Fig. 11.7 Bilateral lagophthalmos

Fig. 11.8 Lagophthalmos on the right resulting from levator incorporation into the wound at time of upper blepharoplasty

of the ocular surface. Ophthalmic ointment or topical artificial tear supplements in drop or gel form can be used protect the cornea. Forced orbicularis closure via taping of the eyelids may reduce mild to moderate postoperative lagophthalmos.

11.3.1.2 Surgical Management

If conservative management fails, then surgery designed to correct the underlying process that created the lagophthalmos is indicated. In instances where the orbital septum is tethered, the operative wound is opened and the orbital septum released. If ptosis repair was performed with the blepharoplasty, or in cases where the levator complex has been inadvertently shortened or incorporated into the wound closure, lagophthalmos may result from the tightening of the levator muscle complex (Fig. 11.8). To improve the lagophthalmos, these attachments are released until full eyelid closure is achieved. Rarely, the good results of surgery are reversed by the secondary release of tissues to protect the patient’s cornea and vision, and improve comfort.

Some patients with symptomatic lagophthalmos may have vertical shortening of the eyelid skin (anterior lamellar deficiency) as the primary etiology. In these cases, a full thickness skin graft (FTSG) is the best mechanical way of improving eyelid closure. The skin graft should be harvested from skin that is similar in texture and color. The contralateral upper eyelid skin is the preferred donor site, but preauricular, retroauricular, or supraclavicular skin can also be used. It is important to size the graft with a slight overcorrection in order to account for intraoperative and postoperative contraction [25].

11.3.2 Dry Eye Syndrome

Patients experiencing dry eye syndrome will complain of ocular irritation, foreign body sensation, redness of the conjunctiva, and potentially blurred vision. Individuals with preexisting dry eye syndrome can experience an increase in symptoms following blepharoplasty. Dry eye predominantly results from inadequate tear production, instability of the tear film, or a deficiency in quality of the any tear film component. In postblepharoplasty patients, dryness may be caused or exacerbated by lagophthalmos, alteration of blink, or rarely, lacrimal gland injury. Patients with a history of laser vision correction are at an increased risk of developing dry eye after blepharoplasty, with some authors suggesting that blepharoplasty not be performed for a minimum of 6 months after refractive surgery [26]. Patients in this population should be identified during the preoperative assessment and informed of the potential for increased risk of complications. Also at risk are older patients, related to involutional reduction in tear production, orbicularis weakness, reduced Bell’s reflex, eyelid closure, and lower lid deficiencies. These patients require a detailed assessment of the factors which may lead them to symptomatology after surgery.

11.3.2.1 Medical Management

Dry eye syndrome is managed with ocular lubrication such as artificial tears and lubricating ointment. Postoperative dryness may occur even in the absence of lagophthalmos. Patients with preexisting conditions of dry eye syndrome should be lubricated more aggressively in the early postoperative recovery period. In patients who are refractory to simple eye lubrication, punctal occlusion is sometimes beneficial in alleviating symptoms of dryness [27]. Topical cyclosporine (Restasis, Allergan, Inc., Irvine, CA) has been used to increase tear production, but is better suited as a long-term intervention for chronic dry eye syndrome than as an immediate postoperative medication. Symptoms of dryness may abate as the normal speed and frequency of the blink returns when orbicularis function normalizes.

11.3.2.2 Surgical Management

Surgical management of dry eye syndrome is limited to correction of concomitant complications such as lagophthalmos and eyelid retraction. In cases where punctal occlusion is clinically beneficial, permanent surgical punctal occlusion can be performed. However, this should only be performed after evaluation and recommendation by an ophthalmologist.

11.3.3 Lacrimal Gland Injury

Injury to the lacrimal gland can occur during upper blepharoplasty, especially in patients whose lacrimal gland(s) is/are