9.2.1 Analysis of the Problem

With proper preoperative planning and closure, upper blepharoplasty incisions are known to heal well with minimal complications. However, there are several potential issues related to wound healing that are demonstrated by this patient, including right upper lid wound dehiscence, hypertrophic scarring, and postoperative asymmetry. Wound dehiscence typically occurs laterally along the thicker skin when the blepharoplasty incision is closed with running suture. This may have been avoided by instructing the patient to avoid eye rubbing, or with additional interrupted sutures and closer spacing of the running suture along the incision at time of closure.

Postoperative asymmetry is a common source of dissatisfaction after double-eyelid “Asian blepharoplasty” surgery, occurring in 13 to 35% patients. Contributing factors may include unrecognized asymmetric eyelids, asymmetric brow, or mild preoperative unilateral ptosis, which may be amplified after resection of eyelid skin. Stretching eyelid skin during operative planning, double checking measurements and markings, and careful fixation of the eyelid may minimize postoperative asymmetry.

Hypertrophic scarring, although not completely understood, is caused by a combination of hypercellularity, augmented neovascularization, inflammatory cytokines, and excessive collagen production. The resultant imbalance between collagen production and collagenases leads to dysfunctional remodeling of granulation tissue and resultant scar hypertrophy. Risk factors for hypertrophic scar formation are young age, bacterial colonization, and skin subjected to stretch. Cigarette smoking, chemotherapy, and statins may have a protective effect against hypertrophic scarring.

Although infrequently seen with blepharoplasty, the potential for hypertrophic scar formation exists from trauma to the dermis including surgery. The eyelid dermis of Asians contains a relatively higher concentration of collagen and tends to be thicker compared with that of Caucasians, potentially increasing the risk of hypertrophic scarring. According to studies of breast reduction and sternotomy incisions, approximately 60 to 65% of patients develop hypertrophic scarring within the first postoperative year, typically within the first 3 months. Around 30 to 35% of surgical wounds result in persistent hypertrophic scarring at 1 year, representing a spontaneous regression rate of nearly 50% by postoperative month 12. To our knowledge, no study has been performed evaluating the incidence of scar formation after blepharoplasty and the spontaneous involution rate if hypertrophic scarring occurs. However, it is well known that upper eyelid hypertrophic scar formation is much less frequent than in other areas of skin.

A multitude of treatments have been proposed to reduce the appearance of hypertrophic scars. There is insufficient evidence to support treatment of hypertrophic scars with vitamin E, onion extract, imiquimod cream, and massage therapy. Studies have suggested silicone products, pressure garments, corticosteroids, chemotherapeutics, and Botox to prevent excessive scarring, but many of these treatment options are presented without clinical trials.

A recent review of hypertrophic scar interventions by Kafka et al details the few clinical trials available that provide evidence-based treatment for hypertrophic scars. Silicone gel dressings have been proven effective for treatment and prevention of hypertrophic burn and posttraumatic scars with level 1 evidence. These silicone gel dressings have been shown to reduce scar thickness, increase pliability, alleviate pain and pruritus, and improve pigmentation. The effect was enhanced with concurrent pressure dressings in one controlled clinical trial by Li-Tsang et al. A recent clinical trial of a silicone elastomeric dressing, the “embrace device,” demonstrated that an elastic silicone dressing with resulting reduction in wound tension resulted in improved scar appearance. Most silicone gel dressings are available over the counter, or patients may cut the silicone sheets down to an appropriate size and apply them to eyelid scars overnight.

Intralesional triamcinolone acetonide (TAC) is frequently used to suppress aberrant scar formation, and has been shown effective in multiple low-power studies. However, it has been associated with side effect such as injection site pain, hypopigmentation, skin and subcutaneous fat atrophy, and telangiectasias at a rate of approximately 37%.

In three prospective, randomized, blinded, controlled clinical trials with level 1 evidence, treatment with intralesional TAC was compared with a combination of TAC and 5-fluorouracil (5-FU). Combination therapy (TAC + 5-FU) resulted in reduced side effects, decreased scar height, improved pigmentation/erythema, and pliability compared to the TAC-only treatment groups. Asilian et al included an additional treatment group that added irradiation with 585-nm pulsed-dye laser to the TAC + 5-FU treatments. This group demonstrated improved pigmentation/erythema relative to the TAC + 5-FU group. In a large meta-analysis including many smaller studies, Ren et al supported these findings, demonstrating improved scar height, patient satisfaction, and erythema when TAC was combined with 5-FU for the treatment of hypertrophic scars and keloids.

Given the paucity of clinical trials with strong evidence of effectivity, there are no universally accepted guidelines for treatment of hypertrophic scars. Of the options presented above, intralesional injections of TAC + 5-FU appear to be the most effective, evidence-based approach to hypertrophic scar treatment. Unfortunately, these studies were not specifically targeting facial scarring and the results may not be directly applicable to hypertrophic scars due to blepharoplasty.