Ptosis of the eyebrows, eyelids, lips after botulinum toxin injections: symptoms, prevention, treatment

Ptosis – abnormal drooping of the anatomical zone, which in aesthetic medicine almost always occurs due to injections of botulinum toxin type A into a non-targeted zone. Most often, this complication of botulinum therapy develops due to the inexperience of the injectionist. Depending on the area to be treated, Botulinum toxin injection may cause ptosis of the eyebrows, upper, lower eyelids and lips.

The drooping may persist during the period of action of botulinum toxin, but often the eyelid ptosis resolves on its own after 3-4 months, and the eyebrows – within 6 weeks after the procedure. The estet-portal.com article presents Dr. Martyn King's recommendations for prevention and treatment of ptosis after botulinum toxin injections.

• Signs, symptoms and risk factors for ptosis after botulinum toxin administration
• How to avoid ptosis after botulinum toxin injections: general recommendations
• How to avoid eyebrow ptosis after botulinum toxin injections
• How to avoid ptosis of the upper eyelid after botulinum toxin injections
• How to avoid lip ptosis after botulinum toxin injections
• Treatment of eyelid ptosis after botulinum toxin therapy
• Eyebrow ptosis correction after botulinum toxin injection

Signs, symptoms and risk factors for ptosis after botulinum toxin administration

With complaints of ptosis of the eyebrow or upper eyelid, patients usually turn to the doctor within 3–7 days after botulinum therapy.

Ptosis can be unilateral or bilateral. Sometimes the complication is mild and may not be noticeable immediately. In such cases, the patient feels the heaviness of the eyelid or eyebrow, in some cases he cannot fully open his eyes, and there are difficulties with applying makeup. The patient complains of  tired and heaviness around the eyes, which increases throughout the day. In some cases, severe ptosis may limit vision.

 

 

Risk Factors:  

1. Patient Related:

• age;
• lifestyle;
• "heavy" eyebrows;
• short eyebrows;
• photodamage;
• loss of elasticity, skin density;
• leading activity of the frontalis muscle.

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2. Medical condition related:

• history of facial surgery;
• neurological diseases (misasthenia gravis, MS);
• Ptosis or Bell's palsy in anamnesis.

3. Product Related:

• breeding;
• quality.

4. Procedure related:

• introduction technique;
• introduction points;
• dosage.

How to avoid ptosis after botulinum toxin injections: general recommendations

Before performing botulinum toxin injections, it is important to take a complete medical history and inform the patient of all possible risks, side effects, and complications of the procedure. Facial anatomy and musculature should be assessed, in particular anatomical position and eyebrow asymmetry  . The size and degree of brow droop and the tone of the frontalis muscle at rest should be assessed to ensure that this muscle is not supporting the brow.

Ask the patient to sit up straight, look forward and close their eyes: if the eyebrows drop during the test, do not correct forehead wrinkles with botulinum toxin injections.

It is also necessary to take a photo before and after the procedure.

To avoid unwanted spread of the toxin, for 

at least 4 hours

 after botulinum toxin injections the patient is advised to refrain from:

sauna visits;

• massages;
• solar 
• baths and solariums.
How to avoid eyebrow ptosis after botulinum toxin injections

Eyebrow ptosis can be avoided after forehead wrinkle correction with botulinum toxin type A injections by following simple rules:

When injecting into the frontalis muscle, botulinum toxin should be injected into the middle forehead or above (

minimum 2 cm above the eyebrow
1.   in all patients; in older patients – 4 cm above the eyebrow). According to one study, intradermal injection of botulinum toxin into the forehead provides comparable results to intramuscular injections, but with a lower risk of ptosis.

Read also

: How to solve the problem of ptosis of the upper eyelid after the introduction of botulinum toxin preparations

Correction 

of the intereyebrow
3.  should be performed in parallel with forehead botulinum therapy (the drug is not injected only into the frontal muscle), especially in patients over 50 years of age (botulinum toxin is simultaneously injected into depressors and eyebrow levators). In case of doubt, when working with botulinum toxin type in the forehead or other target area, it is better to administer the minimum doses of the drug, and during the re-evaluation after 2 weeks, make additional correction if necessary. Especial care must be taken when working with patients who have previously undergone surgery 
4. on the face.

K

How to avoid ptosis of the upper eyelid after botulinum toxin injections To prevent ptosis of the upper eyelid after botulinum toxin correction:

When correcting the intereyebrow, the drug should be injected 

1 cm above the eyebrow
1. , not lateral to the central pupillary line. To minimize the risk of botulinum toxin diffusion, the supraorbital rim should be pressed with the free hand when inserting into the brow wrinkler.
2. When injecting the drug into the glabellar complex
the needle should be directed upwards from the orbit
3. . When correcting 
crow's feet
4.  botulinum toxin type A should not be injected medially to the central pupillary line; the point of injection must be located at a distance at least 1 cm from the orbit. Do not inject directly under the eyes if the patient has scleral overvisualization, has had previous eye surgery, or has a negative lower eyelid tone test.
5. How to avoid lip ptosis after botulinum toxin injections
In order to prevent lip ptosis after botulinum toxin therapy:

During the correction of crow's feet, the drug should be injected within the limits of the orbicular muscle of the eye

. If botulinum toxin is injected lower, it can lead to dysfunction of the large zygomatic muscle, which lifts the corner of the mouth up and takes it to the side. Ptosis in this area becomes more noticeable when smiling.

Ptosis of the lips can also result from the correction of smoker's wrinkles and overcorrection with botulinum toxin type A 
1. orbicularis musculus. In this area, small doses of the drug
must be used, and the procedure should only be performed by 
2. experienced injector. Treatment of eyelid ptosis after botulinum therapy Ptosis resolution can be accelerated by 
mechanical or electrical stimulation

. Many experts recommend that patients massage the affected muscle with the back of an electric toothbrush for several minutes a day.

Appraclonidine 0.5% 

apraclonidine –  1–2 drops 3 times a day

. This substance is an alpha-adrenergic receptor agonist and mydriatic agent that causes contraction of the Müllerian muscle. This approach allows you to lift the eyelid by 1-2 mm. Before using this remedy, it is important to study the patient's ophthalmic analysis.

Apraclonidine is generally well tolerated, but long-term use may cause eye sensitivity. Ptosis of the lower eyelid may result from hypercorrection of the palpebral part of the orbicularis oculi muscle. This complication can lead to dysfunction of the eyelid. There is no specific treatment for this complication – it usually resolves on its own within a few weeks. However, if ectropion

 shall occur refer 

 to 

ophthalmologist. Eyebrow ptosis correction after botulinum toxin injection To weaken the activity of the depressor muscles and raise the eyebrow by 1–2 mm, 0.01 ml (5 units of abobotulinum toxin

 Dysport) can be injected intradermally 2–3 mm below the lateral part of the eyebrow, and then – 0.01 ml (5U of Dysport abobotulinum toxin) deep to the medial brow wrinkle.

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Management of complications after injections of botulinum toxin type A

To avoid overspread and further complications, the author recommends administration of 2 units of onabotulinumtoxin A (Botox, Vistabel) or incobotulinumtoxin

 A (Bocouture, Xeomin) with similar dilution 0.01 ml.

If it is not possible to raise the eyebrow, a good aesthetic result can be obtained by lowering the second eyebrow symmetrically. Such procedures should only be performed by an experienced physician. All patients with ptosis require careful monitoring. Regular photos help to make an objective assessment of the results of the correction.

Adapted from J Clin Aesthet Dermatol.

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