly emerged. These subsequent techniques de-
scribed wide skin undermining, modifi cations to the
brow depressor muscles, and eventual subgaleal dissec-
tion. By the latter half of the 20th century, descriptions of
multiplanar brow dissection became commonplace, and
the coronal browlift became the procedure of choice. In
1992 Isse and Vasconez introduced a minimally invasive
technique of brow rejuvenation: the endoscopic fore-
headplasty.3–5 Although no single procedure has proven
defi nitively to be the best for forehead rejuvenation,
the endoscopic browlift or a combination of the endo-
scopic and open trichophytic browlift has been widely
embraced, challenging their predecessors in pursuit of
the procedure of choice for brow rejuvenation.6–11 Endo-
scopic brow rejuvenation is the focus of this chapter.

◆ Patient Selection and
General Considerations
Rejuvenation of the aging brow is not complex in na-
ture; however, there are pitfalls to avoid in the quest for
the ideal result. Prevention of a bad outcome starts with
appropriate patient selection and a thorough preopera-
tive evaluation. Poor patient selection, that is, perform-
ing the wrong operation on an inappropriate patient, is
often at fault. The surgeon should always strive to avoid
this situation by selecting the correct operation for an
appropriate patient.
The prospective browlift patient should be healthy
enough to undergo the proposed operation and the
accompanying level of anesthesia, and it is incumbent
upon the operating surgeon to discover any medical or
psychiatric history that could lead to a contrary result.
A history of poor wound healing, chronic steroid use,
brittle diabetes mellitus, inability to lie supine, dry eyes,
or frontal bone fi brous dysplasia may alter the surgi-
cal plan. A history of prior forehead surgery or injury
(craniofacial trauma, frontal sinus fracture, forehead or
temple skin cancer reconstruction, paramedian fore-
head fl ap, osteoplastic fl ap, CN VII injury, scalp avulsion
or extensive laceration, or hair transplantation) may
also require a change in the rejuvenation strategy. Com-
munication with the patient’s primary care physician
or consultation with a medical specialist is important if
there is any doubt regarding the patient’s prior medical
history. As with all surgical procedures, it is prudent to
communicate any concerns regarding anesthesia (air-
way compromise, vocal fold motion impairment, sleep
apnea, prior diffi cult intubation, prior cervical spine
9
Prevention and Management of
Adverse Outcomes in Brow Rejuvenation
Randolph B. Capone

9 Prevention and Management of Adverse Outcomes in Brow Rejuvenation
69
Fig. 9.1 Patient before (A, C) and after (B, D) endoscopic browlift with upper blepharoplasty.
A
B
C
D

Complications in Facial Plastic Surgery
70
should be noted. Pay particular attention to the presence
of eyebrow asymmetry, blepharoptosis, and superolat-
eral orbital hooding. Is there evidence of eyelid ptosis ac-
companied by compensatory brow elevation? (Fig. 9.2)
Is ptosis absent, but brow asymmetry present? (Fig. 9.3)
Surgeons must recognize that browlifting does not
correct eyelid ptosis (Fig. 9.4), and those surgeons un-
comfortable with ptosis repair should consider having
an oculoplastic surgeon perform this concomitantly
with the browlift.
After the inspection of the patient at rest, the prac-
titioner should perform a dynamic exam. The mobil-
ity of the soft tissue envelope and the strength of the
frontalis, corrugator supercilii, procerus, and orbicularis
oculi muscles should be assessed. Is there evidence of
frontotemporal branch weakness, or is there skin teth-
ering suggestive of prior trauma? Is there any evidence
of forehead lipomata or cystic masses? The bony brow
and the frontal skull should be palpated to ensure there
are no irregularities (e.g., osteomata) that may hamper
brow rejuvenation.
surgery, latex allergy, family history of malignant hy-
perthermia or pseudocholinesterase defi ciency, etc.) to
the anesthesiologist. In other words, always attempt to
forecast obstacles from induction to recovery. It is ul-
timately better to refuse to perform the browlift or to
alter strategy than to proceed in an unsafe or uncertain
fashion.
While talking with prospective browlift patients, ob-
tain a sense of their motivations for and expectations
of surgical rejuvenation. Do they seem appropriate and
realistic? Often, the patients most enamored with their
surgical experience have the most realistic expecta-
tions at the outset. Many individuals may initially be
surprised by your suggestion of a browlift, thinking that
their upper eyelids are the sole problem. Patients are of-
ten unaware of the link between upper eyelid aging and
brow ptosis. If they have eyelid ptosis (e.g., levator dehis-
cence) or excess skin (blepharoptosis), the eyelids may
indeed be at issue, but it is the surgeon’s responsibility
to educate the patient suffi ciently about the eff ects of
brow ptosis and its contribution to an aged eyelid ap-
pearance. The patient needs to know what a browlift is,
why it is being proposed, how it is achieved, and what
it might look like once it is performed. It is incumbent
upon the surgeon to explain how a browlift augments
facial rejuvenation as a whole when it is performed in
concert with other procedures, especially blepharoplas-
ty and rhytidectomy.
The surgeon must also openly discuss the eff ect that a
browlift may have on the patient’s hairline. If the patient
has a high hairline, forehead shortening may need to be
utilized.12 Too often the forehead shortening modifi ca-
tion is overlooked, contributing to inappropriate hairline
elevation. If the patient has alopecia or pattern baldness,
a standard endoscopic approach may not be indicated,
and incision orientation and/or browlift technique may
need to be altered (e.g., midforehead or transblepharo-
plasty). Spending time discussing these myriad topics
during the consultation will go far to educate patients
and crystallize their postoperative expectations, which
will ultimately lead to enhanced patient satisfaction.
The Brow Exam
The old idiom “forewarned is forearmed” is particularly
appropriate with regard to cosmetic surgery, and a thor-
ough physical examination is the surgeon’s early warn-
ing system. With the relaxed patient directly in front of
the examiner, the position and shape of the eyebrows as
well as the location of the hairline and status of hair pat-
tern (using the Norwood classifi cation for males) should
be noted.13 Eyebrow position should be documented
relative to the underlying bony brows. Note whether the
patient exhibits exophthalmos, lateral canthal dystopia
with inferior eyelid rounding, or a negative vector that
might predispose him or her to exposure keratitis. Skin
thickness, skin condition, alopecia, and any relevant scars
Fig. 9.2 Illustration of right-sided ptosis with compensatory
frontalis muscle hyperfunction.
Fig. 9.3 Patient with right frontotemporal nerve palsy and
brow asymmetry, elicited more dramatically on upward gaze.

9 Prevention and Management of Adverse Outcomes in Brow Rejuvenation
71
patient selection and careful postoperative care, while
solid surgical experience and careful preparation will
help the surgeon avoid perturbations in judgment (for
example, doing an endobrowlift without the forehead
lowering modifi cation in a patient already self-con-
scious about a high hairline).
Errors or inadequacies in browlift technique, which
are myriad and are similarly minimized with impec-
cable training and increased experience with the opera-
tions, are the focus of the rest of this chapter (Table 9.1).
Facial Nerve Injury
In surgical brow repositioning, injury to the frontotem-
poral branches of the facial nerve is a serious concern;
although it has not been defi nitively defi ned in the liter-
ature, its incidence is estimated at 3–5% (both transient
and permanent cases). The surgeon can protect the
frontotemporal branches and preserve the motion of the
frontalis muscle by understanding the anatomy in this
area.16 After the main trunk of the facial nerve exits the
stylomastoid foramen, the frontotemporal branch fi bers
depart the pes anserinus, coursing superiorly through
the parotid gland and over the zygomatic arch, ultimate-
ly sending motor fi bers to synapse with the frontalis and
orbicularis oculi muscles (Fig. 9.5).
Photographic documentation should be performed
next. Studying the patient’s preoperative photographs
often provides the surgeon with additional information,
as they are a good supplement to the physical examina-
tion. The images should be reviewed with the patient,
and any preexisting asymmetries, ptosis, scars, alope-
cia, hairline position, etc. should be clearly illustrated,
openly discussed, and thoroughly documented. Lastly,
providing there is consent to do so, before and after pho-
tographs of other browlift patients should be reviewed
with the patient. This review will help candidates for
surgery to bring their expectations of benefi t into bet-
ter focus.

◆Browlift Pitfalls
As Withey et al. pointed out in their review of 100 en-
doscopic browlifts, no in-depth studies of the compli-
cation rates of this operation have been published.14
Even so, adverse outcomes do occur and are generally
attributable to one or more of the following: (1) inap-
propriate surgical technique, (2) inappropriate surgical
judgment, (3) inappropriate recovery, or (4) inappropri-
ate patient expectations. Regarding expectations, pa-
tients must fi rmly understand that the goal of a browlift
is not perfection but rather improvement that has a
natural appearance. Therefore, preoperative discussion
and counseling are absolute necessities. This allows
prospective browlift patients to develop appropriate ex-
pectations and leads to increased satisfaction with the
outcome. As indicated previously in this text, Dr. Eugene
Kern advises that preoperative preparation should be
taken a step further, by preparing the patient for a sec-
ond operation (i.e., revision) before performance of the
fi rst.15 Problems in recovery are avoided with prudent
Fig. 9.4 Patient with bilateral eyelid ptosis.
Table 9.1
Adverse Endoscopic Browlift Outcomes
Facial nerve injury (neuropraxia, axonotmesis, neurotmesis,
brow ptosis)
Sensory nerve injury (paresthesias, formication, pruritus,
chronic pain)
Inappropriate or inadequate fi xation (quizzical look, stare,
asymmetry)
Hardware failure (abrupted duration, foreign body reaction,
exposure)
Infection
Forehead elongation
Alopecia
Telogen effl uvium
Hairline distortion
Hematoma
Intracranial hemorrhage
Periocular venous congestion
Equipment failure

Complications in Facial Plastic Surgery
72
Metzenbaum scissors in a controlled pushing fashion,
rather than with excessively forceful blunt dissection.
If motor nerve injury is diagnosed postoperatively, in-
jection of botulinum toxin into the unaff ected frontalis
muscle can enhance symmetry while watchful waiting
is undertaken. Reassuring the patient at frequent inter-
vals while nerve function returns is mandatory.
Sensory Nerve Injury
Less worrisome to the surgeon (but not less bothersome
from the patients’ perspective) is injury to the supra-
trochlear and supraorbital nerves that convey sensation
from the frontal scalp and forehead skin. Such injury can
cause prolonged numbness, disturbing paresthesias (e.g.,
Anywhere from 2 to 5 rami cross superfi cial to the
zygomatic arch at approximately the junction of the
medial and middle thirds of the zygomatic arch, or ap-
proximately 2 cm lateral to the lateral orbital rim.17–19
Neuropraxia, axonotmesis, or neurotmesis of these
branches can occur from aggressive soft-tissue dissec-
tion, fl ap traction at the lateral brow, or dissection that
strays too superfi cially (Fig. 9.6).
Injury will cause unilateral frontalis hypofunction,
brow ptosis, accompanying brow asymmetry, and
asymmetric relaxation of the forehead. Although com-
plications are usually temporary (resolving in a matter
of two to three months), permanent injury can also oc-
cur. Because the surgeon has little ability to manage this
complication once it occurs, prevention is the key. Care-
ful, controlled dissection in the subgaleal (subperios-
teal) plane across the forehead and directly on the deep
temporal fascia laterally is safe. Lysis of the conjoined
tendon (where the deep temporal fascia fuses with the
galea) should also be done with care, and minimal trac-
tion should be placed upon the fl ap during release of the
arcus marginalis and lateral periorbital area. Release of
these formidable periosteal refl ections at the supero-
lateral brow area can be achieved with partially open
Fig. 9.5 Branches of the frontal division of the facial nerve
(VII) relative to surface anatomy. The intersection of Pitan-
guy’s line (blue) and the tragal canthal line (red) roughly ap-
proximates where the branches cross the middle third of the
zygomatic arch (box). (Illustration by Robert Brown.)
Fig. 9.6 Frontotemporal branches of the facial nerve travel from
deep to superfi cial in their course from the pes anserinus to the
frontalis muscle: (a) superfi cial temporal fascia, (b) SMAS, (c)
zygomatic arch, (d) deep temporal fascia, (e) intermediate tem-
poral fascia (superfi cial refl ection of the deep temporal fascia),
(f) deep refl ection of the deep temporal fascia with the overlying
intermediate fat pad, (g) temporalis muscle, (h) parotid gland,
and (i) masseter muscle. (Illustration by Robert Brown.)

9 Prevention and Management of Adverse Outcomes in Brow Rejuvenation
73
Venous Congestion
Another general landmark that has been described for
identifi cation of the frontotemporal branch of the fa-
cial nerve is the sentinel vein and associated bridging
veins.18,20 These veins can be observed endoscopically
and course from the deep temporal fascia into the el-
evated fl ap at the temple and are associated with the
position of the frontal branch. Disruption of these bridg-
ing vessels has been posited to cause another potential
browlift complication: periocular venous congestion.
Some authors report that this complication is signifi -
cant enough to recommend preservation of these veins
during endoscopic dissection.21 No studies, however, il-
lustrate long-term implications from periocular venous
congestion after browlifting.
Hematoma and Infection
The scalp is richly vascularized, and traditional browlift
methods (e.g., bicoronal incision) incurred a risk of he-
matoma from the lack of incisional hemostasis and per-
sistent incisional bleeding. This typically necessitated
hemostatic sutures to close the galea and scalp. Since
the endoscopic browlift approach is less invasive, utiliz-
ing small incisions parallel to neurovascular structures,
its chance of forming a hematoma is substantially less.
Skin incision closure and gently compressive dressings
placed at the conclusion of the case are typically all that
are required to prevent hematoma complication. If a he-
matoma is recognized, it should be evacuated by open-
ing of the closest incision or by serial aspiration.
Infection is also a rare complication of endoscopic
browlift procedures. As previously mentioned, the vas-
cular supply to the scalp is abundant and protective.
Even with manipulation of hair proximate to the inci-
sion and frank insertion of hair into the wound in the
presence of indwelling alloplastic or metal implants, in-
fection is an endobrowlift complication that some sur-
geons never see. However, most prudent surgeons still
routinely administer perioperative antibiotics against
gram-positive organisms for prophylaxis.
Alopecia and Hairline Distortion
Even with meticulous hair preparation and gentle tis-
sue handling, alopecia is often observed with browlift-
ing, because incisional trauma can result in hair follicle
injury. Mechanical avulsion, electrocautery, friction
from the endoscope sheath, and manipulative stress can
create ischemia that results in hair follicle death and
resulting telogen effl uvium along the incisional site. In
the subgaleal brow lift, alopecia should not be a concern
with proper tension applied at the appropriate sites. Pa-
tients should be warned, however, not to be overly anx-
ious about seeing an inordinate amount of hair in the
tub drain after the fi rst few hair washings. Avoid overly
pins and needles, formication), bothersome scalp pruri-
tus, and even chronic pain.14 Careful understanding of the
anatomic relationships of the sensory nerves, the corru-
gator supercilii muscle, and the frontalis muscle is essen-
tial to avoid complications. Typically, the supraorbital and
supratrochlear nerves emanate from the skull via a fora-
men located within the supraorbital notch; however, in
10% of cases one or both nerves can emanate from a true
foramen located outside of the notch (Fig. 9.7).18
Marking the supraorbital notch with a marking pen
before injection of local anesthetic can be useful. Using
the endoscope, the surgeon should watch for the pres-
ence of a true foramen and attempt to visualize the neu-
rovascular bundles as they emanate from the corrugator
supercilii muscles on the undersurface of the fl ap. Injury
in a proximal location will result in altered sensorium
across a wide distribution of the forehead and frontal
scalp. Transient sensory loss in the vicinity of the endo-
browlift incisions is expected, although the orientation
of the midline and paramedian incisions should always
be parallel to the nerve fi bers to minimize the chance of
transection. Patients should be informed of this.
If a hairline-lowering or hairline-preserving endo-
browlift is performed, care must be taken to ensure that
the skin excision is superfi cial to the frontalis muscle.12
Almost always, however, excision of skin at the top of
the forehead that accompanies this variation will result
in numbness, paresthesia, and pruritus posterior to the
incision, since the frontalis muscle attenuates superi-
orly, leaving the nerves vulnerable. Let patients know
to expect this, but also inform them that it will typically
become less bothersome and resolve over the course of
a few months.
Fig. 9.7 Frontal view of human skull with a true supraorbital
foramen on the right.

Complications in Facial Plastic Surgery
74
onal browlift and the endoscopic browlift will increase
the length of the forehead in all patients. Although this
can be an acceptable or even a desirable outcome in se-
lect patients with a low hairline and short forehead, if
patients have a high hairline and tall forehead, they will
generally view further elongation of the forehead as un-
acceptable. In these patients, use of the forehead short-
ening modifi cation is advisable so the hairline can be
lowered to make the outcome more aesthetically pleas-
ing. If this technique is used, it is incumbent upon the
surgeon to discuss preoperatively the rationale for the
longer incision and numbness that will occur. Tricho-
phytic incisions are beveled across the hair shafts to en-
courage hair regrowth through the scar for camoufl age,
and precise closure of the incision without tension is
paramount. The use of trichophytic incisions makes the
incision nearly undetectable, which allows patients to
wear a desired hairstyle rather than camoufl aging a high
forehead with bangs. The possibility of aberrant wound
healing after hairline preservation leading to visible
scarring or hairline distortion must be discussed openly
with the patient preoperatively.
Scars
Undesirable scarring is often a matter of poor technique
and a failure to handle tissue gently during an endo-
scopic browlift. Fortunately, keloid scars have not been
observed, and hypertrophic scarring is almost nonexis-
tent. Wide scars are more likely the result of incisional
alopecia than excessive cicatrix formation. The use of
trichophytic incisions is advisable when the surgeon is
excising skin in the forehead-shortening modifi cation. If
an endoscopic browlift is undertaken in male patients
with pattern baldness, there are special considerations.
First, the surgeon should discuss with the patient the
reason for selecting an endoscopic browlift rather than
performing a browlift that respects the hairline (e.g., a
mid-forehead browlift). Patients with Norwood Class
I, II, or III pattern baldness need to understand that
placement of their hairline will be aggravated with an
endoscopic browlift and that a forehead-shortening
modifi cation cannot be performed due to the inability
to hide resultant scarring. Such patients should be in-
formed that hair restoration surgery would allow the
browlift to be achieved and the hairline to be lowered,
thereby keeping the incisions hidden. If patients with a
more advanced Norwood classifi cation (IV, V, or VI) elect
to undergo an endoscopic browlift, incisions can be
made in the transverse orientation if the surgeon feels
these scars would be more acceptable to the patient.
Inadequate or Inappropriate Brow Correction
Unfortunately, inadequate or inappropriate brow cor-
rection is not uncommon after a browlift, although
no studies documenting an accepted rate of incidence
compressive dressings.In addition, making the port inci-
sions along (instead of across) the hair shafts preserves
hair follicles. The blade should be kept orthogonal to
the skin without beveling. If the forehead-shortening
modifi cation is used, however, incisions should be bev-
eled across the hair follicles to encourage hair regrowth
through the scar for camoufl age (Fig. 9.8). Strict avoid-
ance of electrocautery along the base of the hair follicles
is another way to limit resultant alopecia.
Hairline distortion after browlifting is a signifi cant
concern, even when the procedure is performed by
skilled surgeons. Without careful planning, both the cor-
Fig. 9.8 Rendition of trichophytic versus pretrichial incision.
(A) The dotted line denotes a trichophytic skin incision, placed
4–5 mm posterior to the hairline and beveled to include the
most anterior 2–3 follicular units. (B) After excision of excess
skin, the forehead fl ap is advanced superiorly to match the
bevel of the scalp fl ap. This allows hair growth through the
forehead fl ap from preserved hair follicles. (C) A pretrichial
incision is made parallel to the hair shafts.

9 Prevention and Management of Adverse Outcomes in Brow Rejuvenation
75
fi xation. Other fi xation techniques have evolved that use
absorbable screws or barbed devices (Lactosorb, Biomet
Fixation, Jacksonville, FL; or Endotine, MicroAire, Char-
lottesville, VA). Although these devices are purportedly
temporary, there is a small rate of inabsorbability and
formation of a foreign body granuloma that can neces-
sitate incision and debridement of the implant remnant
and any associated scar tissue or granuloma (Figs. 9.10,
9.11, 9.12).
Another fi xation method obviates the need for any im-
plant and simply relies on the creation of a bony tunnel
or bone bridge to secure the lift. Although elegant, this
fi xation method is not immune to either suture shear or
bone tunnel breakage, and it can be challenging because
of the oblique nature of the drilling and necessity to pro-
tect the hair from getting wound around the drill.
are available. The term inadequate refers to a defi cient
amount of correction, usually resulting from failure to
release the fi rm periosteal attachments at the lateral or-
bital rim, thereby hampering fl ap mobility. Care should
be taken to elevate the entire brow widely in a symmet-
ric fashion, with conjoined tendon release, arcus mar-
ginalis release, and lateral brow release. Preoperative
botulinum toxin injections to weaken the brow depres-
sor muscles can aid the surgeon by decreasing the base-
line tone of these muscles at the time of surgery to favor
superior fl ap movement. In addition, continued botuli-
num toxin injections at regular intervals after surgery
are strongly recommended by most surgeons despite
surgical disruption of the brow depressors.
Inappropriate brow correction refers to a browlift
with an unanatomic result, such as seen with excessive
elevation of the medial brow.22 This causes a surprised,
shocked, or quizzical appearance, and contributes to an
operated look instead of a rejuvenated one. Occasion-
ally, inappropriate browlifting causes the patient to
appear to have an unnatural stare. It is paramount to re-
alize that the focus of the browlift is on achieving lateral
instead of medial brow elevation. Iatrogenic asymmetry
is also a possible cause of inappropriate brow correction
and occurs if one brow is elevated more than the oth-
er. The surgeon should attempt to compensate for any
preoperative brow asymmetry, restoring as much sym-
metry as possible. Obviously, it should be remembered
that native brow position should be documented inde-
pendent of the brow position achieved after botulinum
injections have taken eff ect.
If either inadequate or inappropriate brow correc-
tion occurs, watchful waiting is the fi rst and best step.
Staples or sutures must be out, edema must be resolved,
and adequate time allowed for the resolution of any
frontotemoporal branch weakness before action is tak-
en. Furthermore, the eff ects of preoperative botulinum
toxin will be present for three to four months, and these
eff ects may be a contributory factor until the normal
brow depressor activity has resumed. Once the surgeon
is convinced there are no other factors at play, improve-
ment may obtained with corrective botulinum toxin in-
jections, reoperation, or both.
Hardware Failure
Complications related to browlift fi xation are not un-
common and may include fi xation failure, fi xative ex-
posure through the skin fl ap, patient intolerance of the
fi xation device, device inabsorbability, and even brain
injury. Although titanium screws inserted into the
skull’s outer table provide a stable method for browlift
fi xation, the screw can loosen and fail to osseointegrate
and thus become painfully palpable or even exposed
through the overlying skin fl ap (Fig. 9.9).
In addition, suture materials used to fi xate the fl ap
can shear on the screw, with complete loss of unilateral
Fig. 9.9 Incision dehiscence and exposed titanium screw after
browlift.
Fig. 9.10 Patient with infl ammatory nodules at the site of
absorbable browlift devices.

Complications in Facial Plastic Surgery
76
The most dread complication of browlift fi xation is
brain injury; although vanishingly rare, it can occur if
the drilling associated with fi xation traverses the skull
and penetrates the dura mater. Subdural or epidural he-
matoma, meningitis, intracranial hemorrhage, or corti-
cal brain injury can result (Figs. 9.13, 9.14). Great care
must be taken, therefore, to limit the depth of drilling to
the outer table of the skull only. If injury is suspected,
MRI or CT brain imaging, close observation, and an ex-
pedited neurosurgical consultation are imperative.
Fig. 9.11 High resolution H&E stain showing diff use foreign
body giant cell granulomatous response after a browlift using
an absorbable fi xation device.
Fig. 9.12 Accompanying light micrograph showing polariz-
able material.
Fig. 9.13 Coronal T1-weighted MRI of the brain showing a left
cortical injury with edema after endoscopic browlift.
Fig. 9.14 Axial T2-weighted MRI of the same patient‘s brain
showing left cortical bleed.

9 Prevention and Management of Adverse Outcomes in Brow Rejuvenation
77
4. Vasconez LO. The use of the endoscope in brow lifting (video).
Presented at the Annual Meeting of the American Society of
Plastic and Reconstructive Surgeons; September 1992. Wash-
ington, DC.
5. Core GB, Vasconez LO, Graham HD III. Endoscopic browlift.
Clin Plast Surg 1995;22(4):619–631
6. Chiu ES, Baker DC. Endoscopic brow lift: a retrospective re-
view of 628 consecutive cases over 5 years. Plast Reconstr Surg
2003;112(2):628–633, discussion 634–635
7. Cilento BW, Johnson CM Jr. The case for open forehead reju-
venation: a review of 1004 procedures. Arch Facial Plast Surg
2009;11(1):13–17
8. Chadwell JB, Mangat DS. The endoscopic forehead-lift. Facial
Plast Surg Clin North Am 2006;14(3):195–201
9. Dayan SH, Perkins SW, Vartanian AJ, Wiesman IM. The fore-
head lift: endoscopic versus coronal approaches. Aesthetic
Plast Surg 2001;25(1):35–39
10. Puig CM, LaFerriere KA. A retrospective comparison of
open and endoscopic brow-lifts. Arch Facial Plast Surg
2002;4(4):221–225
11. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Endoscopic
forehead lift: review of technique, cases, and complications.
Plast Reconstr Surg 2002;110(6):1558–1568, discussion
1569–1570
12. Ramirez AL, Ende KH, Kabaker SS. Correction of the high fe-
male hairline. Arch Facial Plast Surg 2009;11(2):84–90
13. Norwood OT. Male pattern baldness: classifi cation and inci-
dence. South Med J 1975;68(11):1359–1365
14. Withey S, Witherow H, Waterhouse N. One hundred cases of
endoscopic brow lift. Br J Plast Surg 2002;55(1):20–24
15. Kern EB. The preoperative discussion as a prelude to man-
aging a complication. Arch Otolaryngol Head Neck Surg
2003;129(11):1163–1165
16. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy
of the frontal branch of the facial nerve: the signifi cance
of the temporal fat pad. Plast Reconstr Surg 1989;83(2):
265–271
17. Bernstein L, Nelson RH. Surgical anatomy of the extra-
parotid distribution of the facial nerve. Arch Otolaryngol
1984;110(3):177–183
18. Sabini P, Wayne I, Quatela VC. Anatomical guides to precisely
localize the frontal branch of the facial nerve. Arch Facial Plast
Surg 2003;5(2):150–152
19. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the fa-
cial nerve: how reliably can we predict its path? Plast Reconstr
Surg 1997;99(5):1224–1233, discussion 1234–1236
20. Liebman, EP, Webster RC, Berger AS, Della Vecchia M. The fron-
talis nerve in the temporal brow lift. Arch Otolaryngol Head
Neck Surg 1982;108(4):232–235
21. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an im-
portant reference point for surgery in the temporal region.
Plast Reconstr Surg 1998;101(1):27–32
22. Freund RM, Nolan WB III. Correlation between brow lift out-
comes and aesthetic ideals for eyebrow height and shape in
females. Plast Reconstr Surg 1996;97(7):1343–1348

◆Conclusion
In recent years, the endoscopic approach to browlift-
ing has proven successful in upper facial rejuvenation
by safely capitalizing on minimal access through hid-
den incisions with dissection using contemporary op-
tics to achieve youthful brow repositioning. Successful
outcomes depend upon (1) complete release of the brow
at the supraorbital rim and arcus marginalis, (2) brow
depressor muscle resection and disruption, (3) adequate
and appropriate fi xation of the new brow position, and
(4) ideal patient selection, education, and preparation.
Adherence to these general guidelines will protect pa-
tients from adverse outcomes that can be associated
with contemporary brow rejuvenation.
PEARLS OF WISDOM
A thorough examination with careful documentation of pre-
operative brow and eyelid position will help prevent browlift
complications.
Limiting fl ap traction during takedown of the arcus marginalis
and lateral brow periosteum will reduce the incidence of fron-
totemporal branch weakness.
It is important to consider the hairline shortening modifi cation
with trichophytic incisions whenever a patient with brow ptosis
is bothered by an accompanying high hairline.
Be wary of patients with true ptosis and understand Herring’s
Law.
Preoperative use of botulinum toxin, intraoperative release of
the lateral brow attachments, and use of appropriate vectors
of elevation will help the surgeon achieve an anatomic browlift
that avoids the operated look.
Because there is no clear evidence for the best browlift fi xation
technique, surgeons should use the technique they feel most
comfortable performing that yields the best outcomes.
References
1. Knoll BI, Attkiss KJ, Persing JA. The infl uence of forehead,
brow, and periorbital aesthetics on perceived expres-
sion in the youthful face. Plast Reconstr Surg 2008;121(5):
1793–1802
2. Passot R. La churgerie esthetique des rides du visage. Presse
Med 1919;27:258
3. Isse NG. Endoscopic forehead lift. Presented at the Annual
Meeting of the Los Angeles County Society of Plastic Surgeons;
September 12, 1992, Los Angeles, CA

78
Most plastic surgeons consider rhinoplasty one of the
most complex facial plastic operations. Precise preop-
erative diagnosis and meticulous surgical technique
are required to produce a favorable outcome and avoid
complications. As anatomies diff er and patient expec-
tations vary, no single technique is appropriate for all
patients. Rhinoplasty complications not only encom-
pass those common to most surgeries, such as infection
and hematoma, but also are frequently associated with
functional and aesthetic problems. Traditional rhino-
plasty techniques involve reductive, excisional methods,
which may be associated with many untoward long-
term changes. Grafting in rhinoplasty may also result
in problems, such as graft visibility, mobilization, and
extrusion. Methods to prevent or correct common rhi-
noplasty complications are detailed below.

◆Preoperative Evaluation
The preoperative consultation is a critical step to avoid
complications after rhinoplasty. It is essential that both
the surgeon and patient have realistic expectations. If
they cannot achieve common goals, due to either patient
limitations (e.g., damaged soft-tissue skin envelope) or
a surgeon’s inexperience with or lack of comfort in per-
forming the proposed procedure, the surgery should not
proceed. This is especially true in patients seeking sec-
ondary rhinoplasty.
Computer imaging of the proposed changes can facili-
tate communication between the surgeon and patient.
Perhaps more importantly, it can also provide a visual
explanation of the proposed outcome. Patients often
have diffi culty expressing the changes they desire, or
they may be unaware of what results are realistic and
surgically attainable. Computer imaging may help over-
come this problem. In fact, one study demonstrated that
patient satisfaction was signifi cantly improved when
the procedure included preoperative imaging versus no
imaging.1 If computer imaging is used, the image shown
should realistically represent what the surgeon can
achieve. In fact, under-imaging, or showing less than
ideal outcomes that the surgeon can generally achieve,
is the most eff ective means of using computer imaging.
The surgeon is warned against trying to sell the opera-
tion with unrealistic or idealized imaging.
The surgeon must assess the quality and thickness of
the skin/soft tissue envelope (SSTE) preoperatively. In
fact, a damaged SSTE may be the deciding factor as to
whether or not a revision rhinoplasty can be undertak-
en. In some cases, signifi cant scar tissue may be present
from a previous surgery in which aggressive thinning
of the subcutaneous tissue and/or dissection in the in-
correct plane took place. If patients have an immobile
SSTE that adheres tightly to the underlying cartilaginous
framework, surgery is postponed until the SSTE loosens.
In cases of severely damaged SSTE, surgery may not be
off ered at all. At times, the SSTE will be thin or devascu-
larized from prior surgery. Visible irregularities, cutane-
ous telangiectasias, and purple discoloration of the skin
are signs of SSTE damage (Fig. 10.1). It is important that
these skin changes are recognized, because in such cas-
es extensive soft-tissue elevation may lead to ischemia
and skin necrosis. Moreover, revision surgery should
be postponed until changes in skin color resolve, which
may take years. Any irregularities or skin damage should
documented in the chart and by close-up photography
before surgery. Finally, the patient with a damaged SSTE
needs to be counseled preoperatively about the risk of
further skin damage, even necrosis, with surgery.2
During the preoperative evaluation for secondary rhi-
noplasty, the surgeon should assess the patient for the
presence of alloplastic implants. These implants may
result in SSTE damage and signifi cant scar tissue (Fig.
10.2). The surgeon should be prepared to replace the
alloplastic implants with alternative grafting materials,
such as cartilage.
The surgeon should discuss the postoperative heal-
ing process candidly at the initial consultation. The pa-
tient should be aware that postoperative nasal edema
10
Rhinoplasty Complications
Jaimie DeRosa, Ryan M. Greene, and Dean M. Toriumi

10 Rhinoplasty Complications
79
is normal in the healing period and may be signifi cant,
especially in patients with thick skin. Patients should
be made aware that the healing process will continue
throughout their lifetime as wound contracture con-
tinues; therefore, aesthetic changes will occur over a
period of many years. Risks and possible complications
should also be discussed.
A thorough medical history should be taken, and
physical examination should be performed. All prior na-
sal surgery should be documented, and any accessible
reports of these operations should be reviewed. Pre-
operative laboratory and other diagnostic studies need
to be obtained. The specifi c panel of studies ordered is
chosen according to the patient’s age and overall health.
A complete blood count and coagulation studies are
performed on every patient. Any history of unusual
bleeding or excessive bruising, as well as any family
history of abnormal bleeding, should lead to further
investigation. This may involve coagulation studies
or a more extensive hematologic workup. In fact, one
study found that 9 of 1000 (0.9%) plastic surgery pa-
tients were diagnosed with von Willebrand’s disease.3
Patients should also be told to stop aspirin, ibuprofen,
vitamin E, and herbal supplements at least three weeks
before surgery to reduce the risk of excessive periop-
erative bleeding. In summary, a careful preoperative
evaluation and good communication with a potential
rhinoplasty patient may help to avoid some unwanted
surgical complications.

◆Intraoperative Complications
Unfortunately, many intraoperative errors made in rhi-
noplasty are either unrecognized or not revealed until
the postoperative time period. Therefore, the surgeon
must be meticulous to avoid untoward complications. A
few specifi c problems that the surgeon may encounter
intraoperatively are described below.
As the face is so well vascularized, bleeding is to be
expected during rhinoplasty. Excessive bleeding can im-
pair visibility and the surgeon’s ability to execute the
desired maneuvers. The use of a topical vasoconstrictive
agent and deliberate injection of a local anesthetic con-
taining epinephrine can help to reduce the amount of
bleeding. Dissection in the correct plane (just superfi cial
to the perichondrium) can also decrease the degree of
bleeding. Bipolar electrocautery is used for hemostasis
and should be specifi cally targeted to reduce the risk of
vascular compromise to the SSTE.
During dissection, damage to the SSTE or the underly-
ing cartilaginous structural framework may occur. It is
preferable to avoid such complications (by careful dis-
section in the correct tissue plane), but once such prob-
lems are encountered, the surgeon must try to correct
them. Violation of the SSTE should be treated either by
local wound care or (if large) suture reapproximation. If
Fig. 10.1 Patient who underwent previous rhinoplasty with
excessive thinning of the supratip skin that resulted in perma-
nent damage.
Fig. 10.2 Patient with an infected MEDPOR dorsal implant.
The dorsal skin is severely damaged and scarred from the
infection. Treatment required removal of the implant and
resolution of the infection prior to reconstruction.

Complications in Facial Plastic Surgery
80
ervation of the middle vault mucosa by the formation of
precise pockets for spreader grafts will help minimize
posterior displacement of the upper lateral cartilages
following hump removal.4
One of the more common reasons that patients seek
rhinoplasty is correction of a crooked nose. This is one
of the most diffi cult problems encountered in rhinoplas-
ty. Deviated segments of the nose are shifted back to the
midline by fracturing bone or manipulating and realign-
ing the cartilage framework. Absolute correction can be
diffi cult to achieve, and there may be residual convexi-
ties or concavities along the dorsal nasal subunit that
produce contour defects. Ideally, a contour line should
be created by shadows that extend from the brow and
dorsal nasal subunit to the tip-defi ning point.
Deviation in the upper third of the nose can be ad-
dressed with medial or lateral osteotomies. However, in-
adequate osteotomies may result in a greenstick fracture,
which can result in a deviated bony nasal vault postop-
eratively. In some cases, double lateral osteotomies can
be performed to mobilize the bony vault completely and
decrease the likelihood of this deformity. However, the
surgeon must take care to avoid comminution of the na-
sal bones, which may lead to their displacement.
In many crooked noses, there is also deviation in the
lower two-thirds of the nose. It is essential that the car-
tilaginous structures are reoriented to the midline. If
this realignment is not achieved after osteotomies, the
nose may shift back to its preoperative position due to
the memory of the deviated cartilaginous structures.6
In instances where the nose cannot be shifted back to
midline or where a residual concavity exists (as may be
seen in a C-shaped deformity), an onlay cartilage graft
can be placed lateral to the upper lateral cartilages to
camoufl age the defect.7,8
A fairly common complication following rhinoplasty
is the collapse in the supra-alar region (Fig. 10.4). In pa-
tients with a weakened lateral wall, alar batten grafts
can be placed prophylactically to prevent the develop-
ment of any supra-alar pinching. They can also be used
to correct preexisting external valve compromise, lat-
eral wall collapse, or supra-alar pinching. An alar batten
graft is placed into a precise pocket at the point of maxi-
mal lateral wall collapse or supra-alar pinching (Fig.
10.5).9,10 A common tendency is to place the grafts too
far cephalically along the upper lateral cartilage, which
can result in a persistent fullness in the lateral wall. The
surgeon should also avoid dissecting too far laterally, as
this may cause bleeding and damage to the lateral nasal
arteries that supply the nasal tip.
Excessive alar width or fl aring may be corrected with
alar base reduction. If not done properly, this proce-
dure can lead to signifi cant complications, including
unsightly scarring and distorted nostrils (Fig. 10.6). To
reduce the risk of visible scars, the skin edges should be
everted on closure, which can be achieved by creating
a favorable bevel with the excision.11 This bevel should
the surgeon recognizes that he is dissecting too super-
fi cially (potentially damaging the SSTE), then he should
return to the correct tissue plane, take care not to apply
a tight nasal dorsal dressing (to avoid compromising the
vascular supply to the skin), and monitor the skin close-
ly postoperatively for any signs of damage or necrosis.
Another intraoperative complication that warrants
discussion is the inadvertent disarticulation of the car-
tilaginous septal strut from the perpendicular plate of
the septum. When this occurs, the strut must be reat-
tached to prevent postoperative saddling. One method
of stabilizing the septal strut is to suture it to the nasal
bones via holes that are made along the caudal aspect
of each nasal bone. Destabilization of the caudal aspect
of the septal strut can also occur, which can be repaired
by securing the caudal septum to the nasal spine (or its
periosteum) with a permanent suture, such as a 5–0
clear nylon suture.
Manipulation of the nasal dorsum can lead to middle
vault collapse. It is imperative that the surgeon iden-
tify preoperatively those patients who may be at risk
of middle vault collapse. These include patients with
short nasal bones, long weak upper lateral cartilages,
thin skin, and a narrow projecting nose (Fig. 10.3).4,5 In
patients at high risk for middle vault collapse, several
precautions can be taken. Attempts should be made to
preserve the middle vault structures, and in many cases
augmentation with spreader grafts is recommended.
Additionally, osteotomies should be conservative. Pres-
Fig. 10.3 Patient with short nasal bones and long upper
lateral cartilages. Note the collapse of the upper lateral carti-
lages, resulting in an inverted-V deformity.

10 Rhinoplasty Complications
81
tissue can lead to a depressed scar. Special care should
be taken when approximating the subcutaneous tissues
to ensure precise alignment. Any time base reduction
is performed, conservative removal of tissue is recom-
mended to reduce the risk of nostril distortion or exces-
sive narrowing.
It is critical to avoid visible scars whenever external
rhinoplasty is performed. Scarring can be minimized by
both careful incisional technique and meticulous clo-
sure. Precise reapproximation of the incisions can vastly
reduce the visibility of these scars. If the incisions do
not align correctly during closure, the surgeon should
remove the sutures and try to correct the closure. A sub-
cutaneous suture and multiple 7–0 vertical mattress ny-
lon sutures can be used to close the midcolumellar and
alar base reduction incisions. Moreover, careful closure
of the mucosal incisions is important to reduce the risk
of internal nasal scarring, which can lead to vestibular
stenosis and nasal airway compromise.
Whenever costal cartilage is harvested for grafting
purposes in rhinoplasty, there is a risk of pneumotho-
rax. To ensure that the pleura is intact, the wound cavity
is fi lled with antibiotic solution after the costal carti-
lage has been taken, and the anesthesiologist creates a
positive ventilatory pressure for the patient (a Valsalva
maneuver). Air bubbles in the wound should alert the
surgeon to a possible rent in the pleura, which should
be repaired if identifi ed. The wound is closed over a red
rubber catheter placed on suction. With the chest ex-
panded, the catheter can be removed. A postoperative
chest X-ray can confi rm full expansion of the lungs.
The key to repairing any intraoperative complication is
the surgeon’s ability to recognize the problem intraopera-
tively and then to try to remedy it promptly. Ignoring such
problems intraoperatively will lead to a greater number of
postoperative complications and unhappy patients.
Fig. 10.4 Patient with severe supra-alar pinching due to over-
resection of the lateral crura.
Fig. 10.5 Alar batten grafts can be placed into a pocket at the
site of maximal supra-alar pinching. This auricular cartilage
graft is placed with its concave surface placed medially.
be subtle, with an angle no greater than 10 to 15 de-
grees. Cautery should be avoided in this area as well,
for necrosis or atrophy of the underlying subcutaneous
Fig. 10.6 Patient who underwent over-reduction of nasal
base, leaving the patient with very small nostrils and airway
obstruction.

Complications in Facial Plastic Surgery
82
commonly, a pollybeak deformity may be improved by
reducing an excessively high anterior septal angle.
The use of grafting in rhinoplasty enables the surgeon
to accomplish not only structural stabilization but also
aesthetic refi nements. However, without proper camou-
fl age, grafts are at risk of postoperative visibility and con-
tour irregularity. Tip grafts are a good example of a graft
that is at risk for postoperative visibility if camoufl age
is not adequately performed intraoperatively (Fig. 10.8).
Often a graft becomes visible only after many years of
scar contracture and gradual thinning of the nasal skin.
Tip grafts should be avoided in patients with thin skin.
For any graft at risk for postoperative visibility, the
surgeon can employ several techniques to decrease the
risk of this complication. Every graft should be carved
so that there is a smooth transition between it and its
surrounding structures. The edges of a shield-like tip
graft should be beveled (Fig. 10.9). A buttress graft can
be placed behind the superior edge of a shield-like tip
graft to help smooth the transition between the graft
and its surrounding structures (Fig. 10.10). It also helps
to prevent cephalic rotation of the tip graft. Any tip graft
that sits 3 mm or more above the surrounding cartilage
should be camoufl aged with lateral crural grafts. These
grafts are positioned at 45 degree angles from the pos-
terior margin of the superior edge of the shield-like tip
graft (Fig. 10.11).
The surgeon can achieve additional camoufl age over
grafts at risk of becoming visible postoperatively by
covering the leading edge of the graft with crushed
cartilage or perichondrium. Cephalic trims are an ideal

◆ Postoperative Complications and
Their Prevention
In the immediate postoperative period, the patient is ex-
pected to have nasal edema. This is especially true if the
patient has thick sebaceous skin. Elevation of the head,
reduction in sodium consumption to less than 1200
mg daily, and avoidance of overheating can help reduce
the degree and persistence of nasal swelling. Although
some surgeons advocate early injection of steroids to
help reduce postoperative nasal edema, the senior au-
thor prefers to avoid steroid injections during the early
postoperative period. The patient should be reassured
that the swelling is normal and that it should begin to
subside by four to six weeks postoperatively.
Nasal Tip
Many problems seen after rhinoplasty can be attributed
to loss of nasal tip projection. Without intraoperative
control of tip projection, the surgeon is forced to try to
anticipate where the tip will eventually settle. When
surgeons leave such an important component of the
overall result to chance, they are likely to have patients
with postoperative loss of tip projection. A critical fac-
tor in controlling the nasal tip is stabilization of the na-
sal base.12 Methods to stabilize the nasal base include
suturing the medial crura onto the septum or placing
a columellar strut graft, a caudal extension graft, or an
extended columellar strut graft. The indications and
technical aspects of each method are beyond the scope
of this chapter. For an in-depth discussion of nasal tip
surgery, the reader is referred to alternate resources.11,13
A favorable tip-supratip relationship is essential.
Postoperative loss of nasal tip projection can result in
a supratip pollybeak, as the nasal tip drops below the
supratip (Fig. 10.7). This leads to a rounded appearance
of the tip, with the absence of a supratip break or a fa-
vorable columellar-lobule relationship. Pollybeak defor-
mity may also result from a failure to reduce an overly
elevated middle vault and supratip dorsum. Excessive
excision of the dorsal septal cartilage may also result in
a pollybeak deformity. This is especially true in patients
with thick nasal skin, because the overlying SSTE may
not redrape appropriately over the underlying struc-
tural framework if it is overly reduced. Scar and fi brosis
then may develop within this tissue void, causing a su-
pratip fullness and a soft-tissue pollybeak.
In general, correction (or avoidance) of a pollybeak
deformity may be addressed in one of several ways, de-
pending on the etiology of the problem.2,14 When the
pollybeak deformity arises from over-reduction of the
underlying cartilaginous framework in a patient with
thick, sebaceous skin, correction involves projecting the
tip into the thick SSTE, sometimes with the addition of
dorsal augmentation. If there was loss of tip projection
with resultant pollybeak deformity, reestablishing tip
support and projection is necessary for correction. Less
Fig. 10.7 Postoperative supratip pollybeak deformity from
over-reduction of the nose and postoperative loss of nasal tip
projection.

10 Rhinoplasty Complications
83
source of soft cartilage for this purpose, as is the thick
perichondrium from costal cartilage. The cartilage or
perichondrium should be placed in a horizontal fashion,
with complete coverage of the lateral aspect of the tip
graft (Fig. 10.12).
Nasal tip bossae may result from unequal excision of
the lower lateral cartilages, suturing asymmetries, or
structural grafting. Bossae may also form due to knuck-
ling and weakening of the lower lateral cartilages or tip
grafts as SSTE contracture occurs. These bossae may be
more pronounced in patients with thin nasal skin, in-
tralobular bifi dity, or strong cartilages.15 Many of these
irregularities may not be apparent for several months
(until postoperative edema resolves), and they have
been known to develop as late as 10 years after surgery.16
Avoidance of tip irregularities involves smooth contour-
ing of the domal regions, maintaining the strength of
the lower lateral cartilages (without weakening their
cephalic margin), and performing adequate camoufl age.
Bulbosity of the nasal tip is often addressed with a
cephalic trim of the lateral crura. However, overly ag-
gressive resection of the lateral crus of the lower lateral
Fig. 10.8 Thin skin has contracted over the tip graft, leaving a
visible deformity.
Fig. 10.9 Shield tip graft with beveled edges to help avoid
visibility.
Fig. 10.10 Tip graft with buttress graft to stabilize and
camoufl age.
Fig. 10.11 Tip graft with lateral crural grafts to stabilize and
camoufl age.
Fig. 10.12 Tip graft camoufl aged with the cephalic trim of
the lateral crura.

Complications in Facial Plastic Surgery
84
cartilage may lead to cephalic retraction of the alar mar-
gin. If a cephalic trim is performed, 8 mm to 12 mm of the
vertical height of the lateral crus should be preserved to
reduce the risk of alar retraction. Alar retraction occurs
as scar contracture moves the tissue in a direction away
from lesser support (the free alar margin) to an area of
greater support (the bony-cartilaginous pyramid).
A
B
C
D
E
F
Correction of alar retraction can be challenging.17
Sometimes the placement of alar rim grafts corrects
the problem. In other patients, repositioning the lateral
crura more caudally helps to push down the alar margin
and correct the retraction (Fig. 10.13). In these cases,
lateral crural strut grafts are placed on the undersurface
of the cartilage (between the lateral crura and the ves-

10 Rhinoplasty Complications
85
Fig. 10.13 Patient with severe retraction of left alar
margin. Treatment required placement of a left lateral
crural strut graft, alar rim graft and composite skin
cartilage graft from auricle. (A) Placement of lateral
crural strut graft that is sutured to undersurface of
lateral crura. The lateral crura is then repositioned into
a caudally positioned pocket to push the alar margin
down. (B) Alar rim graft along left alar margin. (C)
Composite auricular skin cartilage graft. (D) Compos-
ite graft positioned into pocket along left marginal
incision. (E,G,I,K) Preoperative views. (F,H,J,L) Postop-
erative views.
G
H
I
J
K
L