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Upper eyelid ptosis: what a cosmetologist needs to know

Blepharoptosis, ptosis, ptosis of the upper eyelid, omitted upper eyelid – these terms are usually used to describe a condition in which the upper eyelid is omitted or displaced, which leads to a narrowing of the palpebral fissure and overlapping part of the eye2. In this case, the omission of the upper eyelid can be both congenital and acquired and can be a sign or symptom of a more serious neurological disease or tumor in the orbit (ptosis that arose in adulthood) .

Normally, the edge of the upper eyelid in an adult is 0.5–2 mm below the upper limb of the cornea and does not cover the pupil
Blepharoptosis can occur at any age due to various factors. It should be remembered that when a patient complains of a prolapse of the upper eyelid, this is just a symptom, not a diagnosis3. A thorough assessment is paramount in determining the cause. The presence of ptosis of the upper eyelid must be indicated to the patient before the procedure.

Anatomy of the century
To understand the mechanism of ptosis formation, we turn to the anatomy of the upper eyelid.

Muscle
The orbicularis oculi muscle is the main mover of the eyelid. The contraction of this muscle, which is innervated by the cranial nerve VII, narrows the palpebral fissure.

Upper eyelid retractors are levator muscles (which are innervated by the cranial nerve III) and its aponeurosis and upper tarsus (Mueller muscle). In the lower eyelid, capsulopalpebral fascia and lower talus muscle are retractors.

Closing and opening of the eyelids is achieved due to the response of the levator palpebra and the eyeball.

Leather
The skin of the eyelids is the thinnest area, it also participates in the movement of the eyelid. Attaches dorsally to the upper eyelid orbicularis and is looser to preseptal orbicularis.

Orbital septum
The orbital septum closes the entrance to the orbit, acting as a barrier.

The orbital septum changes anatomically and can be thick or thin.

The orbital septum is an important structure. When blepharochalasis, subcutaneous fat slides down due to weakening of the septum.

Tarsal plate and fold of the upper eyelid
The upper tarsal plate is located on the lower edge of the upper eyelid under the circular muscle of the eye, and is usually 30 mm long and 10 mm wide. The lower tarsal plate is located on the upper edge of the lower eyelid, usually 28 mm in length and 4 mm in width, a circular muscle, capsulopalpebral fascia and conjunctiva are attached to it.

Intraorbital fat
It performs the function of a shock absorber and surrounds the eyeball from all sides. Portions of upper and lower intraorbital fat are divided into internal, central and external. Near the upper outer portion is the lacrimal gland.

What is ptosis
Types of Ptosis
Ptosis can be classified as congenital (in children from birth or up to a year due to an abnormality of levator muscle development) and acquired6.

Acquired adult ptosis (see table) is further classified based on etiological factors:

Myogenic
Neuromuscular
Neurogenic
Mechanical
Cerebral
Acquired involutional aponeurotic ptosis, due to age-related lowering of tissues, is one of the most frequent ones.

Table 1. Causes of Acquired Blepharoptosis

Ptosis Reason
Myogenic

Chronic progressive external ophthalmoplegia
Oculopharyngeal Muscular Dystrophy
Myotonic dystrophy

Neuromuscular

Myasthenia gravis
Botulism

Neurogenic

Horner’s syndrome
Oculomotor paresis
Guillain-Barré Syndrome (Miller-Fischer Version)
Ophthalmoplegic migraine

Mechanical

Involutional (senile) or aponeurotic
Injury
Inflammation or infiltration of the eyelid (with amyloid or malignant tumor)
Dermatochalasis, tumors of the eyelids or orbit,
Chalazion, postoperative edema
Contact lens injury

Cerebral

Brain lesions (especially the right hemisphere)

Pseudoptosis
Experts also highlight a phenomenon called pseudoptosis, in which the upper eyelid only seems ptotic, but in fact it is not.

This condition is important to differentiate from true ptosis!

The causes of pseudoptosis include 8,9,14:

blepharospasm,
hemifacial spasm,
narrowness of the palpebral fissure,
Enophthalmos, microphthalmos, anophthalmos,
dermatochalasis (excess skin of the eyelids),
eyelid retraction
high myopia,
structural features of the upper eyelid (view from the ceiling).
How to determine blepharoptosis
Medical history
Lower eyelids (symmetrical bilateral minimally pronounced lowering of the eyelids with a full tour of the upper eyelids. Functionally, the upper eyelid is full, but aesthetically does not satisfy the patient).
Patients look sleepy or tired.
Patients may complain of visual impairment, increased lacrimation, and a decrease in the upper field of vision.
Difficulties in everyday life, such as driving a car, reading and climbing stairs.
Complaints of a headache caused by tension in the forehead due to excessive use of the forehead muscles when trying to indirectly raise the eyelids and raise the eyebrows.
The patient can raise the eyelid with a finger or the entire eyebrow to improve visibility.

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