Lacrimal gland fistula after upper eyelid blepharoplasty.

To report the first case of lacrimal gland fistula after upper eyelid blepharoplasty for blepharochalasis. Standard upper blepharoplasty and the hooding excision were performed in a female with blepharochalasis. The patient developed a fistulous tract with tearing from the incision few days after hooding excision. Fistula excision and lacrimal gland repositioning were performed. There were no complications after the repositioning procedure (6 months follow up). Prolapsed lacrimal gland and fistula formation can occur after upper blepharoplasty hooding excision.

INTRODUCTION

Postoperative complications of blepharoplasty range from skin changes to vision-threatening emergencies.1 Some of these complications occur early in the postoperative period, such as retrobulbar hemorrhage, infection, and eyelid hematoma. Other complications occur later in the postoperative period, such as eyelid malposition, strabismus, scar and over- and under-resection of skin or orbital fat.1 There has been a case report of persistent lateral hooding after upper lid blepharoplasty that has been treated with lacrimal gland repositioning.2 To the best of our knowledge, we report the first case of lacrimal gland fistula after upper lid blepharoplasty.

CASE REPORT

A 25-year-old female referred with bilateral eyelid swelling and blepharoptosis. She had a history of repeated lid swelling for almost 3 years before the age of 10 years. The patient underwent bilateral blepharoptosis repair at 12 years of age, re-operation on the right lid at the age of 18 years, and laser resurfacing of periocular region at the age of 20.

On examination, the patient had bilateral blepharoptosis (margin reflex distance of +2.5 mm on the right and +2 mm on the left side), dermatochalasis with mild lateral hooding, and medial and preaponeurotic fat protrusion. There was no detectable lacrimal gland prolapse.

The patient underwent upper blepharoplasty and levator resection. Upper blepharoplasty included skin-orbicularis muscle flap excision, medial fat excision, and partially preaponeurotic fat excision through a hole in the center of the septum. She had an uneventful postoperative follow-up with the exception of lateral hooding of the right lid. An elliptical lateral hooding excision was performed 2 months after upper blepharoplasty. At 1 week post-hooding excision, there was wound dehiscence with clear watery drops discharging from the wound [Figure 1]. A palpable lacrimal gland was found at the wound site.

Figure 1

Post-lateral hooding excision right upper eyelid wound dehiscence and watery drops show a fistulous tract from lacrimal gland to the wound

The patient was scheduled for repair of the wound and repositioning of the lacrimal gland. There was a tract from the lacrimal gland to the skin of the upper eyelid at the site of wound dehiscence. The lacrimal gland was repositioned into the lacrimal gland fossa using 4-0 prolene suture. The fistula tract was resected and the wound was closed. The postoperative course was uneventful out the last visit at 6 months after repair [Figure 2].

Figure 2

Last follow up (6 months) after repair of the wound and repositioning of the right prolapsed lacrimal gland

DISCUSSION

Despite the facile nature of the blepharoplasty, high patient expectations can make this procedure quite challenging to the surgeon. In order to attain a good result and avoid patient dissatisfaction, the surgeon must perform a careful history and physical exam and address specific patient complaints and expectations.3

Blepharochalasis is a rare eyelid disorder characterized by exacerbation and remission of painless edema, eventually leading to atrophy of the periorbital skin. These episodes of eyelid swelling usually become less frequent with age, and eventually most cases enter a relatively quiescent stage. Ptosis is a common finding in blepharochalasis; however, the levator function is preserved.4

Surgical management should be performed during the quiescent phase of blepharochalasis to avoid recurrent bouts of lid swelling leading to further ptosis and lid atrophy. Surgeons advocate that blepharochalasis symptoms should be quiet for 6-12 months before surgical treatment is contemplated.4 Our case did not report any exacerbation for at least 15 years prior to the recent operation.

A prolapsed lacrimal gland occasionally occurs due to atrophic changes in the septum in patients with blepharochalasis. In cases of frank preoperative prolapsed lacrimal gland, a blepharoplasty and suspension of the lacrimal gland should be performed.4 Our patient did not present with a prolapsed lacrimal gland preoperatively. She only had post-blepharoplasty lateral hooding on the right side without a palpable lacrimal gland. Thus, she underwent an elliptical hooding excision. We assume that blepharoplasty and consequently right-side hooding excision pulled an undetected partially prolapsed lacrimal gland inferiorly into the wound and resulted in the formation of a fistula. A similar case has been reported with hooding after blepharoplasty due to lacrimal gland prolapse; however there was no history of blepharochalasis or postoperative wound dehiscence and fistula.2

Repositioning of the lacrimal gland to the right side was successful without postoperative sequelae out to 6 months postoperatively. The procedure can complex especially in the context of chronic inflammatory conditions.5 This case report illustrates an uncommon post-blepharoplasty complication in patients with blepharochalasis. Surgeons who perform blepharoplasty should have a high index of suspicion for lacrimal gland herniation in the presence of lateral hooding specially in patients with a history of blepharochalasis.