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Blepharoplasty complications

01 May 2006

A consultant plastic surgeon, Dr I, undertook bilateral upper and lower lid blepharoplasties on a male patient, Mr C. Postoperatively, Dr I noted that the lids were settling well and further reviews throughout the following year indicated the same.

Later the same year, Mr C complained that his eyes were watering. Dr I wrote to Mr C’s GP, Dr M, stating that he could find no evidence of an entropion but suggested there may be a block of the lacrimal system. He added that, if the symptoms did not settle, Mr C should be referred to an ophthalmologist.

The watering persisted and, early the following year, Dr M referred Mr C to an ophthalmologist who found the lacrimal system clear so referred the patient to Ms B, an ophthalmologist with an interest in oculoplastics.

Ms B felt that the patient’s problems were related to the original blepharoplasty. The lower lids were swollen due to intact medial fat pads that should have been removed at the initial operation. The watering was caused by poor apposition of the lid to the globe caused by shortening of the lid secondary to excess skin removal.

Ms B advised that corrective surgery would be required to remove the fat pads and correct the lid position. The patient underwent this surgery two years later.

Later that year, Dr I received a letter from the patient’s solicitor alleging negligence, citing failure to remove the lower lid fat pads giving an unsatisfactory cosmetic appearance and removal of too much skin from the lower lids causing watery, sore eyes.

Expert opinion

Ms B, for the claimant, restated her view that the medial fat pads should have been removed at the initial operation and that too much lid skin had been removed.

She noted that the operation took 20 minutes to perform when she would expect it to be completed in not less than 45 minutes.

Ms B criticised Dr I for not personally referring the patient to an ophthalmologist after he complained of eye watering instead of asking Dr M to do this. Furthermore, although Dr I knew that the patient had ongoing complaints, he did not arrange to review him personally. It also became clear that Dr I only saw the patient for the very first time on the morning of the surgery.

A plastic surgery expert said that the operative time was too short and that Dr I should have personally referred the patient to an ophthalmologist and followed up the outcome (although failing to do this was not in itself negligent).He also noted that the patient felt that he had not been properly counselled preoperatively.

After seeing preoperative photographs of the patient, the expert agreed that the surgical result was suboptimal, but that these were not in themselves indicative of negligence.

However, the combination of poor preoperative consultation (including seeing the patient for the first time on the morning of surgery), poor record keeping and the very short operating time made the case a very difficult one to defend.

On the strength of expert opinion, MPS settled out of court for £475,000 plus £165,000 costs. The payment was significantly less than the sum claimed by the claimant.

Learning points

  • For a surgeon to see a patient for the first time and operate on the same day is not acceptable practice, unless in an emergency situation. Not seeing the patient at all in advance of surgery is not acceptable in any specialty.
  • The anatomy of the lids and ocular adnexa is unique and should be approached only by those who are experienced in its complexities.
  • A suboptimal result is not negligent in itself, but becomes so in the context of poor preoperative counselling, poor records or failure to deal with any resulting complications.
  • Keeping good clinical records is vital, not only for legal purposes but as good medical practice.
  • Keeping accurate clinical photographs can be invaluable – especially in relation to cosmetic procedures.

Further information

  • For discussion of blepharoplasty, including complications and consent, see www.emedicine.com
  • For information regarding the responsibilities of medical practitioners, including consent and record keeping, see www.gmc-uk.org.
  • For essential guides on consent and keeping medical records, see MPS factsheets.