Blepharoplasty Risks and Complications: Dry Eyes, Lid Malposition and the Rare Bleed

The main risks of blepharoplasty are dry, gritty or watery eyes and trouble fully closing the lids (both common and usually temporary), lower-lid malposition where the lid pulls down or turns out, and the rare, sight-threatening bleed behind the eye. Blepharoplasty is real surgery millimetres from the eye, so the risks deserve naming precisely rather than waving away as “rare”¹.

Most of what follows is mild and passes. I want to be honest about the whole range anyway, because the two questions I could never get a straight answer to before my own surgery were how likely each problem actually was, and which ones were a nuisance versus which were an emergency. This is that list. For where the risks sit in the bigger picture of the operation, the full guide to blepharoplasty sets out the types, recovery and cost alongside them.

How common are complications, and how satisfied are people?

Serious complications from blepharoplasty are uncommon, and satisfaction is among the highest of any facial procedure, with most series reporting well over 85% of patients pleased with the result. The routine after-effects, dryness and swelling, are common; the sight-threatening ones are rare².

It is worth holding both of those truths at once. The operation has an excellent track record and a genuinely happy majority, and it still has a short list of real problems that are worth understanding before you consent. The rest of this article works through them roughly in order of how often they happen, from the near-universal dry patch to the one-in-thousands emergency.

Dry, gritty and watery eyes

Dry, gritty or watery eyes are the commonest after-effect of blepharoplasty, usually temporary and settling over about 1 to 2 weeks as the swelling that peaks at 2 to 3 days goes down, occasionally lasting longer. Surgery briefly disturbs the tear film and how completely the lids close, so the eye surface is under-lubricated for a spell and, paradoxically, can water in response³.

This was the part of my own recovery I had most underestimated. For the first two weeks my eyes felt as though there was sand in them, worst on waking, and I lived on lubricating drops and a gel at night. It eased steadily and was gone by a few weeks, which is the usual story, but pre-existing dry eye can be pushed further and is checked before surgery for exactly that reason. The full account is in dry eyes after blepharoplasty.

Trouble fully closing the eyes (lagophthalmos)

A short period of not fully closing the eyes, called lagophthalmos, is common early, mostly at night, and usually resolves over the first 1 to 2 weeks as the swelling goes down and the new tissue relaxes. Temporary blurred or double vision from ointment and swelling belongs in the same early, self-limiting group³.

It matters chiefly because it worsens the dryness above: an eye that does not close over completely dries out overnight. Taping the lids and using lubricants are the usual answers for the first days, and eye makeup and contact lenses are held off for about 2 weeks while the surface recovers. Persistent lagophthalmos, from removing too much upper-lid skin, is uncommon and is precisely why a careful surgeon takes a conservative strip rather than the most that could come off.

Lower-lid malposition: retraction and ectropion

Lower-lid malposition, the lid sitting too low (retraction) or turning outward (ectropion), is the complication lower blepharoplasty is chiefly judged on, and it is more likely after the external (transcutaneous) approach and in lids with pre-existing laxity. Retraction shows white below the iris; ectropion rolls the rim away from the eye, leaving it exposed and watery¹.

This is the reason lower-lid surgery is treated with more caution than upper, and the reason a surgeon tests how far your lower lid can be pulled from the eye and how quickly it snaps back before operating. The scarless approach that works from inside the lid, rather than cutting below the lashes, carries a lower risk of it. Why it happens and how it is avoided and repaired is set out in lower eyelid malposition.

Asymmetry, hollowing, scars, milia and infection

Asymmetry, an over-resected hollow or sunken look, visible scarring, milia and infection are all reported, and asymmetry or over- and under-correction are the usual reasons a revision is needed. These are the “not quite right” outcomes rather than the dangerous ones, and most are minor or treatable⁴.

A degree of asymmetry is normal because faces are not symmetrical to begin with and the two sides swell and settle on different schedules, so the eyes should be judged at months, not at one week. Taking too much fat can leave a hollow, which is why fat is increasingly repositioned rather than simply removed. The upper-lid scar hides in the crease and fades as it matures over up to around 6 months, and milia (tiny white cysts) along the line are easily cleared, as covered in blepharoplasty scars and the eyelid crease. Infection near the eye is uncommon but is one reason to follow the aftercare closely.

Retrobulbar haemorrhage: the rare emergency

The rare, sight-threatening emergency is a retrobulbar haemorrhage, a bleed behind the eye that raises the pressure and can cut off the blood supply, reported at roughly 1 in 2,000 to 1 in 25,000 and needing immediate treatment. It typically announces itself in the first hours with sudden pain, a feeling of pressure, a firm proptosed eye and dropping vision².

This is the one risk on the list that is a true emergency, and it is why the eye is not a place to be casual. Treated quickly, often by releasing the pressure at the lid, sight is usually saved; left, it can be lost. Practically, it means knowing before you book how your surgeon covers the first hours after you go home, and, if anything is done abroad, who you would reach on the day. That is a large part of why choosing the right surgeon, covered in choosing an eyelid surgeon, is not a formality.

How to lower your risk

The main levers are not smoking, having pre-existing dry eye and lower-lid laxity assessed before surgery, choosing a surgeon who performs this operation often, and going in with realistic expectations. Most of the serious risk is designed out beforehand, in the assessment and the choice of technique, rather than managed afterward⁵.

The candidacy checks are not box-ticking. A tear-film test flags the eye that will struggle with dryness, a laxity test flags the lower lid at risk of pulling down, and the brow assessment stops skin being removed under a forehead that should have been lifted instead. Weighing all of that honestly against the benefit is the part of the decision most worth slowing down for.