Blunt Trauma

Blunt trauma can result in ptosis secondary to edema or stretching or dehiscence of the levator aponeurosis. Ptosis secondary to blunt trauma is usually transient, with full recovery of levator function in most cases. Patients who constantly rub their eyelids are predisposed to blepharoptosis. It is thought to be the result of repetitive microtrauma to the levator aponeurosis [40].

Traumatic Ptosis Secondary to Restrictive Scarring

Sharp injuries to the upper eyelid, whether traumatic or iatrogenic following surgical procedures, may result in restrictive eyelid scarring. It may be due to improper repair of the wound with poor attention to the anatomical layers. Adhesions between the levator muscle and the skin or between the eyelid and the orbital rim may create a tethering effect and restrict the levator muscle motility and eyelid excursion (Figs. 13.4 and 13.5).

Lacerating Trauma

Traumatic lacerations of the upper eyelid involving the levator aponeurosis and/or muscle result in various degrees of ptosis (Fig. 13.3). Small lacerations, when properly repaired, with repositioning of prolapsed preaponeurotic fat, usually do well. On the other hand, eyelid avulsion is a more challenging scenario with a higher incidence of permanent ptosis. Exploration of the laceration, identification, and reapproximation of the levator muscle can improve outcomes of these extensive injuries [41].

Traumatic Ptosis Following Facial Fractures

Facial fractures involving the inferior or medial orbital wall or the zygomatico-maxillary complex (ZMC) may result in enophthalmos (Figs. 13.5 and 13.6), with potential esthetic and functional consequences. The functional deficits that accompany enophthalmos include gazeevoked diplopia, eyelid malposition, and exposure keratitis [42]. A sunken globe may affect the support of Whitnall’s ligament, thereby altering eyelid mechanics [10]. Enophthalmos also

Fig. 13.3  (a) Complete avulsion of the left upper eyelid following severe motor vehicle accident. (b) The eyelid was explored, and levator was reapproximated with 6-0 vicryl suture. He also had a ruptured globe that was repaired initially. He underwent

subsequent enucleation and prosthesis fitting. (c) Six months following the injury, patient had persistent complete ptosis and underwent a frontalis sling procedure. (d) Two weeks status postfrontalis sling procedure

Fig. 13.5  (a) Right enophthalmos and ZMC fracture secondary to motor vehicle accident. The right upper eyelid is bound down to the superior orbital rim. The right upper eyelid laceration was used for surgical access to repair the fractures by nonophthalmology ser-

vice leading to this complication. (b) Six month posttrauma, there is persistent enophthalmos and ptosis. The restrictive component has improved in part. (c) Coronal view of CT scan revealing a persistent ZMC malalignment

induces narrowing of the palpebral fissure and hence upper lid pseudoptosis (Fig. 13.7). The levator muscle function is usually normal. Correction of the enophthalmos may alleviate the ptosis (Figs. 13.8 and 13.9). Ptosis, commonly

transient, may accompany orbital roof (“blow-in”) fractures due to bone fragments that impinge upon the levator-superior rectus muscle complex. Ptosis repair may be necessary if it does not resolve spontaneously over time [43–45].

Fig. 13.8  A 25-year-old female post Le Fort II fractures secondary to motor vehicle accident. (a) She has right upper lid ptosis and residual enophthalmos. (b) The right

upper eyelid blepharoptosis improved after the correction of enophthalmos. She underwent Y-to-V medial canthoplasty and retrobulbar fat injection

Fig. 13.9  (a) Left enophthalmos following blowout fracture of the orbital floor. (b) The residual ptosis, after the correction of the enophthalmos with a high-

density porous polyethylene implant, was addressed with external levator resection and eyelid crease formation