Purpose

To describe the clinical management and surgical reconstruction of post-traumatic eyelid malposition associated with epiphora following complex orbito-facial trauma.

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Methods

A female patient was referred for right upper eyelid ptosis with associated epiphora and ocular discomfort, predominantly in the morning. Her history included severe craniofacial trauma from a road traffic accident in 2014, resulting in multiple fractures involving the right orbit and fronto-naso-orbital complex, treated with open reduction and internal fixation. Clinical examination revealed mild right ptosis (MRD1 2.5–3 mm) with good levator function (13–14 mm) and positive response to phenylephrine, lower eyelid retraction with cicatricial changes, and mild restriction in upgaze with diplopia at extreme positions. Lacrimal probing was inconclusive; however, dacryocystography confirmed patency of the lacrimal drainage system. The patient underwent lateral canthotomy and cantholysis with transconjunctival approach, extensive fibrosis release, posterior lamella reconstruction using hard palatal mucosal graft, and lateral canthal resuspension.

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Results

At one month postoperatively, the patient demonstrated good recovery, with resolution of epiphora and no significant complications aside from mild medial lower eyelid retraction. A second-stage procedure, consisting of conjunctivomüllerectomy and further anterior lamellar repositioning, was performed. At one month follow-up, the patient reported high satisfaction, with only mild residual undercorrection of the upper eyelid.

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Conclusion

Complex post-traumatic eyelid malpositions require a staged and individualized surgical approach. Combined reconstruction of the posterior lamellae and canthal support can achieve satisfactory functional and aesthetic outcomes, even in the presence of significant cicatricial changes.

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Additional Authors

First name	Last name	Base Hospital / Institution
Henrique	Cruz	ULS Leiria
Joana	Pacheco	ULS Lisboa Ocidental
Alberto	Ribas	ULS Lisboa Ocidental
João	Romana	ULS Lisboa Ocidental
Carolina	Bruxelas	ULS Lisboa Ocidental
Rita	Silva	ULS Lisboa Ocidental

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