CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

Antibiotic Prophylaxis in
Blepharoplasty: Review of the Current
Literature
Elie M. Ferneini, DMD, MD, MHS, MBA,* Steven Halepas, BS,y
and Steven I. Aronin, MDz

The purpose of this study was to provide an evidence-based overview of antibiotic prophylaxis in
blepharoplasty. We performed a literature search that evaluated the risk of infection associated with
blepharoplasty, as well as the risks and benefits of antibiotic prophylaxis. The overall infection rate
associated with eyelid surgery is extremely low. However, the use of antibiotic prophylaxis has
increased over the past 25 years in esthetic facial procedures. There is no standard of care for or against
antibiotic prophylaxis, and routine practices vary widely. This leads to the question of whether
reducing the risk of surgical-site infection to near zero outweighs the real danger of antibiotic-
related complications, including the escalating emergence of antibiotic-resistant bacteria. No direct
consensus can be drawn from the current literature; thus, at this time, there is no current standard
of care for oral and maxillofacial surgeons to adhere to in terms of when and if antibiotic prophylaxis
is needed when performing blepharoplasty.
Ó 2017 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:1477-1481, 2017

The desire for blepharoplasty is twofold: cosmetic and Review of Literature

functional. Patients benefit from the procedure es-
thetically, and they also often benefit from an
increased field of vision. The number of blepharo-
plasty procedures is constantly increasing in conjunc-
tion with the rising population age. One must
acknowledge that this trend is associated with an
increasing number of complications. Numerous diffi-
culties can result from blepharoplasty, with postoper-
ative infections of considerable importance. Before
the principles of asepsis were established, surgical-
site infection was a major cause of postoperative com-
plications and even death. As the number of facial
cosmetic surgical procedures continues to rise, the
oral and maxillofacial surgeon must be mindful of
possible surgical-site infections and their potential
complications.
The most common organisms causing surgical-site
infection are Staphylococcus and Streptococcus spe-
cies.1 Although coagulase-negative staphylococci
have been associated with myriad diseases, it is often
difficult to discern whether the presence of these bac-
teria in culture represents skin contamination or the
true cause of an infection, especially in the absence
of prosthetic material. On the contrary, Staphylo-
coccus aureus is nearly always considered pathogenic
and is currently the most common cause of surgical-
site infection.2 Infectious complications of blepharo-
plasty include preseptal and orbital cellulitis. Orbital
cellulitis is a sight-threatening complication that re-
sults from bacterial infection posterior to the orbital
septum. As with other surgical-site infections, this

*Medical Director, Beau Visage Med Spa; Private Practice, Greater Address correspondence and reprint requests to Dr Ferneini:
Waterbury OMS, Cheshire, CT; and Assistant Clinical Professor, Beau Visage Med Spa, 435 Highland Ave, Ste 100, Cheshire, CT
University of Connecticut, Farmington, CT. 06410; e-mail: eferneini@yahoo.com
yStudent, School of Dental Medicine, University of Connecticut, Received January 7 2017
Farmington, CT. Accepted January 20 2017
zChief, Section of Infectious Disease, Waterbury Hospital, Ó 2017 American Association of Oral and Maxillofacial Surgeons
Waterbury, CT; and Associate Clinical Professor of Medicine, Yale 0278-2391/17/30110-6
University School of Medicine, New Haven, CT. http://dx.doi.org/10.1016/j.joms.2017.01.025
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.

1477
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1478
complication may be due to Staphylococcus and Strep-
tococcus species, especially S aureus. For surgical-site
infections in general, the proportion of S aureus infec-
tions due to a methicillin-resistant strain has increased
substantially.2 There have been limited reports of
methicillin-resistant S aureus infection involving the
ocular region, but the rate of infection of this type is
hypothesized to be increasing.3
In general surgery, the value of antibiotic prophy-
laxis is well-established. Bowater et al4 found anti-
biotic prophylaxis to be an effective intervention for
preventing postoperative wound infections in a
meta-analysis involving 250 clinical trials in over 23
different types of surgery. To be most effective, one
must consider the timing of administration, dose,
and medication type. Research has concluded that
administration within 60 minutes before the surgical
incision provides optimal prevention.2 Administration
of antibiotics 60 minutes before and discontinuing
24 hours after surgery is consistent with the national
guidelines described by The Joint Commission and
Centers for Medicare & Medicaid Services.2,5
Although there is a clear benefit of antibiotic
prophylaxis for major surgical procedures, the same
cannot be said for minor surgical procedures such as
clean facial and nasal procedures. Furthermore, the
most recent practice guidelines2 are inconsistent in
that they recommend routine antibiotic prophylaxis
for plastic surgery procedures, but no prophylaxis
for clean head and neck procedures. Accordingly, the
use of prophylactic antibiotics in clinical practice has
varied widely.
The use of antibiotic prophylaxis has increased
over the past 25 years, especially in esthetic proced-
ures. Lyle et al6 found 11% of surveyed surgeons al-
ways or often used antibiotics in blepharoplasty
procedures in 1985. The same study reported that
46.9% of those surveyed in 2000 always or often
used antibiotics. No direct scientific evidence
became available in the interim period to warrant
such an increase in antibiotic use. In 2006 Grune-
baum and Reiter7 reported 91% of their surveyed
facial plastic surgeons routinely used preoperative
intravenous antibiotics, but only 34% of respondents
used prophylaxis for all cases, and there was wide
variation in terms of whether and how long antibi-
otics were continued postoperatively. First-
generation cephalosporin was the antibiotic of
choice picked by 91% of respondents. In 2013 the
New England Oculoplastics Society Study Group
published a retrospective review of nearly 700 cases
to assess the role of prophylactic postoperative anti-
biotics in enucleation and evisceration orbital sur-
gery and found no evidence to support their use.8
More recently, the Study Group conducted a
follow-up multinational survey of 782 oculoplastic
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ANTIBIOTIC PROPHYLAXIS IN BLEPHAROPLASTY
surgeons.9 For all regions, only 13.5% of respon-
dents reported that they routinely used periopera-
tive intravenous antibiotics for routine, elective
eyelid procedures, but there was considerable
geographic variability (ranging from 2.9% in the
United Kingdom to 86.7% in India; mean, 24%).
Postoperative antibiotics were found to be more
commonly prescribed, including oral (23.6%) and
topical (>85%) routes. Although one must question
why such a high number of surgeons are using anti-
biotic prophylaxis for these procedures given no
substantiating clinical evidence, it is evident that
increased antibiotic use is a contemporary trend in
all aspects of health care.
The overall complication rate associated with eyelid
surgery in the outpatient setting is low.10 Carter et al11
found 5 of 1,861 patients who underwent blepharo-
plasty with or without laser resurfacing in their retro-
spective study to have postoperative infections. Most
patients in this study received only topical oral antibi-
otics. Those patients who did have an infection were
treated successfully with topical antibiotics post-
operatively.
Blepharoplasty infections, although rare, can be
quite devastating. Klapper and Patrinely3 concluded
the infection rate to be as low as 0.2%. Infections
can range from mild wound dehiscence to significant
cellulitis. The incidence of cellulitis after this type of
procedure is low because of the rich vasculature of
the area.1 Necrotizing fasciitis is a potential risk after
a procedure of this nature when a postoperative group
A Streptococcus infection presents.12 Early detection
and treatment are vital for a favorable outcome. Treat-
ment includes debridement of necrotic tissue and
administration of effective antibiotics. Other consider-
able complications include retrobulbar hemorrhage
that can result in vision loss. The rate of postsurgical
orbital hemorrhage in this setting is estimated to be
0.05%, with permanent vision loss estimated at
0.01%.3 Vision loss due to postseptal orbital cellulitis
is also of concern.
A postoperative infection is typically due to Staphy-
lococcus and/or Streptococcus species, but one must
consider infection due to alternative pathogens such
as gram-negative bacilli and methicillin-resistant S
aureus, especially when the infection is not respond-
ing to standard antimicrobial therapy. This type of
infection is especially problematic in special hosts
such as users of injection drugs, diabetic patients, he-
modialysis patients, and patients with other immuno-
compromised conditions. This concept is further
highlighted by Mauriello and the Atypical Mycobacte-
rial Study Group,13 who reported a case series of pa-
tients from 7 practices in which 8 patients had
nontuberculous mycobacterial infection after blepha-
roplasty. They concluded that atypical mycobacterial
FERNEINI, HALEPAS, AND ARONIN 1479

Table 1. RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS BY PROCEDURE, DOSING, AND REDOSING INTERVALS

Dose of Redosing Interval Dose of Redosing

Recommended Recommended for Recommended Alternative Alternative Interval for
Type of Procedure Agent Agent* Agent Agent Agent* Alternative Agent

Head and neck

Clean None None
Plastic surgery
Clean facial or None None
nasal procedures
without an
implant
Facial or nasal Cefazolin 2 g (3 g if weight 4 hours Clindamycin 900 mg 6 hours
procedures with >120 kg)
an implant
Cefuroxime 1.5 g 4 hours
* Doses listed are for adult patients, and the first dose should be administered within 60 minutes before surgical incision.
Ferneini, Halepas, and Aronin. Antibiotic Prophylaxis in Blepharoplasty. J Oral Maxillofac Surg 2017.

infection may complicate blepharoplasty and surgeons
need to be mindful of this rare infection. It typically
presents as a delayed infection with erythematous
nodules, especially in the setting of foreign-body im-
plantation, but may mimic a chalazion, develop in a su-
tured incision, present as an abscess, or occur without
any signs of inflammation.13
Discussion
Although the complications of blepharoplasty can be
quite severe, it is evident that the incidence of postoper-
ative infection is quite low. It is thus surprising to see
such an increase in the use of prophylactic antibiotics.
Although studies have found prophylaxis to be useful
in a wide variety of surgical procedures, no such data
exist for the blepharoplasty procedure. In today’s world,
with the ongoing emergence of antibiotic-resistant path-
ogens, as well as life-threatening complications of antibi-
otics, including allergic reactions and Clostridium
difficile colitis, the oral and maxillofacial surgeon must
be mindful of overprescribing antibiotics. The 1999
Centers for Disease Control and Prevention guidelines
for prevention of surgical-site infections state that pro-
phylactic antibiotics should only be administered
when indicated.14 The Centers for Disease Control
and Prevention has not released any major or specific
updates to these guidelines, leaving surgeons reluctantly
needing to extrapolate information from other relevant
research. In 2013 a clinical practice guideline was devel-
oped jointly by the American Society of Health-System
Pharmacists, Infectious Diseases Society of America, Sur-
gical Infection Society, and Society for Healthcare Epide-
miology of America. This guideline supports no
prophylaxis in clean facial and nasal procedures in
which implants are not used. When implants are used,
antibiotic prophylaxis with a single dose of cefazolin
should be considered.2 For the patient with a history
of b-lactam allergy, clindamycin is a good alternative.
With systemic antibiotics not proven necessary and
the potential for complications related to antibiotic
use (proliferation of antibiotic resistance, C difficile
colitis, allergic reactions, drug interactions), many sur-
geons are exploring topical antibiotic use. Alexander
et al15 recommended that topical antibiotics should
be used whenever there is a concern for any potential
serious surgical wound infection. The study suggested
using aminoglycosides, such as gentamicin, because of
their broad spectrum of antimicrobial activity
including S aureus, Streptococcus pyogenes, and mul-
tiple gram-negative bacilli. The authors noted that anti-
biotic prophylaxis in general, as well as the systemic
versus topical route, is a very complex issue that re-
quires much more research. A few points are not
controversial, however. A wound infection cannot
occur if there is no microbial contaminant: Most
wounds have a microbial inoculant to some extent
because one cannot operate in a perfectly sterile envi-
ronment. In addition, the extent of the infection de-
pends on the quantity of the inoculant and the
specific microbial contaminant, as well as the host’s
response. In a letter to the editor, Mehta et al16 noted
that more research is needed on the best prophylactic
topical antibiotic and proven efficacy before giving a
generalized recommendation. At this time, systemic
antibiotics have been shown repeatedly to be very
effective in reducing surgical-site wound infections.
Using sterile precautions, following isolation pre-
cautions, and irrigating surgical sites have been shown
to be the most important ways to minimize post-
blepharoplasty infection. Preoperative bathing with
chlorhexidine reduces pathogenic organisms on the

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1480
skin, but results in a nonsignificant reduction in
wound infections.15 Alexander et al15 also reported a
meta-analysis of antibiotic prophylaxis of 23 different
types of surgery showing a benefit no matter what
the level of contamination. For the antibiotic to be
effective, the surgeon should ensure that it is adminis-
tered within 60 minutes of the incision. A single dose
is reported to be as effective as multiple doses for anti-
biotic prophylaxis. Cefazolin was proved to be the pre-
operative antibiotic of choice in facial cosmetic
surgery. The antibiotic of choice must be appropriate
for the pathogen the surgeon is expecting. Because
Staphylococcus and Streptococcus infections are the
most common postsurgical infections in blepharo-
plasty wounds, a first- or second-generation cephalo-
sporin would be appropriate. For the patient with a
history of b-lactam allergy, clindamycin is a good alter-
native (Table 1). The surgeon must be mindful of the
potential risk of cellulitis by these pathogens. To treat
this, the surgeon must look for this potential infection.
Patients having an infection after this surgical proced-
ure often present with erythematous, tender, en-
gorged eyelids.1
Gonzalez-Castro and Lighthall17 acknowledged the
lack of evidence supporting the need for antibiotic
prophylaxis in blepharoplasty and the need for more
research. No standard of care has been established
for or against antibiotic prophylaxis, and routine prac-
tices vary widely around the world.9 As stated earlier,
Carter et al11 concluded that topical antibiotic prophy-
laxis was sufficient in blepharoplasty procedures.
Although it was sufficient, it was not 100% effective
in preventing all infections.11,18 This leads to the
question of whether reducing the risk of surgical-site
infection to near zero and preventing these rare but
serious infections outweigh the real danger of
antibiotic-related complications including the esca-
lating emergence of antibiotic-resistant bacteria.
Surgeons are aware that prescribing any type of
medication is not risk free and must always run the
risk-benefit analysis. Patients can be knowingly or un-
knowingly allergic, endangering them to undergo
anaphylactic shock and even death with just a single
dose. Although the rate of true allergic reactions to an-
tibiotics, specifically the cephalosporin family, is rela-
tively low, it is a potential risk factor of which the
surgeon must be mindful.19 As stated earlier, one of
the greatest challenges facing medicine is the
increasing use of antibiotics promoting bacterial resis-
tance.20 Studies have shown an antibiotic given after
wound closure has little to no effect and only increases
the chance of bacteria adapting with antibiotic resis-
tance. Many antibiotics cause some adverse side ef-
fects in patients as well. Patients commonly
complain of gastrointestinal discomfort and other is-
sues including nausea, vomiting, and/or diarrhea. In
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ANTIBIOTIC PROPHYLAXIS IN BLEPHAROPLASTY
addition, rashes or pruritus can occur. Antibiotics
disrupt the microbial balance in a patient’s gastrointes-
tinal system, and they can lead to the acquisition of
opportunistic infections and can predispose to the
development of C difficile colitis.
Finally, it is our opinion that no direct consensus can
be drawn from the current literature and thus, at this
time, there is no current standard of care for oral and
maxillofacial surgeons to adhere to in terms of when
to provide antibiotic prophylaxis when performing
blepharoplasty. It remains up to the surgeon’s clinical
judgment; for a given patient, if the surgeon believes
that there is a measurable risk of surgical-site infection,
a reasonable and effective approach, following clean
surgical-site preparation, is to administer a single
dose of intravenous cefazolin or cefuroxime 1 hour
before the procedure. Otherwise, given that the infec-
tion rate in these types of procedures is exceedingly
low, antibiotic prophylaxis can be withheld as the
risk of routine antibiotic prophylaxis outweighs the
potential benefit associated with such therapy.
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2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.