Local anesthetic orbicularis myotoxicity: a possible
unrecognized cause of post-blepharoplasty lagophthalmos
John A. McFate
Charles N. S. Soparkar
James R. Patrinely
Received: 22 October 2013 /Accepted: 23 December 2013 /Published online: 18 January 2014
Springer-Verlag Berlin Heidelberg 2014
Background Injection of local anesthetics into the upper and
lower eyelids is routinely performed during a variety of com-
mon surgical procedures, including cosmetic blepharoplasty.
Although skeletal muscle injury is a very well documented
side effect of virtually all local anesthetics, there are few
reported cases of orbicularis myotoxicity despite its common
exposure to periocular injections. Post-operative localized and
occasionally persistent orbicularis oculi weakness may be
presumably attributable to local anesthetic myotoxicity.
Methods A non-randomized retrospective clinical case series
identified 32 patients seen in a tertiary care referral
oculoplastic practice over a 7-year period. Follow-up ranged
from 0.5 to 7 years with an average of 1.3 years.
Results Patients demonstrated varying degrees and duration
of orbicularis oculi dysfunction manifesting primarily as
lagophthalmos. Although most patients improved with obser-
vation alone, 6 of 32 patients did not.
Conclusions Orbicularis oculi dysfunction may result from
local anesthetic injections. In most cases, this complication
is transient, yet permanent dysfunction can occur. To mini-
mize the risk of developing this complication, local anes-
thetics should be judiciously administered in low volume
and concentration away from the critical pretarsal orbicularis.
Additionally, patients should be counseled preoperatively
about the potential risks of local anesthetic use.
Level of Evidence: Level IV, prognostic / risk study.
Injection of local anesthetics into the upper and lower eyelids
is routinely performed during a variety of common surgical
procedures, including cosmetic and functional blepharo-
plasties. A myotoxic effect of both amide and ester-based
local anesthetics on skeletal and extraocular muscle has been
well documented in the laboratory, where profound, almost
complete degeneration of injured muscle has been seen [1–3].
Clinically, significant myotoxicity of extraocular muscles and
levator palpebrae superioris, though a rare and uncommon
side effect of local anesthetics, has been reported to result in
both permanent and temporary diplopia and ptosis with the
use of periocular anesthesia [4, 5].
Although skeletal muscle injury is a very well docu-
mented side effect of virtually all local anesthetics, there
are few reported cases of orbicularis myotoxicity despite
its common exposure to periocular injections. The relative
immunity of the orbicularis to local anesthetic
myotoxicity has been studied in the past. After repeated
injections of high concentrations of local anesthetics, in-
jury but not destruction of the myofibers has been ob-
served. From these observations, it is assumed that the
tight fasciculation of the myofibers prevents infiltration of
the local anesthetic to the individual fibers . Hence, it
has hitherto been assumed that the orbicularis is relatively
safe from local anesthetic myotoxicity.
Our experiences lead us to believe otherwise and, herein,
we report the first cases, to our knowledge, of persistent
orbicularis oculi weakness resulting in post-operative
lagophthalmos, secondary to presumed local anesthetic
myotoxicity and suggest strategies to minimize this problem.
This material was presented in part as a presentation at the annual meeting
for the American Society for Aesthetic Plastic Surgery in New York City,
New York, April 2013.
J. A. McFate (*)
C. N. S. Soparkar
J. R. Patrinely
Department of Plastic Surgery, Houston Methodist Hospital, 1401 St.
Joseph Pkwy, GWS 3392, Houston, TX 77002, USA
Eur J Plast Surg (2014) 37:201–204