Which of the following is the most appropriate initial management?

(A) Application of ice packs and elevation of the head
(B) Application of ice packs and administration of furosemide and a narcotic agent
(C) Ophthalmology consultation
(D) Administration of a corticosteroid and ophthalmology consultation
(E) Administration of acetazolamide and a corticosteroid and repeat operative exploration

The correct response is Option E.

In this 49-year-old man who has worsening pain after undergoing four-eyelid blepharoplasty, the most likely diagnosis is retrobulbar hematoma. This is most likely caused by hemorrhage from a transected vessel within the periorbital fat pad. Retrobulbar hematomas are typically characterized by steady, severe, lancinating pain in the globe and orbit. Other characteristic symptoms include firmness and tenderness of the globe and early discharge from the eye. Because retrobulbar hematomas can ultimately result in loss of vision, emergent treatment is indicated. This includes intravenous administration of acetazolamide and a corticosteroid and release of the sutures, followed by operative exploration to release the hematoma and confirm or obtain hemostasis. An ophthalmologist should also be consulted, especially if the patient experiences changes in vision.

The other treatments mentioned above will not adequately treat the hematoma and instead will delay definitive care.

References
1. Guyuron B. Blepharoplasty and ancillary procedures. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations and Outcomes. Saint Louis, Mo: Mosby - Year Book, Inc; 2000:2539-2543.
2. Jelks G, Jelks E. Blepharoplasty. In: Peck GC, ed. Complications and Problems in Plastic Surgery. New York, NY: Gower Medical Publishing; 1992:5.18-5.19.

Which of the following muscles is injured most commonly during blepharoplasty?

(A) Inferior oblique
(B) Lateral rectus
(C) Medial rectus
(D) Superior oblique
(E) Superior rectus

The correct response is Option D.

Because of its relatively superficial anatomic location, the superior oblique muscle is injured most commonly during blepharoplasty. Injury in this region is characterized by pain, diplopia accompanied by a tendency to close one eye, abnormal tilting of the head, and depression of the chin.

Blepharoplasty procedures of the upper eyelid typically involve resection of excess fat. The upper eyelid contains the medial and central fat compartments, which lie deep to the orbital septum and are separated by the superior oblique muscle-tendon unit and trochlea. To resect fat, the surgeon can make either one incision across the entire orbital septum to access the fat compartments, or two separate, smaller incisions in the orbital septum over each isolated compartment.

It is important for the surgeon to know the anatomy of the upper eyelid and orbit to incise in the area of the fat compartments without injuring the trochlea or superior oblique muscle. If the upper eyelid fat is not teased carefully, the superior oblique muscle can be inadvertently crushed, attenuated, teased through the septum, and even excised. Resecting only the bulging fat that lies anterior to the septum is most likely to prevent injury. If there is no pressure on the orbit and no traction on the fat, the muscle will not bulge anterior to the orbital septum.

Cauterization of excised fat, especially with the clamp-and-cauterize technique, is also associated with injury to the superior oblique muscle and trochlea. When the clamp is removed, vessels that were cauterized inadequately will retract and bleed deep within the fat compartment. In addition, entrapment of the superior oblique tendon has been shown to occur with closure of the orbital septum.

The inferior oblique and superior rectus muscles can be injured during blepharoplasty, but trauma to these structures is less likely than injury to the superior oblique muscle. The lateral and medial recti are rarely injured during blepharoplasty.

References
1. Lisman RD, Hyde K, Smith B. Complication of blepharoplasty. Clin Plast Surg. 1988;15:309.
2. Smith B. Superior oblique paresis after blepharoplasty. Plast Reconstr Surg. 1980;66:287.
3. Wesley RE, Pollard ZF, McCord CD Jr. Superior oblique paresis after blepharoplasty. Plast Reconstr Surg. 1980;66:283.
4. Wilhelmi BJ, Mowlavi A, Neumeister MW. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Plast Reconstr Surg. 2001;108:2137-2140.