- Email: [email protected]
Infection after blepharoplasty with and without carbon dioxide laser resurfacing
Infection after Blepharoplasty with and without Carbon Dioxide Laser Resurfacing Susan R. Carter, MD,1 Jay M. Stewart, MD,1 Jemshed Khan, MD,2 Kathleen F. Archer, MD,3 John B. Holds, MD,4 Stuart R. Seiff, MD,1 Roger A. Dailey, MD5 Purpose: To determine the rate of infection in patients who underwent blepharoplasty with and without carbon dioxide laser resurfacing. Design: A retrospective, nonrandomized, consecutive case series. Participants: Eighteen hundred sixty-one patients who underwent upper or lower blepharoplasty, with or without carbon dioxide laser resurfacing. Methods: Charts of patients who underwent blepharoplasty, with or without laser resurfacing, were analyzed for the presence of postoperative infection, method of treatment, and possible sequelae. Main Outcome Measures: The rate of infection (%) was determined for each group of patients. Results: Infection occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and 0.4% of patients who had adjunctive laser resurfacing. No permanent functional or cosmetic sequelae resulted from the episodes of infection. Conclusions: Infection after blepharoplasty without laser resurfacing is uncommon, indicating that topical antibiotic ointment prophylaxis is a sufficient postoperative regimen. The use of adjunctive laser resurfacing may increase the infection rate slightly. Ophthalmology 2003;110:1430 –1432 © 2003 by the American Academy of Ophthalmology.
Blepharoplasty, one of the most commonly performed cosmetic operations in the United States, involves the elimination of redundant tissue of the eyelids, which can also cause functional visual problems. Infection occurring after blepharoplasty has the potential to cause the devastating complication of vision loss, orbital cellulitis or abscess, other functional problems resulting from cicatrization of the orbital or adnexal tissues, and esthetic abnormalities.1–9 A rational basis for antibiotic use in conjunction with blepharoplasty should be based on knowledge of the rate of infection after this procedure. We examined a consecutive series of patients undergoing both upper and lower blepharoplasty to determine this rate.
Originally received: June 24, 2002. Accepted: January 15, 2003. Manuscript no. 220427 1 Department of Ophthalmology, University of California San Francisco, San Francisco, California. 2 Department of Ophthalmology, Kansas University School of Medicine, Kansas City, Kansas. 3 Department of Ophthalmology, Oculoplastic & Reconstructive Surgery, University of Texas Health Science Center, San Antonio, Texas. 4 Departments of Ophthalmology and Otolaryngology–Head and Neck Surgery, Saint Louis University Health Sciences Center, St. Louis, Missouri. 5 Ophthalmic Facial Plastic Surgery, Casey Eye Institute, Oregon Health and Sciences University, Portland, Oregon. Supported in part by That Man May See, Inc. (SRC), and an unrestricted departmental grant from Research to Prevent Blindness (UCSF). Correspondence to Susan R. Carter, MD, 26 Sunset Drive, Chatham, NJ 07928. E-mail: [email protected]
1430
© 2003 by the American Academy of Ophthalmology Published by Elsevier Inc.
Materials and Methods Six ophthalmic plastic surgeons of comparable training, all members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, performed a retrospective review of all consecutive patients who underwent upper and lower blepharoplasty, with or without laser resurfacing, over a range of 3 to 16 years. Patients with follow-up of less than 2 months or who underwent concurrent blepharoptosis repair were excluded from the study. Records of the patients in whom possible or probable infection developed after surgery were examined for predisposing factors or similarities. The criteria for possible or probable infection, defined as erythema, warmth, increased edema, and tenderness of the eyelid, was used by all surgeons. This, combined with prompt resolution of the signs and symptoms with treatment with oral antibiotics, led to the diagnosis of infection. Culture results, when available, were recorded. The rate of infection in patients who underwent blepharoplasty without laser resurfacing and with laser resurfacing was calculated.
Results A total of 1861 patients underwent blepharoplasty with or without laser resurfacing (Table 1).The patients had their procedures performed in offices, ambulatory care centers, or hospital operating rooms. Of the 1627 patients who underwent blepharoplasty without laser resurfacing, most were treated with topical antibiotics alone. The antibiotic ointment was used on the incisions for 1 to 2 weeks after surgery. Only 11 patients with prosthetic joints or heart valves or 6.8% were given oral antibiotics prophylactically during the postoperative period. Patients who underwent blepharoplasty with adjunctive laser resurfacing often took systemic antibiotics and antivirals for prophylaxis for infection of the laser-treated skin, in addition to topical antibiotic ointment. Of the 234 patients who ISSN 0161-6420/03/$–see front matter doi:10.1016/S0161-6420(03)00447-0
Carter et al 䡠 Infection after Blepharoplasty Table 1. Infection Occurring after Blepharoplasty
Procedures Performed Without Laser Resurfacing Upper lids only Upper and lower lids (transconjunctival) Upper and lower lids (transcutaneous) Lower lids only (transconjunctival) Lower lids only (transcutaneous) All procedures With Laser Resurfacing Upper lids only Upper and lower lids (transconjunctival) Lower lids only (transconjunctival) All procedures
Infections (% of Procedures Performed)
1332 120
4 (0%) 0 (0%)
46
0 (0%)
96
0 (0%)
33
0 (0%)
1627
4 (0.2%)
24 123
0 (0%) 1 (0.8%)
87 234
0 (0%) 1 (0.4%)
All procedures were bilateral.
underwent blepharoplasty with laser resurfacing, 127, or 54.3%, were given oral antibiotics. Oral steroids were given by four surgeons to some patients in the immediate postoperative period, except in patients with contraindications, such as diabetes. Of the 1627 patients who underwent upper or lower blepharoplasty, or both, without laser resurfacing, 4 patients were diagnosed clinically with probable postoperative infection, presumed bacterial in origin. Three patients had their procedures in a hospital operating room; the fourth was performed in a clinic minor surgery room. None of the patients were taking oral antibiotics at the time. The patients sought treatment for their symptoms between 4 and 7 days after surgery. Two patients had mild lid edema and erythema, a clinical picture difficult to distinguish from a suture reaction. The other two cases had wound dehiscence and a mild discharge, in addition to pain and erythema; both of these patients were more than 70 years old, and one was diabetic. Orbital cellulitis did not occur in any patient. Cultures were not sent in any of the cases, and all 4 patients were treated empirically with oral antibiotics. None of the patients required intravenous antibiotics, surgical exploration, debridement of the infection site, or hospitalization. The incisions healed well, and no permanent functional or cosmetic sequelae resulted from the episodes of possible infection. The rate of infection for patients undergoing blepharoplasty without laser resurfacing was 0.2%. Of the 234 patients who underwent upper or lower blepharoplasty, or both, with adjunctive laser resurfacing, 127 received prophylactic preoperative and postoperative oral antibiotic and antiviral medications, and 107 did not. In only one patient did a probable infection develop after surgery. The procedure was performed in a clinic minor surgery room. The infection was diagnosed clinically as herpetic in nature based on the presence of erythema and vesicles. The patient had not received prophylactic oral antibiotic or antiviral treatment before or after surgery. Cultures for bacterial, fungal, and herpetic infection were negative. As with the patients who did not have laser resurfacing, the infection responded to treatment with oral medications, in this case cephalexin and valacyclovir. In the laser-resurfaced area, mild postinflammatory hyperpigmentation developed that resolved without treatment. The rate of infection after blepharoplasty with adjunc-
tive laser resurfacing was 0.4%, 0.0% for patients treated with oral antibiotic and antiviral medications, and 0.9% for patients without prophylactic oral therapy.
Discussion We present the cumulative results of all patients who underwent blepharoplasty with or without laser resurfacing by 6 ophthalmic plastic surgeons. Most patients who underwent blepharoplasty without laser resurfacing were treated with topical antibiotics only, whereas most patients who had adjunctive laser resurfacing received oral antibiotics in addition to topical treatment. Oral steroids were used in a minority of the patients. In our series, infections occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and in 0.4% of patients who underwent blepharoplasty with laser resurfacing. The infections occurred in the hospital as well as clinic operating room settings, indicating that the risk of infection was not increased in the clinic setting. All infections presented between 4 and 7 days after surgery. In all cases, the diagnosis was presumptive only; cultures either were not performed, or did not confirm the presence of microorganisms. Erythema, lid swelling, and tenderness were the main clinical features of the presumed infections. Orbital extension was not noted in any case. Treatment with oral antibiotics was successful promptly in all cases, lending credence to the diagnosis of infection, and none of the patients experienced any permanent untoward functional or cosmetic effects. Suture reactions, which also cause erythema, edema, and tenderness, can be difficult to distinguish from early bacterial infections of the eyelid. For this reason, patients who underwent concurrent blepharoptosis repair, with suture material left inside the eyelid, were excluded from the study. Because of the frequent lack of culture material available, diagnosis of infection of the eyelid based on culture positivity is difficult. The development of infection after blepharoplasty is one of the main complications feared by cosmetic surgeons who operate on the eyelids. Serious bacterial infections have been reported previously, all in patients who did not receive prophylactic oral antibiotics after surgery. Orbital cellulitis resulting in no light perception occurred in one patient as a result of infection with Staphylococcus aureus and -hemolytic streptococci after blepharoplasty.9 Necrotizing fasciitis resulting from group A streptococcus has been reported twice after blepharoplasty.3,4 In one of these cases, adjunctive laser resurfacing had also been performed; the patient was young and responded well to antibiotic treatment without permanent sequelae. The other patient, an elderly diabetic, was stabilized only after intubation and vasopressor therapy, and required further eyelid surgery to obtain a normal result. An orbital abscess resulting from Staphylococcus aureus occurred in a 60-year-old man who underwent blepharoplasty, but it was treated successfully with drainage and antibiotic treatment.8 A patient with known nasolacrimal duct obstruction experienced dacryocystitis and orbital cellulitis after blepharoplasty.7 Bacterial cultures
1431
Ophthalmology Volume 110, Number 7, July 2003 of the nasolacrimal discharge in this case grew Eikenella corrodens and Enterobacter aerogenes. In addition to bacterial infections presenting within days after blepharoplasty, delayed infections, presenting 1 month or more after surgery, have been reported. In these cases, mycobacteria have been identified as the culprit organisms. Although one case occurred in a patient undergoing treatment for pulmonary tuberculosis at the time of surgery2 and another occurred in a patient with a Jones tube in place who underwent breast implant exchange during the same operation, immediately before the blepharoplasty,6 other cases have been reported after straightforward blepharoplasty cases in apparently healthy patients.1,5,10 The typical clinical presentation for postoperative mycobacterial infection after blepharoplasty was the development of nodular swelling near the incision sites 1 to 3 months after surgery. The diagnosis usually was suspected after the condition failed to improve despite treatment with oral cephalosporins or ampicillin. All but one reported case2 required debridement or drainage of the lesions to obtain complete resolution of the infection. Of note, the eyelids may be less likely to develop mycobacterial infections than other operative sites in cosmetic surgery. In a series of patients with Mycobacterium chelonae infections that were attributed to contaminated gentian-violet skin markers, infections developed at the face-lift or augmentation-mammoplasty surgical sites, but not at the blepharoplasty site, even when blepharoplasty was performed concurrently with a face-lift that subsequently became infected.11 Our finding that the infection rate after blepharoplasty without laser resurfacing was 0.2%, despite the fact that almost all patients received only topical antibiotic prophylaxis, confirms that routine perioperative oral antibiotics are unnecessary in most cases. Some patients received perioperative oral steroids, which may be expected to increase the risk of infection, yet none of the infections developed in patients treated with steroids. The infections that did occur were successfully treated with oral antibiotics and resulted in no permanent negative sequelae. In general, previously reported cases also have responded well to treatment; only one patient experienced permanent vision loss.9 In that case, the patient waited 8 hours after the onset of symptoms before contacting the surgeon; it is possible that the outcome might have been less devastating if treatment had been initiated sooner. In this series, we also found that the rate of infections occurring after blepharoplasty with laser resurfacing was low: 0.4%. This represents one infection in a series of 234 patients undergoing the procedure. The infection occurred in a patient who did not receive oral antibiotic prophylaxis after surgery. The surgeon in this case was the only physician in our series who did not administer antibiotics routinely after blepharoplasty with laser resurfacing. This physician performed 107 such procedures, resulting in an infection rate for this surgeon of 0.9%. Of the other 127 patients who underwent blepharoplasty with laser resurfacing, all received oral antibiotic prophylaxis, and none experienced infections. Although the rate of infection after blepharoplasty with adjunctive laser resurfacing has not been examined previously, studies evaluating full-face laser resurfacing often have reported higher rates of infection; one
1432
group found postoperative infections in 11% of patients undergoing this procedure.12 The difference in risk between fullface laser resurfacing and blepharoplasty with adjunctive laser treatment may be the result of the substantially smaller area of skin that is treated in the latter procedure. Antibiotic prophylaxis after full-face laser resurfacing has not been shown conclusively to have a protective effect against infection.13–15 Taken together, these results suggest that topical postoperative antibiotic prophylaxis alone is sufficient for routine blepharoplasty without laser resurfacing in otherwise healthy patients. For blepharoplasty with adjunctive laser resurfacing, patients may be less likely to experience postoperative infections if oral antibiotic prophylaxis is used. Regardless of whether adjunctive laser resurfacing is performed, clinicians may have a lower threshold for using routine oral antibiotic prophylaxis in higher-risk patients such as those with diabetes.
References 1. Gonzalez-Fernandez F, Kaltreider SA. Orbital lipogranulomatous inflammation harboring Mycobacterium abscessus. Ophthal Plast Reconstr Surg 2001;17:374 – 80. 2. Chen SH, Wang CH, Chen HC, et al. Upper eyelid mycobacterial infection following Oriental blepharoplasty in a pulmonary tuberculosis patient. Aesthetic Plast Surg 2001;25:295– 8. 3. Suner IJ, Meldrum ML, Johnson TE, et al. Necrotizing fasciitis after cosmetic blepharoplasty. Am J Ophthalmol 1999; 128:367– 8. 4. Jordan DR, Mawn L, Marshall DH. Necrotizing fasciitis caused by group A Streptococcus infection after laser blepharoplasty. Am J Ophthalmol 1998;125:265– 6. 5. Moorthy RS, Rao NA. Atypical mycobacterial wound infection after blepharoplasty. Br J Ophthalmol 1995;79:93. 6. Kevitch R, Guyuron B. Mycobacterial infection following blepharoplasty. Aesthetic Plast Surg 1991;15:229 –32. 7. Allen MV, Cohen KL, Grimson BS. Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol 1985;17:498 –9. 8. Rees TD, Craig SM, Fisher Y. Orbital abscess following blepharoplasty. Plast Reconstr Surg 1984;73:126 –7. 9. Morgan SC. Orbital cellulitis and blindness following a blepharoplasty. Plast Reconstr Surg 1979;64:823– 6. 10. Chang WJ, Tse DT, Rosa RH, et al. Periocular atypical mycobacterial infections. Ophthalmology 1999;106:86 –90. 11. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 1987;317:197–201. 12. Waldorf HA, Kauvar AN, Geronemus RG. Skin resurfacing of fine to deep rhytides using a char-free carbon dioxide laser in 47 patients. Dermatol Surg 1995;21:940 – 6. 13. Manuskiatti W, Fitzpatrick RE, Goldman MP, et al. Prophylactic antibiotics in patients undergoing laser resurfacing of the skin. J Am Acad Dermatol 1999;40:77– 84. 14. Ross EV, Amesbury EC, Barile A, et al. Incidence of postoperative infection or positive culture after facial laser resurfacing: a pilot study, a case report, and a proposal for a rational approach to antibiotic prophylaxis. J Am Acad Dermatol 1998;39:975– 81. 15. Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg 1999;25:857– 61.
Blepharoplasty, one of the most commonly performed cosmetic operations in the United States, involves the elimination of redundant tissue of the eyelids, which can also cause functional visual problems. Infection occurring after blepharoplasty has the potential to cause the devastating complication of vision loss, orbital cellulitis or abscess, other functional problems resulting from cicatrization of the orbital or adnexal tissues, and esthetic abnormalities.1–9 A rational basis for antibiotic use in conjunction with blepharoplasty should be based on knowledge of the rate of infection after this procedure. We examined a consecutive series of patients undergoing both upper and lower blepharoplasty to determine this rate.
Originally received: June 24, 2002. Accepted: January 15, 2003. Manuscript no. 220427 1 Department of Ophthalmology, University of California San Francisco, San Francisco, California. 2 Department of Ophthalmology, Kansas University School of Medicine, Kansas City, Kansas. 3 Department of Ophthalmology, Oculoplastic & Reconstructive Surgery, University of Texas Health Science Center, San Antonio, Texas. 4 Departments of Ophthalmology and Otolaryngology–Head and Neck Surgery, Saint Louis University Health Sciences Center, St. Louis, Missouri. 5 Ophthalmic Facial Plastic Surgery, Casey Eye Institute, Oregon Health and Sciences University, Portland, Oregon. Supported in part by That Man May See, Inc. (SRC), and an unrestricted departmental grant from Research to Prevent Blindness (UCSF). Correspondence to Susan R. Carter, MD, 26 Sunset Drive, Chatham, NJ 07928. E-mail: [email protected]
1430
© 2003 by the American Academy of Ophthalmology Published by Elsevier Inc.
Materials and Methods Six ophthalmic plastic surgeons of comparable training, all members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, performed a retrospective review of all consecutive patients who underwent upper and lower blepharoplasty, with or without laser resurfacing, over a range of 3 to 16 years. Patients with follow-up of less than 2 months or who underwent concurrent blepharoptosis repair were excluded from the study. Records of the patients in whom possible or probable infection developed after surgery were examined for predisposing factors or similarities. The criteria for possible or probable infection, defined as erythema, warmth, increased edema, and tenderness of the eyelid, was used by all surgeons. This, combined with prompt resolution of the signs and symptoms with treatment with oral antibiotics, led to the diagnosis of infection. Culture results, when available, were recorded. The rate of infection in patients who underwent blepharoplasty without laser resurfacing and with laser resurfacing was calculated.
Results A total of 1861 patients underwent blepharoplasty with or without laser resurfacing (Table 1).The patients had their procedures performed in offices, ambulatory care centers, or hospital operating rooms. Of the 1627 patients who underwent blepharoplasty without laser resurfacing, most were treated with topical antibiotics alone. The antibiotic ointment was used on the incisions for 1 to 2 weeks after surgery. Only 11 patients with prosthetic joints or heart valves or 6.8% were given oral antibiotics prophylactically during the postoperative period. Patients who underwent blepharoplasty with adjunctive laser resurfacing often took systemic antibiotics and antivirals for prophylaxis for infection of the laser-treated skin, in addition to topical antibiotic ointment. Of the 234 patients who ISSN 0161-6420/03/$–see front matter doi:10.1016/S0161-6420(03)00447-0
Carter et al 䡠 Infection after Blepharoplasty Table 1. Infection Occurring after Blepharoplasty
Procedures Performed Without Laser Resurfacing Upper lids only Upper and lower lids (transconjunctival) Upper and lower lids (transcutaneous) Lower lids only (transconjunctival) Lower lids only (transcutaneous) All procedures With Laser Resurfacing Upper lids only Upper and lower lids (transconjunctival) Lower lids only (transconjunctival) All procedures
Infections (% of Procedures Performed)
1332 120
4 (0%) 0 (0%)
46
0 (0%)
96
0 (0%)
33
0 (0%)
1627
4 (0.2%)
24 123
0 (0%) 1 (0.8%)
87 234
0 (0%) 1 (0.4%)
All procedures were bilateral.
underwent blepharoplasty with laser resurfacing, 127, or 54.3%, were given oral antibiotics. Oral steroids were given by four surgeons to some patients in the immediate postoperative period, except in patients with contraindications, such as diabetes. Of the 1627 patients who underwent upper or lower blepharoplasty, or both, without laser resurfacing, 4 patients were diagnosed clinically with probable postoperative infection, presumed bacterial in origin. Three patients had their procedures in a hospital operating room; the fourth was performed in a clinic minor surgery room. None of the patients were taking oral antibiotics at the time. The patients sought treatment for their symptoms between 4 and 7 days after surgery. Two patients had mild lid edema and erythema, a clinical picture difficult to distinguish from a suture reaction. The other two cases had wound dehiscence and a mild discharge, in addition to pain and erythema; both of these patients were more than 70 years old, and one was diabetic. Orbital cellulitis did not occur in any patient. Cultures were not sent in any of the cases, and all 4 patients were treated empirically with oral antibiotics. None of the patients required intravenous antibiotics, surgical exploration, debridement of the infection site, or hospitalization. The incisions healed well, and no permanent functional or cosmetic sequelae resulted from the episodes of possible infection. The rate of infection for patients undergoing blepharoplasty without laser resurfacing was 0.2%. Of the 234 patients who underwent upper or lower blepharoplasty, or both, with adjunctive laser resurfacing, 127 received prophylactic preoperative and postoperative oral antibiotic and antiviral medications, and 107 did not. In only one patient did a probable infection develop after surgery. The procedure was performed in a clinic minor surgery room. The infection was diagnosed clinically as herpetic in nature based on the presence of erythema and vesicles. The patient had not received prophylactic oral antibiotic or antiviral treatment before or after surgery. Cultures for bacterial, fungal, and herpetic infection were negative. As with the patients who did not have laser resurfacing, the infection responded to treatment with oral medications, in this case cephalexin and valacyclovir. In the laser-resurfaced area, mild postinflammatory hyperpigmentation developed that resolved without treatment. The rate of infection after blepharoplasty with adjunc-
tive laser resurfacing was 0.4%, 0.0% for patients treated with oral antibiotic and antiviral medications, and 0.9% for patients without prophylactic oral therapy.
Discussion We present the cumulative results of all patients who underwent blepharoplasty with or without laser resurfacing by 6 ophthalmic plastic surgeons. Most patients who underwent blepharoplasty without laser resurfacing were treated with topical antibiotics only, whereas most patients who had adjunctive laser resurfacing received oral antibiotics in addition to topical treatment. Oral steroids were used in a minority of the patients. In our series, infections occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and in 0.4% of patients who underwent blepharoplasty with laser resurfacing. The infections occurred in the hospital as well as clinic operating room settings, indicating that the risk of infection was not increased in the clinic setting. All infections presented between 4 and 7 days after surgery. In all cases, the diagnosis was presumptive only; cultures either were not performed, or did not confirm the presence of microorganisms. Erythema, lid swelling, and tenderness were the main clinical features of the presumed infections. Orbital extension was not noted in any case. Treatment with oral antibiotics was successful promptly in all cases, lending credence to the diagnosis of infection, and none of the patients experienced any permanent untoward functional or cosmetic effects. Suture reactions, which also cause erythema, edema, and tenderness, can be difficult to distinguish from early bacterial infections of the eyelid. For this reason, patients who underwent concurrent blepharoptosis repair, with suture material left inside the eyelid, were excluded from the study. Because of the frequent lack of culture material available, diagnosis of infection of the eyelid based on culture positivity is difficult. The development of infection after blepharoplasty is one of the main complications feared by cosmetic surgeons who operate on the eyelids. Serious bacterial infections have been reported previously, all in patients who did not receive prophylactic oral antibiotics after surgery. Orbital cellulitis resulting in no light perception occurred in one patient as a result of infection with Staphylococcus aureus and -hemolytic streptococci after blepharoplasty.9 Necrotizing fasciitis resulting from group A streptococcus has been reported twice after blepharoplasty.3,4 In one of these cases, adjunctive laser resurfacing had also been performed; the patient was young and responded well to antibiotic treatment without permanent sequelae. The other patient, an elderly diabetic, was stabilized only after intubation and vasopressor therapy, and required further eyelid surgery to obtain a normal result. An orbital abscess resulting from Staphylococcus aureus occurred in a 60-year-old man who underwent blepharoplasty, but it was treated successfully with drainage and antibiotic treatment.8 A patient with known nasolacrimal duct obstruction experienced dacryocystitis and orbital cellulitis after blepharoplasty.7 Bacterial cultures
1431
Ophthalmology Volume 110, Number 7, July 2003 of the nasolacrimal discharge in this case grew Eikenella corrodens and Enterobacter aerogenes. In addition to bacterial infections presenting within days after blepharoplasty, delayed infections, presenting 1 month or more after surgery, have been reported. In these cases, mycobacteria have been identified as the culprit organisms. Although one case occurred in a patient undergoing treatment for pulmonary tuberculosis at the time of surgery2 and another occurred in a patient with a Jones tube in place who underwent breast implant exchange during the same operation, immediately before the blepharoplasty,6 other cases have been reported after straightforward blepharoplasty cases in apparently healthy patients.1,5,10 The typical clinical presentation for postoperative mycobacterial infection after blepharoplasty was the development of nodular swelling near the incision sites 1 to 3 months after surgery. The diagnosis usually was suspected after the condition failed to improve despite treatment with oral cephalosporins or ampicillin. All but one reported case2 required debridement or drainage of the lesions to obtain complete resolution of the infection. Of note, the eyelids may be less likely to develop mycobacterial infections than other operative sites in cosmetic surgery. In a series of patients with Mycobacterium chelonae infections that were attributed to contaminated gentian-violet skin markers, infections developed at the face-lift or augmentation-mammoplasty surgical sites, but not at the blepharoplasty site, even when blepharoplasty was performed concurrently with a face-lift that subsequently became infected.11 Our finding that the infection rate after blepharoplasty without laser resurfacing was 0.2%, despite the fact that almost all patients received only topical antibiotic prophylaxis, confirms that routine perioperative oral antibiotics are unnecessary in most cases. Some patients received perioperative oral steroids, which may be expected to increase the risk of infection, yet none of the infections developed in patients treated with steroids. The infections that did occur were successfully treated with oral antibiotics and resulted in no permanent negative sequelae. In general, previously reported cases also have responded well to treatment; only one patient experienced permanent vision loss.9 In that case, the patient waited 8 hours after the onset of symptoms before contacting the surgeon; it is possible that the outcome might have been less devastating if treatment had been initiated sooner. In this series, we also found that the rate of infections occurring after blepharoplasty with laser resurfacing was low: 0.4%. This represents one infection in a series of 234 patients undergoing the procedure. The infection occurred in a patient who did not receive oral antibiotic prophylaxis after surgery. The surgeon in this case was the only physician in our series who did not administer antibiotics routinely after blepharoplasty with laser resurfacing. This physician performed 107 such procedures, resulting in an infection rate for this surgeon of 0.9%. Of the other 127 patients who underwent blepharoplasty with laser resurfacing, all received oral antibiotic prophylaxis, and none experienced infections. Although the rate of infection after blepharoplasty with adjunctive laser resurfacing has not been examined previously, studies evaluating full-face laser resurfacing often have reported higher rates of infection; one
1432
group found postoperative infections in 11% of patients undergoing this procedure.12 The difference in risk between fullface laser resurfacing and blepharoplasty with adjunctive laser treatment may be the result of the substantially smaller area of skin that is treated in the latter procedure. Antibiotic prophylaxis after full-face laser resurfacing has not been shown conclusively to have a protective effect against infection.13–15 Taken together, these results suggest that topical postoperative antibiotic prophylaxis alone is sufficient for routine blepharoplasty without laser resurfacing in otherwise healthy patients. For blepharoplasty with adjunctive laser resurfacing, patients may be less likely to experience postoperative infections if oral antibiotic prophylaxis is used. Regardless of whether adjunctive laser resurfacing is performed, clinicians may have a lower threshold for using routine oral antibiotic prophylaxis in higher-risk patients such as those with diabetes.
References 1. Gonzalez-Fernandez F, Kaltreider SA. Orbital lipogranulomatous inflammation harboring Mycobacterium abscessus. Ophthal Plast Reconstr Surg 2001;17:374 – 80. 2. Chen SH, Wang CH, Chen HC, et al. Upper eyelid mycobacterial infection following Oriental blepharoplasty in a pulmonary tuberculosis patient. Aesthetic Plast Surg 2001;25:295– 8. 3. Suner IJ, Meldrum ML, Johnson TE, et al. Necrotizing fasciitis after cosmetic blepharoplasty. Am J Ophthalmol 1999; 128:367– 8. 4. Jordan DR, Mawn L, Marshall DH. Necrotizing fasciitis caused by group A Streptococcus infection after laser blepharoplasty. Am J Ophthalmol 1998;125:265– 6. 5. Moorthy RS, Rao NA. Atypical mycobacterial wound infection after blepharoplasty. Br J Ophthalmol 1995;79:93. 6. Kevitch R, Guyuron B. Mycobacterial infection following blepharoplasty. Aesthetic Plast Surg 1991;15:229 –32. 7. Allen MV, Cohen KL, Grimson BS. Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol 1985;17:498 –9. 8. Rees TD, Craig SM, Fisher Y. Orbital abscess following blepharoplasty. Plast Reconstr Surg 1984;73:126 –7. 9. Morgan SC. Orbital cellulitis and blindness following a blepharoplasty. Plast Reconstr Surg 1979;64:823– 6. 10. Chang WJ, Tse DT, Rosa RH, et al. Periocular atypical mycobacterial infections. Ophthalmology 1999;106:86 –90. 11. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 1987;317:197–201. 12. Waldorf HA, Kauvar AN, Geronemus RG. Skin resurfacing of fine to deep rhytides using a char-free carbon dioxide laser in 47 patients. Dermatol Surg 1995;21:940 – 6. 13. Manuskiatti W, Fitzpatrick RE, Goldman MP, et al. Prophylactic antibiotics in patients undergoing laser resurfacing of the skin. J Am Acad Dermatol 1999;40:77– 84. 14. Ross EV, Amesbury EC, Barile A, et al. Incidence of postoperative infection or positive culture after facial laser resurfacing: a pilot study, a case report, and a proposal for a rational approach to antibiotic prophylaxis. J Am Acad Dermatol 1998;39:975– 81. 15. Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg 1999;25:857– 61.