postoperative complications of blepharoplasty range from skin changes to vision - threatening emergencies.1 
  some of these complications occur early in the postoperative period , such as retrobulbar hemorrhage , infection , and eyelid hematoma .
other complications occur later in the postoperative period , such as eyelid malposition , strabismus , scar and over- and under - resection of skin or orbital fat.1 
  there has been a case report of persistent lateral hooding after upper lid blepharoplasty that has been treated with lacrimal gland repositioning.2 
  to the best of our knowledge , we report the first case of lacrimal gland fistula after upper lid blepharoplasty .
she had a history of repeated lid swelling for almost 3 years before the age of 10 years .
the patient underwent bilateral blepharoptosis repair at 12 years of age , re - operation on the right lid at the age of 18 years , and laser resurfacing of periocular region at the age of 20 . on examination ,
the patient had bilateral blepharoptosis ( margin reflex distance of + 2.5 mm on the right and + 2 mm on the left side ) , dermatochalasis with mild lateral hooding , and medial and preaponeurotic fat protrusion .
upper blepharoplasty included skin - orbicularis muscle flap excision , medial fat excision , and partially preaponeurotic fat excision through a hole in the center of the septum .
she had an uneventful postoperative follow - up with the exception of lateral hooding of the right lid .
an elliptical lateral hooding excision was performed 2 months after upper blepharoplasty . at 1 week post - hooding excision
, there was wound dehiscence with clear watery drops discharging from the wound [ figure 1 ] .
post - lateral hooding excision right upper eyelid wound dehiscence and watery drops show a fistulous tract from lacrimal gland to the wound the patient was scheduled for repair of the wound and repositioning of the lacrimal gland .
there was a tract from the lacrimal gland to the skin of the upper eyelid at the site of wound dehiscence .
the lacrimal gland was repositioned into the lacrimal gland fossa using 4 - 0 prolene suture .
the postoperative course was uneventful out the last visit at 6 months after repair [ figure 2 ] .
last follow up ( 6 months ) after repair of the wound and repositioning of the right prolapsed lacrimal gland
despite the facile nature of the blepharoplasty , high patient expectations can make this procedure quite challenging to the surgeon . in order to attain a good result and avoid patient dissatisfaction , the surgeon must perform a careful history and physical exam and address specific patient complaints and expectations.3 blepharochalasis is a rare eyelid disorder characterized by exacerbation and remission of painless edema , eventually leading to atrophy of the periorbital skin .
these episodes of eyelid swelling usually become less frequent with age , and eventually most cases enter a relatively quiescent stage .
ptosis is a common finding in blepharochalasis ; however , the levator function is preserved.4 surgical management should be performed during the quiescent phase of blepharochalasis to avoid recurrent bouts of lid swelling leading to further ptosis and lid atrophy .
surgeons advocate that blepharochalasis symptoms should be quiet for 6 - 12 months before surgical treatment is contemplated.4 
  our case did not report any exacerbation for at least 15 years prior to the recent operation .
a prolapsed lacrimal gland occasionally occurs due to atrophic changes in the septum in patients with blepharochalasis . in cases of frank preoperative
prolapsed lacrimal gland , a blepharoplasty and suspension of the lacrimal gland should be performed.4 
  our patient did not present with a prolapsed lacrimal gland preoperatively .
she only had post - blepharoplasty lateral hooding on the right side without a palpable lacrimal gland .
we assume that blepharoplasty and consequently right - side hooding excision pulled an undetected partially prolapsed lacrimal gland inferiorly into the wound and resulted in the formation of a fistula .
a similar case has been reported with hooding after blepharoplasty due to lacrimal gland prolapse ; however there was no history of blepharochalasis or postoperative wound dehiscence and fistula.2 repositioning of the lacrimal gland to the right side was successful without postoperative sequelae out to 6 months postoperatively .
the procedure can complex especially in the context of chronic inflammatory conditions.5 
  this case report illustrates an uncommon post - blepharoplasty complication in patients with blepharochalasis .
surgeons who perform blepharoplasty should have a high index of suspicion for lacrimal gland herniation in the presence of lateral hooding specially in patients with a history of blepharochalasis .
 to report the first case of lacrimal gland fistula after upper eyelid blepharoplasty for blepharochalasis . 
 standard upper blepharoplasty and the hooding excision were performed in a female with blepharochalasis . 
 the patient developed a fistulous tract with tearing from the incision few days after hooding excision . 
 fistula excision and lacrimal gland repositioning were performed . 
 there were no complications after the repositioning procedure ( 6 months follow up ) . 
 prolapsed lacrimal gland and fistula formation can occur after upper blepharoplasty hooding excision . 