Association of Decreased Lymphatic Vessel Density with Postoperative Eyelid Edema

Christine L. Bokman¹Roy P. Yu²Shaili Davuluru³Rasika Sudharshan^4,5Kristen E. Park⁶Sarah Guo⁷Joy Li⁷Preeya Mehta⁸Alice Shen⁹Jessica R. Chang¹⁰Alex K. Wong¹¹Young-Kwon Hong⁵Sandy X. Zhang-Nunes^5*

• ¹Suncoast Surgery Center LLC, Fort Myers, United States
• ²University of Miami Health System, Miami, United States
• ³Department of Population and Public Health Sciences, Keck School of Medicine of USC, Los Angeles, United States
• ⁴California Pacific Medical Center, San Francisco, United States
• ⁵University of Southern California Gayle and Edward Roski Eye Institute, Los Angeles, United States
• ⁶Dell Seton Medical Center at The University of Texas, Austin, United States
• ⁷University of California Irvine Gavin Herbert Eye Institute, Irvine, United States
• ⁸NYU Langone Health, New York, United States
• ⁹Byers Eye Institute, Palo Alto, United States
• ¹⁰Los Angeles General Medical Center, Los Angeles, United States
• ¹¹Rutgers New Jersey Medical School Institute of Ophthalmology & Visual Science, Newark, United States

Purpose: We sought to investigate whether variations in lymphatic morphology are associated with postoperative eyelid edema in patients who underwent upper eyelid blepharoplasty. Methods: This was a prospective study in which nine upper eyelid skin samples were stained with Podoplanin to immunochemically mark lymphatic vessels. Lymphatic vessel area, density, and perimeter were calculated from averaging 38 slices across 3 cuts of eyelid skin. Corresponding postoperative patient photographs were graded by four physicians with a standardized postoperative edema grading scale that ranged from zero (no edema) to three (severe edema). Patients were classified as having clinically significant eyelid edema (CSEE) if they received an edema grade greater than zero 90 days postoperatively or a grade of three at any time point. Results: Anti-podoplanin staining demonstrated that there was significantly lower lymphatic vessel density among patients with severe edema (8.00 ± 1.67 vessels/mm2) compared to patients with mild or no edema (12.14 ± 1.93 vessels/mm2, p < 0.05). Lymphatic vessel area and perimeter did not reveal any significant associations with postoperative edema grades. Conclusions: In patients undergoing an upper eyelid blepharoplasty, severe postoperative swelling was significantly associated with lower lymphatic vessel density, but not with lymphatic vessel area or perimeter. These findings suggest that the lymphatic network of the eyelid could play a role in the degree of postoperative swelling.