Blepharoplasty Risks

Blepharoplasty — surgery to the upper eyelids, lower eyelids, or both — is one of the more commonly performed cosmetic surgical procedures. While complication rates are generally low in well-selected patients operated on by experienced surgeons, all surgery carries risk, and the eyelid region in particular demands exceptional care given its proximity to the eye itself.

The risks below apply to blepharoplasty performed for cosmetic reasons. Some also apply when surgery is performed for functional reasons, such as correction of vision obstruction caused by excess upper eyelid skin. The likelihood and severity of each complication varies between individuals and depends on factors including the surgical technique used, your general health, your anatomy, your skin type and quality, whether you smoke, and how well post-operative instructions are followed.

Dr Roth (MED0001185485), Specialist Otolaryngologist & Head and Neck Surgeon (specialist registration — Otorhinolaryngology, Head & Neck Surgery), will assess your individual circumstances and discuss these risks with you in detail before any surgery proceeds.

1. General Anaesthesia

Blepharoplasty is most commonly performed under general anaesthesia, though it can in some cases be performed under local anaesthesia with sedation. General anaesthesia carries its own set of risks, separate from the surgical risks of the procedure itself.

Most people tolerate general anaesthesia without significant problems. A pre-anaesthetic assessment will be conducted before your surgery to identify any factors that may increase your individual risk. You will also be reviewed by the anaesthetist prior to the procedure.

Risks associated with general anaesthesia include:

• Nausea and vomiting: Common in the immediate post-operative period. Anti-nausea medications are routinely used to minimise this.
• Sore throat: Caused by the breathing tube used during anaesthesia. Usually resolves within a day or two.
• Temporary confusion or disorientation: More common in older patients. Usually resolves quickly once the anaesthetic wears off.
• Adverse drug reactions: Reactions to anaesthetic agents can occur, ranging from mild to, rarely, severe. These will be discussed with your anaesthetist.
• Respiratory complications: Including chest infection or breathing difficulties, more common in patients with pre-existing lung conditions or those who smoke.
• Deep vein thrombosis (DVT) and pulmonary embolism: Blood clots in the deep veins of the legs, which in rare cases can travel to the lungs. Risk is low for short procedures in fit patients but is higher in those with relevant risk factors. Preventative measures are taken routinely.
• Serious cardiac or respiratory events: Very rare but potentially life-threatening events can occur under general anaesthesia. These are extremely uncommon in healthy patients undergoing elective procedures in accredited facilities.

You should inform Dr Roth and the anaesthetist of all medications, supplements, allergies, previous anaesthetic reactions, and any relevant medical history prior to surgery.

2. Bleeding and Haematoma

Some bleeding during and immediately after surgery is expected and normal. A haematoma is a collection of blood that accumulates in the surgical site after the wound has been closed.

In blepharoplasty, haematoma formation is uncommon but can occur. A small haematoma may resolve on its own. A larger haematoma may cause significant swelling, discolouration, and pressure, and may require evacuation — either in the clinic or in a return to theatre, depending on its size and location.

Of particular concern with eyelid surgery is a retrobulbar haematoma — a bleed occurring behind the eyeball. This is a rare but serious complication that can cause a rapid increase in pressure within the eye socket. If not identified and treated promptly, it can result in permanent vision loss. This risk, while rare, is one of the reasons blepharoplasty is performed in an accredited surgical facility with appropriately trained staff. Warning signs in the post-operative period include sudden, severe eye pain, rapidly increasing swelling, or any change in vision. These symptoms require immediate medical attention.

To reduce the risk of bleeding, you will be advised to stop blood-thinning medications (including aspirin, ibuprofen, fish oil, and certain herbal supplements) prior to surgery. You should disclose all medications and supplements at your consultation.

3. Inability to Close the Eyes (Lagophthalmos)

Following blepharoplasty — particularly upper eyelid surgery — some difficulty fully closing the eyes is common in the first few days to weeks after surgery, primarily due to swelling. This is usually temporary and resolves as healing progresses.

In some cases, incomplete eye closure may persist beyond the initial healing period. This can occur if too much skin has been removed from the upper eyelid, resulting in insufficient tissue to allow complete closure. Lagophthalmos that persists beyond normal healing is a significant complication because incomplete closure exposes the cornea — the clear front surface of the eye — to drying, abrasion, and potential injury.

Prolonged lagophthalmos may require:

• Lubricating eye drops and ointments, particularly at night
• Protective eye taping or moisture chambers during sleep
• In persistent or severe cases, revision surgery to restore adequate skin coverage

Careful surgical planning and conservative skin removal are essential to minimising this risk. It is discussed in detail during the pre-operative consultation.

4. Infection

Infection following blepharoplasty is uncommon, but as with any surgical procedure involving incisions, it remains a possibility. The eyelid area has a relatively good blood supply, which reduces the risk of infection compared with some other surgical sites.

Signs of infection include increasing redness, warmth, swelling, and discharge at or around the incision site, as well as fever. These symptoms warrant prompt review by Dr Roth. If infection is confirmed, treatment with antibiotic medication is usually effective. In rare cases, more extensive intervention may be required.

A topical antibiotic ointment is routinely prescribed after blepharoplasty. Careful wound care as instructed, and avoidance of touching or rubbing the eyes in the post-operative period, reduce the risk of infection.

Patients with diabetes or immunosuppressive conditions are at higher risk and should ensure these factors are disclosed and discussed prior to surgery.

5. Dry Eyes

Dry eye symptoms — including a gritty, burning, or watery sensation — are common in the first weeks after blepharoplasty. This occurs because the normal blinking mechanism may be temporarily disrupted after surgery, reducing the even distribution of the tear film across the surface of the eye.

In patients who already have pre-existing dry eye syndrome, symptoms can be significantly worsened by blepharoplasty, sometimes persistently. For this reason, a pre-operative assessment of tear function is an important part of the consultation process. Patients with significant pre-existing dry eye may not be suitable candidates for blepharoplasty, or may require a more conservative surgical approach.

In most patients without pre-existing dry eye, symptoms are temporary and managed effectively with lubricating eye drops and ointments. In a smaller number of patients, symptoms may persist longer term. Rarely, dry eye complications can be severe enough to affect corneal health and require ongoing ophthalmological management.

6. Eyelash Loss

Some temporary loss of eyelashes along the incision line can occur following blepharoplasty, particularly with the transcutaneous (external) lower eyelid approach where the incision is placed just below the lash line. This is usually temporary, with lashes typically regrowing over the following weeks to months.

In rare cases, eyelash loss may be permanent if the hair follicles in the area are significantly disrupted during surgery or healing. Permanent lash loss is uncommon and is more likely with revision surgery, complications such as infection, or where significant scarring occurs along the lash line.

Where a lower eyelid approach is being planned, this risk will be discussed in the context of your specific anatomy and the surgical technique recommended.

7. Altered Vision

Some degree of temporary blurring of vision is common immediately after blepharoplasty, caused by antibiotic ointment used during and after surgery, swelling around the eyes, and the effect of anaesthesia. This typically clears within hours to a few days.

More persistent changes to vision are uncommon but can occur. These may include:

• Blurred or double vision (diplopia): Can result from swelling, haematoma, or, rarely, injury to one of the small muscles that control eye movement. Most cases resolve as swelling subsides. Persistent double vision may require further assessment and treatment.
• Sensitivity to light (photophobia): May occur temporarily during healing, particularly if the cornea is exposed due to incomplete lid closure.
• Changes to the visual field: Uncommon but possible if there is significant swelling or haematoma affecting the orbit.

Any sudden, significant, or worsening change in vision after blepharoplasty should be treated as a medical emergency and assessed immediately.

8. Scarring

All surgery that involves incisions results in scarring. In blepharoplasty, incisions are carefully placed to minimise visible scarring — in the natural skin crease of the upper eyelid, or just inside the lower eyelid (transconjunctival approach) or just below the lower lash line (transcutaneous approach).

For most patients, upper eyelid scars fade to fine, pale lines that are well hidden within the natural lid crease and are not visible in normal social interaction. However, the quality of scarring varies between individuals and is influenced by genetics, skin type, sun exposure during healing, and whether complications such as infection occur.

Possible scar-related outcomes include:

• Hypertrophic (raised) scarring: The incision line becomes raised, thickened, or red, and takes longer to settle. This is uncommon in the eyelid region but can occur. Treatment options include topical silicone, steroid injections, or laser treatment.
• Widened or visible scars: Particularly if the wound heals under tension or is subject to complications. More likely in lower eyelid transcutaneous approaches where the incision is visible.
• Webbing or skin folds: Occasionally a band of scar tissue can form at the outer corner of the eye, pulling the skin slightly. This is usually minor and often resolves with time or minor treatment.

Sun protection of the healing scar is important. Incisions should be protected from direct sun exposure for at least three months following surgery.

9. Ptosis (Droopy Eyelid)

Ptosis refers to drooping of the upper eyelid, caused by weakness or disruption of the levator muscle — the muscle responsible for lifting the upper eyelid. It is important to distinguish between ptosis and the appearance of a heavy upper eyelid caused by excess skin or a descended brow; these are different conditions with different treatments.

Pre-existing ptosis is not uncommon and should be identified and assessed at consultation. Patients with unrecognised or borderline ptosis before surgery may notice it becoming more apparent following blepharoplasty, because the removal of excess skin that was previously providing some apparent lid support can unmask the underlying ptosis. This is not a complication of the surgery itself, but it is an important consideration in pre-operative assessment, and patients will be referred to an oculoplastic surgeon or ophthalmologist if ptosis repair is needed.

Post-operative ptosis — where the levator muscle is directly affected by surgery — is uncommon but can occur due to swelling, bruising, or, rarely, inadvertent injury to the muscle or its nerve supply during surgery. Most cases related to swelling resolve as healing progresses. Persistent or significant ptosis may require further surgical correction.

10. Asymmetry

No two eyelids are identical before surgery, and achieving perfect symmetry in blepharoplasty is not always possible. A significant part of the pre-operative consultation involves carefully assessing and documenting the existing differences between the two eyelids — in skin quantity and quality, fat distribution, lid position, and brow position — so that these can be accounted for in surgical planning.

Despite careful planning, some degree of asymmetry in the post-operative result is possible. Factors contributing to asymmetry include:

• Uneven swelling during the healing phase (very common, usually temporary)
• Differences in healing and scarring between the two sides
• Underlying asymmetry that was present before surgery
• Unequal skin removal or fat repositioning

Minor degrees of asymmetry that persist after full healing may be amenable to minor revision under local anaesthesia. More significant asymmetry may require a formal revision procedure. Patients should be aware that revision blepharoplasty carries its own risks and that the ability to achieve improvement is not guaranteed.

11. Blindness

Permanent loss of vision is a rare but recognised risk of blepharoplasty and must be disclosed as part of the informed consent process. It is caused most commonly by a retrobulbar haematoma — a bleed behind the eyeball — that, if not recognised and treated as an emergency, can cause irreversible damage to the optic nerve through increased intraorbital pressure.

The estimated incidence of vision loss following blepharoplasty in the published literature is very low — often cited at less than 1 in 10,000 procedures — but it is not zero, and patients must understand this risk before consenting to surgery.

Additional, less common causes of vision loss following eyelid surgery include direct injury to the eye during surgery and complications of severe, untreated infection involving the orbit.

To minimise this risk:

• Surgery is performed in an accredited facility with appropriately trained staff
• Careful haemostasis (control of bleeding) is maintained throughout the procedure
• Post-operative monitoring instructions are provided to allow early identification of warning signs
• Patients are advised to seek immediate emergency medical attention if they experience sudden severe eye pain, rapidly increasing swelling, or any sudden change in vision after surgery

Making an Informed Decision

Blepharoplasty is a serious surgical procedure. The risks outlined on this page are not exhaustive — they represent the most significant and most commonly discussed complications, but other unexpected outcomes can occur. The decision to proceed should be made after careful reflection, and only after you have had the opportunity to discuss your specific circumstances, goals, and concerns with Dr Roth in detail.

You are encouraged to take as much time as you need before deciding whether to proceed, to bring a list of questions to your consultation, and to seek a second opinion if you wish. No reputable surgeon will pressure you to commit to surgery before you are ready.

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