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Eyelid and Periorbital Necrotizing Fasciitis as an Early Devastating Complication of Blepharoplasty

Lazzeri, Davide M.D.; Agostini, Tommaso M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 1112-1113
doi: 10.1097/PRS.0b013e3181e606a1
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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

Pisa, Italy


1.Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg. 2010;125:1007–1017.
2.Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotizing fasciitis. Br J Ophthalmol. (in press).
3.Ray AM, Bressler K, Davis RE, Gallo JF, Patete ML. Cervicofacial necrotizing fasciitis: A devastating complication of blepharoplasty. Arch Otolaryngol Head Neck Surg. 1997;123:633–636.
4.Jordan DR, Mawn L, Marshall DH. Necrotizing fasciitis caused by group A streptococcus infection after laser blepharoplasty. Am J Ophthalmol. 1998;125:265–266.
5.Suñer IJ, Meldrum ML, Johnson TE, Tse DT. Necrotizing fasciitis after cosmetic blepharoplasty. Am J Ophthalmol. 1999;128:367–368.
6.Goldberg RA, Li TG. Postoperative infection with group A beta-hemolytic streptococcus after blepharoplasty. Am J Ophthalmol. 2002;134:908–910.

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