Risks and Complications of Blepharoplasty Surgery: What Patients Should Know

Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) | Sydney

Every surgical procedure carries risks. Blepharoplasty is no different. What matters is knowing the difference between a normal recovery symptom and a complication that needs attention.

Swelling and bruising in the days after surgery. Tightness. Temporary numbness. All expected. Not complications.

Retrobulbar haemorrhage. Persistent eyelid malposition. Unexpected vision changes. These are different. They’re events that may need closer monitoring, medication, delayed recovery, or further treatment.

This article walks through both, covering upper blepharoplasty, lower blepharoplasty, male blepharoplasty, and combined surgery.

Dr Scott J Turner is a Specialist Plastic Surgeon (FRACS), consulting at his Bondi Junction and Manly clinics in Sydney. All surgery carries risk. This article isn’t a substitute for your personalised consultation or consent process.

Urgent Warning Signs After Eyelid Surgery

Contact the practice urgently or seek urgent medical care if you experience any of the following:

• Sudden or significant vision changes
• Severe new eye pain, particularly if escalating
• Rapidly increasing one-sided swelling
• Bleeding from the incision sites that doesn’t settle with gentle pressure
• Bulging or protrusion of the eye
• Spreading redness, warmth, or pus around incisions
• Wound opening
• Fever
• Shortness of breath, chest pain, or unusual heart rhythm

These can indicate a developing complication that needs same-day or emergency assessment rather than waiting for the next scheduled review. Severe new eye pain, bleeding, and vision changes specifically warrant immediate medical attention.

Expected Recovery Symptoms vs Complications

Most early post-operative experiences are normal recovery, not complications. The table below separates the two.

For practical guidance on managing the expected recovery, see reduce swelling and bruising after eyelid surgery and the blepharoplasty recovery guide.

Why Risks Differ by Procedure Type

Upper Blepharoplasty

Upper eyelid surgery involves an incision along the natural eyelid crease, removal or repositioning of excess skin, and sometimes small amounts of muscle or fat adjustment. The specific risks include:

• Dry eye, often exacerbated by reduced blink mechanics during early recovery
• Lagophthalmos (incomplete eyelid closure), usually temporary
• Asymmetry between the two sides, particularly during the swelling phase
• Visible or asymmetric scarring at the crease incision
• Over-resection of skin or fat, producing a hollowed or feminised appearance
• Missed brow ptosis, which can leave residual heaviness even after good eyelid surgery

The brow assessment matters more than many patients realise. If the actual problem is brow descent rather than eyelid skin excess, upper blepharoplasty alone may not fix the heaviness, and aggressive skin removal in this scenario can create a worse result.

Lower Blepharoplasty

Lower eyelid surgery uses one of two main approaches, with different risk profiles.

Transconjunctival approach (incision on the inside of the lower lid) may preserve orbicularis muscle support and the orbital septum. Current literature suggests this approach may be associated with lower rates of lower-lid retraction or ectropion in selected patients compared with transcutaneous approaches.

Transcutaneous approach (incision just below the lash line) provides access for both fat management and excess skin excision. It may be required when significant skin laxity is present.

Lower blepharoplasty risks include:

• Lower-lid retraction (the lid sitting lower than intended)
• Ectropion (the lower lid turning outward)
• Scleral show (more white of the eye visible below the iris)
• Chemosis (conjunctival swelling)
• Dry eye
• Hollowing from excessive fat removal
• Contour irregularity

For more detail on the technique choice, see transconjunctival vs transcutaneous lower blepharoplasty.

Dry Eye After Blepharoplasty

Dry eye deserves a section of its own because it’s one of the most common complaints after periorbital surgery. The symptoms range from mild irritation to genuinely uncomfortable persistent dryness.

Symptoms can include grittiness, watering (paradoxically, dry eye often causes reflex watering), burning, increased sensitivity to screens or wind, and a foreign-body sensation.

Risk factors that increase the likelihood of post-operative dry eye:

• Pre-existing dry eye disease (often undiagnosed before surgery)
• Contact lens wear
• Thyroid eye disease
• Lower-lid laxity
• Combined upper and lower blepharoplasty rather than either alone
• Excessive skin removal
• Female sex and older age, both associated with higher baseline dry eye rates

What the evidence suggests. A retrospective review of 202 patients found dry eye symptoms persisting beyond two weeks in 10.9% of patients, and beyond two months in 2%. Most cases resolved with conservative management, including artificial tears, ointment, taping the eyelids closed at night, and sometimes topical or systemic anti-inflammatory treatment.

Management typically progresses through:

• Preservative-free artificial tears during the day
• Ointment at night
• Eyelid taping or moisture chambers in selected cases
• Review at the practice if symptoms persist or worsen
• Ophthalmology or oculoplastic input for severe or refractory cases

If you have a history of dry eye, screen at consultation. It’s not a contraindication to eyelid surgery in most cases, but it affects the surgical plan and post-operative monitoring.

Chemosis

Chemosis is swelling of the conjunctiva (the thin clear membrane covering the white of the eye). It can look like a swollen, jelly-like ring around the cornea. The symptoms include irritation, watering, foreign-body sensation, and visible swelling of the eye surface.

Most cases settle with conservative management: lubrication, sometimes topical anti-inflammatory treatment, and time. Persistent or severe chemosis warrants review and is associated with symptomatic dry eyes in the same retrospective periorbital surgery literature, which is why the two conditions are discussed together.

Bleeding, Haematoma, and Retrobulbar Haemorrhage

Bruising after blepharoplasty is expected. A haematoma (a collection of blood) is different.

Pre-septal haematoma affects the eyelid tissues in front of the orbital septum. It usually appears as more substantial swelling than expected, sometimes with a tense or bluish appearance. Most are managed conservatively with cold compresses, head elevation, and monitoring.

Retrobulbar haemorrhage is rare but serious. Bleeding occurs behind the eye, within the bony orbit, which can create pressure on the optic nerve and surrounding structures. This is the main cause of vision loss after blepharoplasty.

Signs of retrobulbar haemorrhage include:

• Sudden severe pain
• Rapid, increasing one-sided swelling, often tense and firm
• Bulging or protrusion of the eye
• Vision changes including blurring or visual field loss
• Pain on eye movement

This is a surgical emergency. Case literature stresses that decompression (lateral canthotomy and cantholysis) may need to happen urgently to preserve vision, sometimes within an hour or two of symptom onset, regardless of whether intraocular pressure measurements are abnormal at presentation.

Visual change after eyelid surgery is always a reason to seek urgent assessment.

Infection and Wound Problems

Infection after blepharoplasty is uncommon, in part because the periorbital region has an excellent blood supply that supports healing. When infection does occur, the signs include:

• Redness spreading beyond the immediate incision area
• Warmth
• Swelling worsening rather than settling after the first few days
• Discharge, particularly if pus-like
• Fever

Superficial infections may respond to topical or oral antibiotics. Deeper infections need more urgent assessment. Wound dehiscence (incision opening) can occur, particularly if there’s been physical strain or rubbing of the area. Avoiding contact lens wear, eye makeup, and rubbing the eyes during early recovery reduces the risk.

Eyelid Malposition: Ectropion, Retraction, and Scleral Show

These three terms describe related but distinct lower-lid problems:

• Ectropion: the lower lid turns outward, exposing the inner conjunctival surface
• Retraction: the lower lid sits lower than intended, exposing more eye than normal
• Scleral show: more of the white of the eye is visible below the iris than is typical

The symptoms include dryness, tearing, irritation, visible asymmetry, and incomplete eyelid closure.

Risk factors include:

• Lower-lid laxity (assessed at consultation with snap-back and distraction tests)
• Prominent eyes (where the eye protrudes more anteriorly than the cheek)
• Negative vector orbit, where the eye sits forward relative to cheek support, making the lower eyelid vulnerable to downward pull
• Excessive skin removal at lower blepharoplasty
• Scarring from prior eyelid surgery
• Previous facial nerve weakness

Mild cases may respond to massage, taping, or time. More significant or persistent malposition may need revision surgery to lift or support the lower lid. Conservative surgical planning and accurate pre-operative assessment of lower-lid laxity are the main preventive factors.

Lagophthalmos and Corneal Exposure

Lagophthalmos is the inability to fully close the eyelids. Some lagophthalmos during the first week is common because of swelling. Persistent lagophthalmos after the swelling has settled is a different problem.

The clinical consequence is corneal exposure: the cornea isn’t fully protected during blinking or sleep, which leads to dryness, irritation, and potentially corneal damage if left unmanaged.

Management options:

• Lubricating drops during the day
• Ointment overnight
• Eyelid taping at night in selected cases
• Review with the surgical team
• Ophthalmology or oculoplastic input for persistent or severe cases
• Surgical correction in some cases

Conservative skin removal at upper blepharoplasty is the main preventive factor. Over-resection in pursuit of a more dramatic result can leave the patient unable to close the eye properly.

Scarring and Skin Changes

Eyelid skin generally heals well. Most blepharoplasty scars become inconspicuous within the natural eyelid crease (upper) or just below the lash line (transcutaneous lower). Transconjunctival lower blepharoplasty leaves no external scar.

That said, scarring can still be a concern. Possible scar issues include:

• Visible scarring outside the natural crease
• Pigmentation changes (lighter or darker than surrounding skin)
• Hypertrophic or thickened scarring, uncommon in this area but possible
• Asymmetric scar appearance between the two sides

Scar maturation typically takes 6 to 12 months. Sun protection during this period helps reduce hyperpigmentation. Silicone gel or sheets may be discussed once incisions are fully sealed and cleared. Don’t apply scar products to unhealed incisions.

Aesthetic Concerns and Revision Surgery

Aesthetic outcomes can be unsatisfactory even when the technical surgery has gone well. Possible concerns include:

• Hollowed upper or lower eyelid from over-resection of fat
• Residual under-eye bags or upper-lid skin from under-correction
• Asymmetry between the two sides
• Crease height that doesn’t match expectations
• Dog ears or contour irregularity at incision ends
• Lower-lid shape change

Revision decisions are usually deferred until swelling has fully settled and scars have matured, typically at least 6 to 12 months post-surgery. Acting earlier risks operating on tissue that’s still changing, which can produce a worse rather than better outcome. The exception is urgent functional problems (such as significant lagophthalmos or ectropion) that need earlier intervention.

Anaesthesia and General Surgical Risks

Beyond the eyelid-specific risks, blepharoplasty carries the general risks of any surgical procedure under anaesthesia:

• Anaesthetic reaction
• Post-operative nausea
• Blood clots, including deep vein thrombosis (rare for procedures of this length but part of general surgical risk)
• Medical complications related to existing health conditions

The anaesthetic risk discussion happens with the anaesthetist before surgery. Full disclosure of all medications, allergies, previous anaesthetic experiences, and medical history is critical.

Who May Be at Higher Risk

Some patients have a higher baseline risk of complications. The main ones worth knowing: pre-existing dry eye disease; thyroid eye disease (Graves’ ophthalmopathy); prominent eyes; negative vector orbit; lower-lid laxity (assessed at consultation); previous eyelid or facial surgery; facial nerve palsy; diabetes or autoimmune disease; current smoking or nicotine use; blood-thinning medication; unrealistic expectations about what the surgery can achieve.

None of these necessarily rules out surgery. They do affect the surgical plan, pre-operative assessment, and the discussion of realistic outcomes.

Medication and Supplement Management

Tell Dr Turner and the anaesthetist about every prescription medication, over-the-counter product, and supplement you take, before surgery. This is genuinely important rather than a formality.

Specific points worth knowing:

• Don’t stop prescribed anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran, clopidogrel) without advice from the prescribing doctor and the surgical team. Sudden discontinuation has its own risks
• Aspirin, NSAIDs (ibuprofen, naproxen), fish oil, high-dose vitamin E, and certain herbal supplements (ginkgo, garlic, ginseng) can affect bleeding risk in some patients
• Medication instructions are individualised. Follow the specific plan provided by your surgical and prescribing doctors rather than generic internet advice

Perioperative medication decisions affect bleeding risk, wound healing, and anaesthetic interactions. They need clinical assessment, not blanket rules.

Post-Operative Care to Reduce Complications

Specific instructions come with surgery. The general principles: cold compresses as instructed (wrapped, not on bare skin); head elevation through the first week; no bending, straining, heavy lifting, or vigorous exercise; no rubbing the eyes; no contact lenses or eye makeup until cleared; prescribed drops and ointments as directed; and attendance at all follow-up appointments.

For practical recovery detail, see the blepharoplasty recovery guide, reduce swelling and bruising after eyelid surgery, and exercise after eyelid surgery.

Frequently Asked Questions

What are the most common risks of blepharoplasty?

The most common issues are temporary recovery symptoms (bruising, swelling, watering, mild blurred vision from ointment, temporary numbness) rather than true complications. Among actual complications, dry eye is the most common, particularly after combined upper and lower blepharoplasty. Other complications include chemosis (conjunctival swelling), asymmetry during healing, lower-lid malposition in lower blepharoplasty cases, and aesthetic concerns such as hollowing or under-correction. Serious complications including retrobulbar haemorrhage and vision loss are rare but documented. Individual risk depends on anatomy, technique, and patient factors and is discussed at consultation.

Is dry eye common after blepharoplasty?

Yes, dry eye is one of the most common patient complaints after periorbital surgery. Symptoms range from mild grittiness to persistent dryness requiring active management. A retrospective review of 202 patients found dry eye symptoms persisting beyond two weeks in around 11% of patients, and beyond two months in 2%. Most cases resolve with conservative management including artificial tears, ointment at night, and sometimes eyelid taping. Risk factors include pre-existing dry eye disease, contact lens wear, thyroid eye disease, lower-lid laxity, combined upper and lower surgery, and aggressive skin removal.

Can blepharoplasty affect vision?

Vision changes after blepharoplasty are uncommon but possible. Temporary blurring from eye ointment or swelling is normal early on and settles within the first few days. Persistent or progressive vision changes are not normal and require urgent assessment. The most serious vision-threatening complication is retrobulbar haemorrhage, which is rare but is the main cause of vision loss after eyelid surgery. Sudden severe pain, rapid one-sided swelling, bulging of the eye, or any vision change after blepharoplasty are reasons to seek urgent medical assessment, since prompt intervention may be needed to preserve vision.

What is ectropion after lower blepharoplasty?

Ectropion is when the lower eyelid turns outward, exposing the inner conjunctival surface. The symptoms include dryness, tearing, irritation, and visible distortion of the lower-lid shape. It’s one of the more concerning complications of lower blepharoplasty because it affects both function and appearance. Risk factors include pre-existing lower-lid laxity, prominent eyes, negative vector orbit, excessive skin removal, and scarring from prior surgery. Mild cases may respond to massage or taping. More significant or persistent ectropion typically requires revision surgery to support or shorten the lower lid. Conservative surgical planning and accurate pre-operative assessment of lower-lid laxity are the main preventive factors.

When should I call the practice after blepharoplasty?

Some signs warrant urgent contact rather than waiting for the next scheduled review. Sudden vision changes. Severe new eye pain. Rapidly increasing one-sided swelling. Bleeding that doesn’t settle. Fever. Spreading redness or pus around incisions. Wound opening. Any of these warrant a same-day call. Most patients have an uneventful recovery, but the threshold for calling should be low if anything seems off. The practice provides specific emergency contact instructions after surgery. If something doesn’t seem right and you can’t reach the practice immediately, hospital emergency departments can assess eyelid concerns out of hours.

Consult with Dr Scott J Turner

Dr Scott J Turner is a Specialist Plastic Surgeon, FRACS (AHPRA MED0001654827). The practice has two Sydney consultation locations in Bondi Junction (39 Grosvenor Street) and Manly (Suite 504, Level 5, 39 East Esplanade). Surgery is performed at Bondi Junction Private Hospital or Delmar Private Hospital, Dee Why.

Consultation fee is $450.

The AHPRA cosmetic surgery pathway applies here. Two consultations are required, with a cooling-off period in between. A GP referral is needed. Psychological screening forms part of the standard process. The $1,000 surgical deposit is payable only after the second consultation, not before.

For procedure detail, see upper blepharoplasty, lower blepharoplasty, and male blepharoplasty.

Book a consultation on 1300 437 758 or [email protected].