Ptosis after botulinum toxin injections: methods of prevention and 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 being treated, ptosis of the eyebrows, upper eyelid, lower eyelid and lips may occur after botulinum toxin.

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 visit 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 a feeling of tiredness 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. The anatomy and musculature of the face should be assessed, in particular anatomical position and eyebrow asymmetry (observed in approximately 90% of patients).

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;
• sun 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:

1. When injecting into the frontalis muscle, botulinum toxin should be injected at or above the middle forehead (minimum 2 cm above the brow in all patients; in older patients – 4 cm above the brow).
2. 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

3. Correction of the intereyebrow should be carried out in parallel with botulinum therapy of the forehead (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 levators of the eyebrows). 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.
4. Especial care must be taken when working with patients who have previously undergone facial surgery.

K

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

For brow correction, 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 glabella complex
, the needle should be directed upwards from the orbit
3. . For correction of
crow's feet
4. botulinum toxin type A should not be injected medially to the central pupillary line; the point of injection should be located at a distance of at least 1 cm from the orbit. Do not administer directly under the eyes if the patient has scleral overvisualization, has previously had 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 administered within

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.

1. Ptosis of the lips can also result from the correction of smoker's wrinkles and overcorrection with botulinum toxin type A orbicularis musculus.
low doses
2. should be used in this area and only experienced injectors should perform the procedure. Treatment of eyelid ptosis after botulinum therapy
Resolution of ptosis 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.

For the treatment of ptosis of the upper eyelid, eye drops based on 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

develops, refer the patient

to an ophthalmologist. Eyebrow ptosis correction after botulinum toxin injection To reduce depressor muscle activity and raise the brow 1–2mm, 0.01mL (

5U of Abobotulinumtoxin

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

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Management of complications after botulinum toxin type A injections To avoid overspread and further complications, the author recommends injection of 2 units of onabotulinumtoxinA (Botox, Vistabel) or

incobotulinumtoxin

A (Bocouture, Xeomin) at the same dilution of 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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