Purpose

To present the surgical management of the long-term upper eyelid edema after repeated blepharoplasty with consequent mechanical ptosis and loss of eyelid folds and crease in both eyes.

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Methods

We present the case of a 48-year-old female patient who presented to our institution in mid-2025 with persistent upper and lower eyelid swelling in both eyes. 24 years ago, she sustained a car accident with injury to the right periocular region. In 2007, the right eye underwent a Fassanella-Servat procedure. Subsequently, upper blepharoplasty was performed three times on the right eye and two times on the left eye. The medial angle was corrected once, after which a skin fold remained. Clinical examination revealed diffuse edema of the upper and lower left eyelids, the right eyelid fold and crease were absent, the lower eyelid crease on the left was shortened, discrete ptosis of a possible mechanical type on the right side, and epicanthus on both sides. Other findings were within physiological limits. Our differential diagnosis included lymphedema and Mb. Morbihan next to clinical diagnosis.

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Results

After a detailed counseling with the patient and preoperative preparation, in December 2025, surgery was performed on the upper eyelid of the right eye, and 3 months later on the left eye, namely upper blepharoplasty with removal of the medial and central fat pads, preaponeurotic fat pad, partial orbiculectomy, reduction of eyebrow fat and ROOF, orbicularis suspension, strengthening of the LMA, and reconstruction of the eyelid crease. Biopsy findings were inconclusive but showed dilated lymphatic vessels and spaces, and thus the pathologist confirmed the working diagnosis of lymphedema and possibly Mb Morbihan.

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Conclusion

Dysfunction of lymphatic flow in the eyelids may be the cause of persistent lymphedema. Fibrosis and tissue remodeling, together with pretarsal fullness, may attenuate the eyelid fold and induce or worsen pre-existing ptosis. Disruption of the levator-dermis connection may result in complete loss of the eyelid fold and crease. Radical tissue debulking may be necessary to address pronounced lymphedema.

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Additional Authors

First name	Last name	Base Hospital / Institution
Igor	Knezovic	Polyclinic Knezovic Zagreb

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