We read with great interest the recent report by Lelli and Lisman entitled “Blepharoplasty Complications” (Plast Reconstr Surg. 2010;125:1007–1017)1 and we would like to point out some information that we consider striking.
Regarding infections as complications in the early postoperative period (first week), necrotizing fasciitis has not been cited. It is a rare and severe infection of the subcutaneous soft tissue and underlying fascia.2 Necrotizing fasciitis seldom involves the head and neck areas and only very rarely involves the periorbital area.2 If left untreated, complications of periorbital necrotizing fasciitis include blindness, orbital lesions, meningitis and other neurologic disorders, and death. Although half of the patients are previously healthy, the infection may follow local blunt trauma or any condition in which the integrity of the eyelid integument is compromised by abrasion, laceration, or penetrating injuries.2 It has also been reported following cosmetic blepharoplasty in four cases.3–6
Differential diagnoses of periorbital necrotizing fasciitis include all the inflammatory processes that affect the eyelids, eye, and orbit.2 In particular, periorbital necrotizing fasciitis should be distinguished from preseptal cellulitis and orbital cellulitis. Initially, necrotizing fasciitis is difficult if not impossible to distinguish from preseptal cellulitis. Rapid progression and eventual cyanosis of the involved tissue (appearing as a violaceous discoloration) and the formation of serous fluid-filled bullae are clues for differentiating this condition from common nonnecrotizing preseptal cellulitis. The observation of dusky erythema in an area of cellulitis enables one to distinguish orbital cellulitis from periorbital necrotizing fasciitis in which parenteral antibiotics do not prevent the progression of the skin lesions to necrosis, because it is controlled only with massive débridement of necrotic tissue along with antibiotic therapy.2 Management of necrotizing fasciitis is predicated on early recognition of symptoms and signs, and aggressive multidisciplinary treatment is mandatory to avoid morbidity (e.g., severe permanent disfigurement, loss of vision, exenteration) and mortality linked to misdiagnosis or delay in diagnosis. If the diagnosis of periorbital necrotizing fasciitis infection is established rapidly, treatment by extensive débridement and antibiotics with or without the use of hyperbaric oxygen therapy can prevent its fulminant course with a fatal outcome.2 Thus, the oculoplastic surgeon needs to watch out for clinical signs of necrotizing fasciitis that may occur also after blepharoplasty.
There are no financial conflicts or interests to report in association with the contents of this communication.
Davide Lazzeri, M.D.
Plastic and Reconstructive Surgery Unit
Tommaso Agostini, M.D.
Burn Center Unit
Hospital of Pisa
1.Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg
2.Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotizing fasciitis. Br J Ophthalmol.
3.Ray AM, Bressler K, Davis RE, Gallo JF, Patete ML. Cervicofacial necrotizing fasciitis: A devastating complication of blepharoplasty. Arch Otolaryngol Head Neck Surg
4.Jordan DR, Mawn L, Marshall DH. Necrotizing fasciitis caused by group A streptococcus infection after laser blepharoplasty. Am J Ophthalmol
5.Suñer IJ, Meldrum ML, Johnson TE, Tse DT. Necrotizing fasciitis after cosmetic blepharoplasty. Am J Ophthalmol
6.Goldberg RA, Li TG. Postoperative infection with group A beta-hemolytic streptococcus after blepharoplasty. Am J Ophthalmol
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.