Fig. 18.4 Completion of chemical peel. There are uniform erythema to the face, fine bismuth coat on the upper eyelid, and Micropore® tape on the lower eyelid

The patient is advised not to apply Vaseline® to the eyelids, as these areas require 8 days to peel.

Once the facial skin peeling has finished, 1% hydrocortisone cream should be applied two or three times a day for 1 week. Thereafter, the pre-peeling conditioning regime, that was described earlier, should recommence. Eight days after the procedure, the patient should begin applying Vaseline® ointment to remove the bismuth layer. One percent hydrocortisone cream should be applied twice a day to the eyelids and the periorbital area for the first week, after which the same pre-peeling skin protocol is begun. After the peeling

skin has been removed on the fourth day, the skin will display a new, fresh, and healthy pink color. After removing the periorbital and eyelid bismuth layer on the eighth day, this skin will also display a new and fresh, though slightly red color. This difference in skin color will gradually disappear over the course of 2–3 months. It is very important to reassure the patient that this difference in color is a normal reaction to the fact that both deep and medium peels were performed. Patients may use makeup after sun protection has been applied to the skin (Fig. 18.6).

18.7 Complications

Chemical blepharoplasty is associated with excellent results and a high level of patient satisfaction. The reason for this is that, with the Exoderm solution, systemic complications and permanent dermatologic complications are not seen as they are with other phenol peels [10, 11]. Chemical blepharoplasty is a safe and an easily performed procedure. It is important that patients be educated to expect significant swelling of the face and eyelids, and that this is normal and temporary.

Fig. 18.6 Blepharoplasty properly performed. (1) Preprocedure. (2) Eight days following chemical peel. (3) Fortyfive days post-procedure. After couple of months skin color tends to get evenness

18.7.1 Ectropion

Patients may experience temporary ectropion lasting 2–3 months. This is unlike the ectropion seen after surgical blepharoplasty, which may be permanent.

Significant ectropium may however occur in patients who have undergone previous lower eyelid surgical blepharoplasty or in patients with a preexisting borderline or frank ectropion.

18.7.2Post-inflammatory Hyperpigmentation

Post-inflammatory Hyperpigmentation (PIH) may occur after a chemical peel, particularly in patients with darker skin (Fig. 18.7). This complication is rare due to the aggressive use of pre-chemical peel skin conditioning, as well as the prompt resumption of this conditioning post-procedure, as described above.

18.7.3Pseudo-Adhesion/Pseudo-Web Formation

During the initial postoperative period, at around the fourth day, the patient may describe some difficulty in completely opening the eyes. In this instance, the bismuth has become thicker in nature and acts like a pseudo-adhesion/pseudo-web, preventing complete upper eyelid movement. This is easily ameliorated by teaching the patient to apply a thin coat of Vaseline® ointment over the bismuth once or at most twice a day for 1 or 2 days. It is important to instruct the patient to only use a thin coat; otherwise the bismuth layer will be removed too soon.

18.7.4 Web Formation

In the author’s experience, there were three cases where patients had scratched their upper eyelids postoperatively. Two cases had scratched the lid and one, in particular, the upper inner eyelid. In the first two cases, healing occurred normally without scar formation, though this healing process was slow. In the third case, where the upper inner eyelid was scratched, a web formed and this was successfully treated with early corticosteroid intralesional injections. In patients