What is the safest way to avoid permanent dry eyes from blepharoplasty? (uppers and lowers)

I'm planning on having an upper and lower (transcon) blephoraplasty with an Oculoplastic Surgeon. Even so I want to avoid permanent dry eyes at all costs, even if it means not the best outcome looks wise and we have to be very conservative. Is there anything I should discuss with my surgeon other than telling him just that? I don't think I have dry eyes now but have not had a Schirmer test which I will ask him if I need one.

Doctor Answers 6

Upper and lower eyelid surgery with dry eyes

First of all, it is very important to document the extent of the dry eyes with a Schirmer's test done by your ophthalmologist. Secondly it's important not to take any strip of orbicularis oculi muscle  when the upper lids are performed.Thirdly it's important to be conservative on amount of skin removal on the upper lids. In the rare event that you do  end up with dry eyes, punctual plugs, eye lubricants and Restasis eyedrops can all help with dry eyes. For many examples, please see  the length below to our eyelid photo gallery

Seattle Facial Plastic Surgeon
4.8 out of 5 stars 143 reviews

Best surgical technique to avoid dry eyes after upper blepharoplasty

Dry eyes result from the eye aperture (the lid opening) being too wide. As a result there is excessive evaporation of the tears from the surface of the eyeball, especially in people who have a weakness of tear film quality, which tends to occur with aging. Interference with a good blink also contributes as the tear film is not evenly placed on the eyeball.
The standard technique of upper lid surgery depends on removal of lid skin for its result. This is a risk, because it is usually necessary to tighten the lid skin for it to be smooth. Whereas, when the tarsal fixation technique is used, the desired aesthetic result is obtained without depending on skin removal.
This is a point of key importance. The tarsal fixation technique first contours the ‘apparent skin excess’ into the depth of the lid crease. Only then can it be determined if there is any ‘true skin excess’, which is removed. As a result, compared to a standard lid operation, less lid skin, if any, removed. The remaining skin is stored in the lid fold and crease as a functional reserve. As the upper lid ‘lengthens’, as occurs when looking down and in lid closure, this skin reserve is automatically released so there is no interference with lid closure.
I am about to publish on a series of patients who had secondary upper lid surgery, on average 8 years after their primary. All had the tarsal fixation technique and not one of the 100 patients developed ‘dry eyes’.

Bryan Mendelson, FRACS, FACS
Melbourne Plastic Surgeon
5.0 out of 5 stars 38 reviews

Blepharoplasty and dry eye

The majority of patients do not get dry eye after surgery that is permanent. Sometimes patients have it initially due to the surgery.  As the swelling subsides and the healing continues usually normal tear production and drainage improves.  It is sometimes hard to predict, but some patients can be prone to it with some tearing issues. Schirmer's tests are not always accurate and can be an unreliable test. One key thing is to be conservative especially with the upper lids to avoid exposure at night or the inability to close with blink.  Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Any surgeon who has never seen dry eye after eyelid surgery does not know what to look for.

In fairness, general plastic surgeons, facial plastic surgeons, dermatologists, basically any surgeon who is not board certified in ophthalmology, lacks the training, skill, and even the equipment to diagnose dry eye.  So it should not be surprising that someone has posted the statement that eyelid surgery does not disturb the lacrimal gland.  While that is true, it is simply not the reason people get dry eye after eyelid surgery.

I am a little discouraged that you are planning to have eyelid surgery with an oculoplastic surgeon but the surgeon did not perform a schirmer's test.  While the Schirmer's test is not that great a test for predicting a post operative dry eye, it is an important diagnostic test that has some predictive value and it is very easy to perform. Not performing it is like cutting a corner.  If you have had your preoperative assessment with this particular surgeon and they did not perform a Schirmer's test, you should be concerned about the diligence of the surgeon in my opinion.

There are very good strategies for avoiding dry eye.  First is deciding if the eyelid surgery is even needed at this time or if there are non-surgical options for accomplishing you goals.  Second there are excellent surgical strategies to minimize the risk of post surgical dry eye.  Dry eye after surgery has nothing to do with disturbing the lacrimal gland at the time of surgery.  It has everything to do with compromising orbicularis oclui muscle function by surgery.  When incisions are made through the orbicularis oclui muscle, the function of this muscle is eyelid closure and it can be permanently effected by surgery.  For individuals very concerned about or at risk for dry eye, depending on your surgical needs, the best option is to avoid procedures that cut through the orbicularis oculi muscle: Skin only lower and upper eyelid surgery preserving the orbicularis oculi muscle.  Other options include lower eyelid transconjunctival surgery or chemical peels to remove lower eyelid rhytids.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Dry eyes from Blepharoplasty

The only sure way of avoiding this possible complication is to not have the surgery. Less than that, you can ask the surgeon to be conservative and not remove too much skin. A temporary tarsorraphy stitch will also help ensure good eyelid closure in the early healing phase. Use a lot of artificial tears after surgery. 
Dr J 

Tanveer Janjua, MD
Bedminster Facial Plastic Surgeon
5.0 out of 5 stars 107 reviews

Permanent Dry Eyes Rare

If you have extremely dry eyes, possibly it is best to do just upper or lower separately and see how you do.   If your eyes are normal you can do both.   The actual glands producing tears are not or should not be disturbed during eyelid surgery, but nevertheless there can be a temporary decrease in tear production.   In 30 years I have never seen a permanent dry eye situation in over 1500 surgeries but it has been reported.   I am not a fan of transconjuctival eyelid surgery because in general this is a procedure done with removal of fat.   Fat removal produces hollowness sooner or later.   The fat puffs are not excess fat but rather normal fat that is showing because of slight herniation or because your normal  fat has atrophied a bit showing the  periorbital fat as puffs.   You should have fat removed only if you have true congenital excess of orbital fat (RARE).   Consider getting 3 opinions about your surgery and then proceed as you see fit.   My Best,  Dr C

George Commons, MD
Palo Alto Plastic Surgeon
4.5 out of 5 stars 36 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.