S05E96 - The Best Ways to Recover After Cosmetic Eyelid Surgery

Join hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic as they discuss the intricacies of managing common complications following eyelid surgery. The surgeons explore various post-operative issues, such as blurred vision, swelling, chemosis, and lid malposition. They provide tips on patient preparation, management techniques like the use of frost sutures, compression, and ice, and emphasize the importance of setting realistic recovery expectations. The discussion is enriched with personal experiences and expert insights aimed at helping patients understand and navigate the recovery process.

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S05E96 - The Best Ways to Recover After Cosmetic Eyelid Surgery

TRANSCRIPT

[00:00:00] Dr. Sam Jejurikar: All right, welcome everyone to another edition of Three Plastic Surgeons and a Fourth. As always, I'm Sam Jejurikar in Dallas, Texas, and I'm joined by Dr. Lawrence Tong at Yorkville Plastic Surgeon.

Uh, in Toronto, Ontario, by Dr. Sal Pacella at San Diego Plastic Surgeon in La Jolla, California. And Dr. Sam Rhee at Bergen Cosmetic in Paramus, New Jersey. Welcome, gentlemen. Um, today we're going to talk about a topic that we don't find that interesting, but I think patients will, and that is how to manage some common complications after eyelid surgery.

Eyelid surgery is incredibly common. Um, um, Complications, at least transient ones, are pretty common as well. And, uh, luckily we have some experts here who can kind of provide some illumination to our patients about how to, how to deal with these. So before we get going to the meat of this, Dr. Tong, you want to read our usual disclaimer?

[00:01:00] Dr. Lawrence Tong: I sure will. So, this show is for information purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something on this show.

[00:01:25] Dr. Sam Jejurikar: So, uh, we, we have talked about this topic before and Dr. Pacella in a previous iteration of this, of the show when Dr. Pacella actually gave us this PowerPoint presentation, but he showed us some pretty severe complications at that point. Kind of the impetus behind all of our topics are things that are happening in our practice.

And in the last couple of weeks, I've had a few patients who have done facelifts and eyelid surgery on and they've had some complaints afterwards. And one of the, one of the patients that has been struggling the most was telling me immediately after surgery that her vision was blurry, um, which I assured her was normal.

My thought was normal. And then over the last, over sort of the first week after surgery as well, her vision was blurry as well. And she was very concerned she was going to lose her vision. Do you guys find that this is a common complication after eyelid surgery, blurry vision? And if so, what are the causes behind it?

[00:02:20] Dr. Salvatore Pacella: um, so first of all, I think we have to kind of separate. The upper lid from the lower lid. You know, I think most of us on the podcast here and most plastic surgeons will kind of agree that upper lid surgery is a much easier phenomenon than lower lid surgery. Really associated with minimal complications, minimal risk, um, minimal recovery, a little bit of bruising, perhaps.

Lower lid surgery is really, uh, oftentimes the, the issue with patients when they complain of. Significant complications. Dry eye, pain, discomfort, swelling, blurry vision, etc. So, um, in your particular patient, Sam, was it a lowered left or?

[00:03:04] Dr. Sam Jejurikar: It was an upper and lower bleph, and I'll just cut to the chase. She had lubricants in her eye right after surgery, which we use to keep the eye. So a hundred percent of my patients typically wake up with blurry vision because of the lubricants that we use to keep their eyes dry. But, but she also had lower eyelid surgery, and I think that segues into sort of the more delayed, um, the more delayed blurriness we were seeing as well.

But it was lower eyelid surgery with a trans, transconjunctival approach and removal of some fat, that kind of stuff.

[00:03:31] Dr. Salvatore Pacella: And so, you know, if you, if you look at the anatomy of the eyelid, you know, the inner lining of the eye Is in continuity with the lid as well as the, the sclera, the, the white of the eye or the cornea, which is the center vision portion of the eye. So anytime you have swelling in and around the eyelid or the periorbital area, that's gonna lead to some swelling of the sclera, the white of the eye, and the conjunctiva.

Okay. That's, it's all anatomically based and so, so I try to do my best before surgery to. Prepare patients for blurriness and vision issues afterwards, which invariably are transient. But the key is really control of the swelling, in my opinion. You know, so we're really pretty aggressive with compression and ice, um, after surgery.

I think one of the, one of the sort of factors that can occur after lower lid surgery in particular is the eyelid not closing. And so, when the eyelid doesn't close exactly right, Um, and that's transient. That can lead to the eye drying out, which can lead to visual changes and blurring. So, it's something we call chemosis.

And so, to me, the best way to control that is on the table, um, during the surgery and immediately after. I often tend to put a little stitch at the very corner of the eye. It's called a frost suture. And to do that, it's very easy to do. It comes out about a week later, and it closes about a third of the eye.

Now patients can still read, they can still do things centrally, um, but the, where you're going to see that, that desiccation is really laterally like this. So I put a little stitch at the very corner and that usually helps to prevent some blurriness, but, or excuse me, some desiccation. But I think the blurriness is a, is a necessary evil after surgery.

So we just got to prepare our patients for that.

[00:05:19] Dr. Sam Rhee: Have you ever seen that, uh

[00:05:23] Dr. Lawrence Tong: oh, just to, uh, elaborate on the point with the frost itch, I think. That is an excellent practice and I do that for all my patients as well. I think that it does two main things. One, it prevents the lid from getting pulled down because even if you, you're pretty conservative with removing skin and, and you're doing things to tighten the tone, just a swelling of the surgery itself can cause the lid to get pulled down.

And what I find that once the lid gets pulled down, then it can take a long time to come back up. It's transient, but sometimes it can take a while. And the other thing is that then the, the, the lid isn't, opposed to the globe anymore, and you're going to get things dried out. So that contributes to it. And plus, if you put the frost ditch and have it up like that, that means that that area is always closed.

So during that healing process, it's always going to stay moist and you're not going to get that chemosis, which is the swelling of the white part of the eye, because the chemosis itself can cause, can worsen things. The chemosis is basically, looks like a clear jelly on the white part of the eye. And that can cause That physically being there was going to push the lid out, um, and further cause a worsening of that problem.

So I think that, uh, Dr. Pacella is exactly correct. Uh, trying to prevent, um, that vicious cycle from, uh, from happening is very important. Sorry, Sam, go ahead.

[00:06:42] Dr. Sam Rhee: Oh, have you ever seen that movie Shallow Hal? There's a sequence where the guy goes to the door, and he doesn't, uh, want, uh, to be seen, so he freakin puts all this, like, petroleum jelly over his face, and it looks like he has this, like, horrible conjunctivitis, like, When my patients leave, they got a crap load of stuff of product on their eyes.

It's a, it's a lot. And I make sure that I provide them with a ton of stuff to keep those eyes lubricated. And I think most of what we're all talking about is. What we want our patients, avoid dryness, cover the eyes, know that you are going to be blurry. I've never had, let me flip it, I've never had a patient who did not report their vision was clear as a bell initially after surgery or, or for some time after surgery.

They, they all expect it, as you said, like we, we tell them, Don't worry if your, if your vision is blurry. Now there are, and we all know about this, reasons why patients vision can be blurry or they can have blur, uh, issues afterwards, but those are, are some major issues if you've dinged one of the eye muscles or something like that.

Like, these are all things that we've learned about. Um, and when you do your anatomic dissections, and when you learn about how to do a blepharoplasty, you know what are the things that could be a problem. And I would imagine some of our patients have probably read up on this stuff, started freaking out, and just like everything else, started being a little bit overly concerned.

But I think for most of us as, um, As surgeons, we examine our patients pretty carefully. If they, if, uh, if everything looks like it's healing well, if there are no issues, then that blurriness is completely expected. Um, it is, uh, part of the normal recovery process. Uh, does that mean that we ignore our patients and never, like, You know, just, just poo poo it.

No, we always, you know, we're always checking our patients, but, um, I think our patients should know that if they have blurriness after a lower lid blepharoplasty, especially, uh, Even at, you know, it's, that's, that's to be expected.

[00:08:55] Dr. Salvatore Pacella: You know, if you, if you've ever sprained your ankle, right, what is the, What do the ER docs or the orthopedic surgeons tell you to do? They tell you to, to put rice on it, right? Not, not rice in the true sense, but R I C E, right? So rest, um, ice, compression, elevation. Right? So, rest. I tell this for eyelid patients as well.

Rest. You have to rest your eyes. This is not a time to watch Netflix and chill. Okay? This is not a time to be scrolling on

[00:09:27] Dr. Lawrence Tong: Well, does Netflix sell?

[00:09:28] Dr. Sam Jejurikar: and chill, that's

[00:09:29] Dr. Lawrence Tong: Yeah, that's a different thing. Ha ha ha!

[00:09:34] Dr. Salvatore Pacella: to be scrolling, you know, and, you know, doing all sorts of Insta stuff, you know, on the Gram, okay? Um, you gotta rest your eyes, okay? You can't really work and cause eye fatigue.

That's gonna cause you much more problems. Ice, okay? Liberal ice. So, unlike, say, when you're icing your wrist, where it's 20 minutes on, 20 minutes off, I, I'm under the impression you can kind of keep ice on it continuously. Ice, unless it's, you know, some massively frozen ice, little chunks of ice are gonna, are gonna get warm after 20 minutes anyway.

So, you gotta keep replenishing the ice on the eye. Compression.

[00:10:12] Dr. Sam Jejurikar: long do you, and how long do you tell your patients to ice for?

[00:10:15] Dr. Salvatore Pacella: At least two weeks, you know, two weeks. Um, I think it's important because you still have swelling. Um, compression. So, sleeping with an eye mask. Oftentimes in the worst of patients, patients that have very prominent eyes, I recommend putting liberal amounts of ointment on, putting an eye mask over, and then actually wrapping an ACE bandage around their head.

Um, I do that anyway, so I don't have to hear anybody, you know, While I'm going to sleep.

[00:10:45] Dr. Lawrence Tong: Are you talking about like a sleep mask or something special for blepharoplasty?

[00:10:48] Dr. Salvatore Pacella: mask, you know, like you get on a, you know, an

[00:10:51] Dr. Sam Jejurikar: I could get in there and play.

[00:10:52] Dr. Salvatore Pacella: Yeah, so, um, and so that sleep mask and the compression really help to, um, I think add physical compression which can assist with generalized swelling of the lid and can also assist with chemosis, right?

And then finally, elevation. You don't want to lay flat, obviously, that's going to cause your eye to sort of take in a lot more swelling and try to have them sleep with their head elevated.

[00:11:15] Dr. Sam Jejurikar: So we've used the term chemosis, uh, at least three times now. Um, when you guys want to explain what chemosis is, I know Pacella, I think you've written a paper that I've read several times on, on this for management of it because chemosis is one of the, one of the things where if it gets kind of severe for a patient, it can be kind of a pain to get rid of.

And so what is chemosis? How serious is it? And how, Can a patient get rid of it or a surgeon get rid of it if their patient has it?

[00:11:43] Dr. Salvatore Pacella: So, it's a very common, uh, complication after eyelid surgery, specifically lower eyelid surgery, okay? And as I mentioned earlier, you know, the lower eyelid is connected to the conjunctiva. of the eye, so, or the sclera, okay? The conjunctiva is a small little membrane on the surface of the white of the eye.

When I say the sclera, I mean the white of the eye, okay? And so what chemosis looks like, it looks like a blister associated with the white of the eye. It's usually on the outside of the eye, okay? And that blister is inflamed, desiccated, dried out eye tissue, okay? And why that's important is when the eyes get too dry, and you develop chemosis, the eyelid is not going to close it.

If you're closing an eyelid over a globe like this, and it's very smooth, that's fantastic. But if you've got some, a bulb of blister right here, all of a sudden that eyelid's not going to close. So chemosis is really a sort of a vicious cycle of eye dryness, which causes the eye to stay open. Which causes more dryness, right?

So that's why it's such a pain to manage. So the key is really managing the eyelid closure as aggressively as possible, even on the day of surgery. Now, how we do that, we mentioned about the frost suture. How do we control for chemosis in the early postoperative period? Well, so, Again, rest, ice, compression, elevation.

If somebody comes in and they still have chemosis a few days after surgery, I am very liberal with ocular decongestants, okay? So, much like you can put Afrin inside your nose if you have a swollen eye, um, they make prescribed medications that you can use for eye redness or, um, Visine, right, for example.

Vizine works very well for chemosis because it constricts blood vessels, causes a, uh, an overall, uh, reduction in the amount of tissue that's exposed. So that can be utilized very well. That with steroid drops, steroid ointments, can usually keep chemosis under control. But the key is, once you recognize it, you've got to get it under control or else it's going to be a problem for weeks and weeks and weeks.

And your patients will hate you.

[00:14:05] Dr. Sam Jejurikar: What, what about, what about a role for mechanical decompression? I know you've taught me about that in the past.

[00:14:11] Dr. Salvatore Pacella: So, a little bit controversial, okay? Uh, my very good friend who's, uh, one of the top oculoplastic surgeons in the world, Mo Algool, he's, was in Chicago and is now in Amman, Jordan. Um, he's a big proponent of if you develop chemosis on the table during the surgery to do an immediate, what's called a conjunctotomy.

So, you, you know, not for the faint of heart, but you can actually lift up that tissue and just trim it. In order to get it under control so that it doesn't become a problem post operatively, okay? I am not that aggressive with treatment on the table because I think with just simple compression and closing the eyelid, early onset chemosis can be managed very easily.

easily with just eyelid closure. So, I would only resect the tissue or remove it probably after about three to four weeks if it looks like it's not improving substantially. Now, that can be done relatively easily in the office. You just numb it up with a little local anesthesia, protect the eyelid, protect the, or excuse me, to protect the eyeball, and you can trim it with a tiny little scissor.

But that can also cause more dryness and more desiccation and more swelling, so it's, it's, it's a little bit of a controversial procedure.

[00:15:28] Dr. Sam Rhee: What, what are the

[00:15:29] Dr. Lawrence Tong: do you, uh,

[00:15:30] Dr. Sam Rhee: sorry, go ahead.

[00:15:31] Dr. Lawrence Tong: I was going to say, do you routinely prescribe, um, steroids?

[00:15:37] Dr. Salvatore Pacella: I usually do it within the context of the ointment, okay, so everyone that I operate on for lower lid surgery, uh, gets a combination of a dexamethasone ointment with an antibiotic in it, okay. I'll, uh, The common one that everybody

[00:15:56] Dr. Lawrence Tong: or something like that?

[00:15:57] Dr. Salvatore Pacella: Topradex, but Topradex is very expensive. It's a few hundred dollars for a tiny little tube.

I use Maxitrol, which is, I think, 30 a tube, which is the generic component of things. A lot easier financially for patients to get that. Um, so I routinely have them use that for the first, um, Uh, six days after surgery. Now the thing to be, the thing you want to keep in mind here is you don't want to use a steroid for more than at max a week after surgery, but because that can put you at risk for glaucoma.

[00:16:27] Dr. Sam Rhee: Yeah. I use it for about a week, but I use both the drops and the ointment usually. And then I, uh, for about a week. Yeah. Maxitrol.

[00:16:37] Dr. Lawrence Tong: What about, is there any role for taping? Do you use taping when they've developed chemosis?

[00:16:43] Dr. Salvatore Pacella: so excellent, excellent question. So, um, so in any lower eyelid surgery, in addition to the frost suture, I use tape and I usually use very thin foam tape. So the way I put this on patients is. I do kind of like a little mask, if you will. Alright, so, take a thin little piece, about 5 millimeters, 5 millimeters width, a couple centimeters thick.

And then I'll start it from the medial canthus, and then place it to the lateral canthus. But it always peels off at the side. So then I put a piece across here, and I put a piece across the nose. So that essentially creates a little bit of a sling for the tape. Okay? Um, I usually leave that on at least a week, take it off when I take off the frost suture.

If it's a super aggressive lower blepharoplasty that I did, meaning a skin muscle flap, I'll have them taped for the next couple weeks. If it's just a simple transconjunctival, Blepharoplasty I did. Uh, I usually see how they look right the week after surgery if the swelling is under pretty good control, I don't have them taped necessarily.

So, taping I think is key.

[00:17:50] Dr. Sam Jejurikar: so, and that leads naturally to yet another complication we can see after lower eyelid surgery and that's lid malposition. So. So let's say your patient doesn't have dry eye, doesn't have chemosis, but you mentioned doing an aggressive operation. Why are you having them tape for the period of time that you are?

Can you explain to the patient sort of what it is you're concerned about? Lower eyelid malposition?

[00:18:11] Dr. Salvatore Pacella: So, so in the lower eyelid, um, Small procedures give small results. Big procedures sometimes give big results, and great results, in my opinion. So when we're doing a more aggressive blepharoplasty, for example, someone has deep, deep set bags, or mailer bags, okay? I think we talked about mailer bags in a previous episode.

Um, blepharoplasty on them. I am, the simple fact of the matter is, when you do that, You are causing a lot of damage. You are causing a lot of damage to the muscle of the eye that's responsible for closing the eye. So you want to treat the muscle with respect. Okay? You want to give it all the support it needs to continue to close the eye.

Okay? And so, that's why I use tape aggressively. I use the frost suture aggressively. Um, and I'll have them massage afterwards to help hold the lid position upwards to prevent early onset scarring.

[00:19:12] Dr. Lawrence Tong: Yeah, another, another very basic point is, um, you know, don't go, don't go too crazy with your skin removal. Cool. And that's probably the number 1 cause of lid malposition is, uh, when surgeons are doing these lower lip blepharoplasties and they, on the table, it looks like you can remove a lot of skin. Um, and that's only going to give you, that's going to give you problems.

So be conservative in the skin removal. And I, I think I, Know how Dr. Pacella does his blepharoplasties, where when you tighten the skin, you're actually shifting a lot of things laterally as opposed to vertically so that you don't have to remove skin. You can just tighten things by shifting things laterally instead of vertically.

So the amount of skin that you remove is only going to be a few millimeters. 1 to 3 millimeters is my sort of average amount. And then, plus the other things that Dr. Pacella had said, reinforce the tone, uh, of the lid either by doing something called a muscle sling or a, or a canthopexy or a canthoplasty, all those things to support the, the lid tone, um, anatomically.

And then the other sort of external things, such as, uh, the taping and the frostage are all sort of working together to prevent lid malposition.

[00:20:22] Dr. Sam Rhee: I think providing that lower lid support is. The difference between how to do a good blepharoplasty and not like once I figured out how to really support that lower lid, Dr. Kladner, huge proponent of, uh, many of his techniques. I still follow, uh, from his videos, uh, that, that just made all the difference for me in terms of lid position.

[00:20:46] Dr. Sam Jejurikar: Agree. Well, any other complications you guys think we should touch upon for our viewers?

[00:20:53] Dr. Sam Rhee: I just think the swelling part, you have to counsel these patients. It's going to take a long time, long time. And, um, I just had a patient, it almost took like, she's a young patient, like almost three to four months before it really got to a point where she was really happy with the swelling. And, and seeing that patient regularly sort of counseling them through that. It was a challenge. And I, and I feel like some of the younger patients seem to have more swelling than the older patients sometimes. And, uh, it's just, just to get them through that part of it was, is, has always been a challenge.

[00:21:29] Dr. Salvatore Pacella: Yeah, I agree with you. I think, you know, setting expectations for patients is critical. Any lower blepharoplasty I tell them three months at the minimum before you even look like you're going to look normal, near normal, you know. So what I suggest to them is, you know, get some cheater glasses, you know, with big sort of, you know, more of the type of Smith glasses with the big side things, you know, the Ray Bans or Wayfarers.

And, you know, you wear them to work or, you know, you wear them socially. Oh, I got some allergies to my eyes, they're a little swollen. They usually can hide things after a couple weeks, you know.

[00:22:06] Dr. Sam Jejurikar: I think that's true. I, when you say it was almost three or four months for your patient, that sounds pretty good to me actually for lower eyelid surgery, Sam. So I've had patients takes, I've had multiple patients take six or eight months and it's a long six or eight months for both the patient and the surgeon. Well, good. I think this has been, you know, it's there. These are things that we deal with all the time in our own practice. We talk to people about them on a near daily basis, but I think it's great for patients to hear about this. So as always guys, great, uh, uh, you know, great podcast and, uh, until next time.