Doing more blepharoplasties than usual?

It’s (not) just the economy — apparently, folks want to look good in cyberspace.

By Christine Bahls, Executive Editor

For practices offering oculoplastic services, here’s a possible reason why your blepharoplasty schedule’s been busier than usual: The American Academy of Facial Plastic and Reconstructive Surgery says its members reported an increase in these procedures from 2012 to 2013; the percentage rose 4% between 2011 and 2012.

In sheer numbers, according to the plastic surgeons’ group, 196,286 eyelid lifts were performed in 2011; in 2012, the figure was 204,015.¹

Dan Garibaldi, MD, an oculoplastic surgeon with the 11-site practice Ophthalmic Consultants of Long Island, has noticed the trend. “Cosmetic surgery tends to wax and wane with the economy. When people have more expendable income they tend to pursue cosmetic options more frequently.”

The selfie trend

It’s possible that plastic surgeons and oculoplastic surgeons are seeing more patients for different reasons. According to the AAFPRS’s press release, people want to look better because of ‘selfies.’ A 2014 AAFPRS survey found that people’s desire to look good in cyberspace hasn’t relented.²

But according to two studies, both authored by plastic surgeons, plastic surgery patients who undergo blepharoplasty develop more complications, including dry eye symptoms and lagophthalmos, at significant rates.^3,4

“In my experience, when [the surgery] is done by a non-ophthalmologist, there is more incidence of dry eye,” says Russell G. Fumuso, MD, a comprehensive ophthalmologist who works with Dr. Garibaldi. It is rare to see an overcorrection from an oculoplastic surgeon, he says.

One study is a retrospective review that looks at the percentage of cases reporting dry eye symptoms and chemosis over a 10-year period3; the other shows how sparing the orbicularis oculi muscle reduces numerous complications, including dry eye symptoms.⁴

The retrospective study, involving 892 cases, reported that dry eye symptoms and chemosis were reported in “26.5% and 26.3% of patients, respectively.” In the second study, patients who had blepharoplasty and whose orbicularis oculi muscle was removed had “significantly higher” incidence of dry eye symptoms, as well as other problems, including lagophthalmos.

“The [first] study is not a surprise. Not at all; I see that,” Dr. Fumuso says.

Surprise, surprise

Dr. Garibaldi said he was surprised the percentages weren’t higher. Retrospective studies relying on patients’ self-reporting symptoms make it hard to tease out what is causing their symptoms; are the “dry eye” patients those who have a decreased blink mechanism? Is there subtle lid malposition? Have they had a flare of blepharitis?

“The reported percentage of dry eye symptoms in the [retrospective] study is actually far lower than I’d expect,” Dr. Garibaldi says.

Fellow colleague Marguerite B. McDonald, MD, who specializes in corneal disorders, cataract and refractive surgery, says she sees dry eye and chemosis after blepharoplasty frequently, though it lasts temporarily.

“The lids are swollen immediately postop, so they do not blink normally and therefore do not distribute the tears in a normal fashion. In addition, the swollen lids do not provide the normal pumping action that extrudes meibum from the meibomian glands with each blink, thereby producing an evaporative dry eye as well,” says Dr. McDonald.

This does not mean that blepharoplasties are a bad idea. The oculoplastic surgeons are acutely aware of these issues and provide the proper regimen for the early postop period, she adds.

The orbicularis muscle

As for the study on the orbicularis muscle, Dr. Garibaldi has tended to leave that muscle intact for years. “If you have cosmetic surgery on the upper or lower lid, the blink will be weaker. Most patients don’t require a significant resection of that muscle during a cosmetic procedure; sparing it will lead to a better blink postoperatively.”

Moreover, as Dr. Garibaldi has found — and the study author as well — patients who have their orbicularis muscle left intact generally do better in terms of ocular surface symptoms. They have fewer of them.⁴

Learning from your patients

Dr. Garibaldi said he has learned part of his postoperative treatment protocol from his patients. For chemosis, the most important trick is to keep them from sleeping on their sides or stomach for several weeks postoperatively. He can tell the position that his patients favor by the preoperative condition of their eyelids, he says.

“Side and front sleepers can have trouble with their incisions and develop severe prolonged chemosis. If you keep them on their back and reclined at a 30-degree position for three to four weeks postoperatively, they will have an easier postoperative course and less swelling,” he explains. Make sure patients stay on their backs for a couple of weeks after the sutures are removed to avoid incision problems and increased scarring.

Besides advising them on their sleeping positions, Dr. Garibaldi also tells his patients to keep their eyes well lubricated in the postoperative period. To avoid ocular surface symptoms and chemosis he has his patients alternate artificial tear drops with topical ophthalmic steroids for two to three weeks. “One advantage of having an oculoplastic surgeon perform a blepharoplasty is that they can use steroid eye drops and ointment postoperatively to prevent and/or treat ocular surface symptoms while monitoring for the rare side effects of these medications.”

But even before patients set a date for their surgery, be it a functional or cosmetic reason, it is the preoperative evaluation that will likely separate those who can, and those who cannot, get surgery. Or at least postpone it.

“Those patients with sleep apnea, thyroid disease, extremely loose lids or who have baseline excess conjunctiva [conjunctivochalasis] are those who are going to be at risk for severe chemosis,” Dr. Garibaldi says. If the patient has “baseline severe ocular surface disease they are not good candidates for cosmetic surgery until this condition is optimized.”

But even if their eyes are perfect, that doesn’t mean patients shouldn’t expect ocular surface symptoms after the surgery.

“In my own clinic, I tell all ‘dry eye’ and ‘blepharitis’ patients that even with ‘perfect surgery’ they should expect at least a temporary increase in their ocular surface symptoms,” Dr. Garibaldi says.

That said, these related ocular-surface complaints generally don’t last a long time [[How long is that? What should doctors tell their patients about what to expect?]].

“There is no way around the risk of increased ocular-surface symptoms with blepharoplasty of any type, though it is far more common when working on the lower lids in conjunction with the uppers,” he says. OM

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