- Anti-wrinkle injections to the frown is the most common cosmetic procedure worldwide.
- Ptosis or eyelid droop occurs in approximately 3% of cases and can last for several months.
- Patient factors such as rubbing the area, or doing exercise or movement afterwards can increase the risk of ptosis.
- Practitioner factors such as injecting too deeply or inappropriate positioning of the injections can increase the risk of ptosis.
- If ptosis occurs, eyedrops that simulate the sympathetic nervous system can temporarily reduce the degree of ptosis present.
What is eyelid ptosis and how does it occur with anti-wrinkle injections?
The word ptosis is derived from the Greek word for ‘fall’ and eyelid ptosis is a drooping or falling of the upper eyelid. It is an unwanted side effect that can occur from anti-wrinkle injections to the frown and occurs in approximately 3% of cases.
It occurs when the anti-wrinkle injections are displaced from the intended area of injection, the corrugator muscle of the frown, downwards into the levator palpebrae superioris muscle. The diffusion usually occurs at the injection performed at the tail end (lateral ends) of the corrugator muscle. The levator palpebrae superioris is one of the elevators of the upper eyelid, and paralysis of this muscle causes partial eyelid ptosis. But because there is also the superior tarsal muscle (Müller’s muscle), that elevates the upper eyelid and remains unaffected, the ptosis that occurs is not complete and only partial.
The onset and offset of the eyelid ptosis complication are the same as the time it normally takes for anti-wrinkle injections to start working and wear off. Onset is usually from 4 to 7 days depending on the type of anti-wrinkle injection used, and the offset is usually around 2 to 4 months.
Eyelid ptosis from anti-wrinkle injections needs to be differentiated from eyebrow ptosis that can occur due to injection of anti-wrinkle injections into the forehead or frontalis muscle. This treatment is typically done to reduce horizontal forehead wrinkles and lines. In those with excess skin in their upper eyelids, eyebrow ptosis can make them feel heavy, like they are having trouble opening both eyes. The mechanism behind eyebrow ptosis is different from eyelid ptosis, as the problem is due to reduced activity of the frontalis or the eyebrow elevator. It is not due to diffusion of anti-wrinkle injection into the eyelid muscles, as seen in eyelid ptosis.
How do you prevent eyelid ptosis from anti-wrinkle injections?
Although the incidence of eyelid ptosis is low, the impact of this complication on those affected is great, and therefore all precautionary measures should be taken.
During the treatment, there are practitioner factors that may lead to eyelid ptosis. The main factor is the positioning of the anti-wrinkle injections. The most likely area where diffusion of the product occurs is at the tail end of the corrugator muscle. This tail injection can be omitted to reduce the risk of ptosis, but omission will also reduce the effectiveness of the treatment in reducing the frown. The depth of the injection in the tail end of the corrugator muscle is also important. Deeper injections in this location tend to have a tendency to be more likely to diffuse downwards into the levator palpebrae superioris muscle and cause eyelid ptosis. Therefore, keeping injections superficial in this region can help reduce the risk. A general reduction in the dose of anti-wrinkle injection will also decrease the risk.
After treatment, there are also patient factors that can prevent unwanted diffusion of anti-wrinkle injections and eyelid ptosis. Exercising or excessive physical activity can cause the anti-wrinkle injection to move from the initial place of injection and should be avoided for several hours after treatment. Massaging the frown after treatment with anti-wrinkle injections can also cause a similar problem. Lying down after a treatment is also a possible factor that has been implicated in the increased incidence of eyelid ptosis.
How is eyelid ptosis from anti-wrinkle injections treated?
As anti-wrinkle injections cannot be reversed, there is no true antidote to the complication. Instead, we can stimulate the other muscle that elevates the eyelid, Müller’s muscle. This muscle is innervated by the sympathetic nervous system. Eyedrops that stimulate this can help to put this muscle into ‘overdrive’ and compensate for the loss of activity of the levator palpebrae superioris muscle. Apraclonidine eyedrops are an example of a medication that can be used. These are α2 adrenergic receptor agonist that stimulate the sympathetic nerve fibres that temporarily activate Müller’s muscle. The action of these eyedrops is only effective for hours and needs to be repeated in order to improve the problem.