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What Is Ptosis?

In the last few weeks, you may have seen images in the news of a Chicago-based beauty blogger - Whitney Buha - who was left with ptosis after going for anti-wrinkle injections. But what is ptosis? What causes it? And how can you prevent it in the first place? Dr Ana Mansouri of Kat & Co Aesthetics explains all.

What is ptosis?

Ptosis is a side effect that can occur following anti-wrinkle injections in the forehead or frown lines, and is, essentially, an unwanted droop, drop or abnormal lowering of the eyebrow or eyelid. It can affect you either on one or both sides of the face.

This is a risk that all patients should be clearly informed about prior to treatment as part of the consent process, as it is a significant risk that should be considered. If one is unfortunate enough to be affected by ptosis, it will usually become evident after a few days and it may get worse up until the two-week mark, post-treatment.

What causes ptosis?

Ptosis happens if the toxin solution has reached and affected a muscle which is either responsible for lifting the eyebrow or the eyelid and has subsequently weakened or paralysed it. This results in either a sensation of heaviness or the inability to fully lift the brow or lid.

It can happen if either the toxin that inadvertently spread into these nearby muscles was injected too deep or too close to the muscles, or if the dose was too high.

In the forehead (frontalis muscle), if the dose is too high or was injected too low (close to the eyebrow) it can result in a frozen or overtreated forehead and thereby cause an inability to use the forehead muscle to lift the brow. This will, subsequently, cause either the sensation of heaviness across the brow or an actual drop in its position. In some cases where the patient already had low set brows or excess skin above the eyelid to begin with, as part of the ageing process, there will be little room for error and the smallest drop can lead to significant discomfort.

When frown lines are treated with toxin, an inadvertent downward spread of toxin into the orbital area, where the little muscles that lift the eyelids are weakened or paralysed, will cause the affected eyelid to droop.

Is ptosis common?

The risk of brow or lid ptosis is estimated as one in 100 for an experienced practitioner, and this rises to approximately five in 100 for a less experienced practitioner. This means that although it is unlikely to happen (99% of patients are likely going to be fine), it is not always possible to completely eliminate the risk, even in the best of hands. As a practitioner, it is, therefore, important to select your patients carefully and avoid treating patients who are already at high risk. In medical terms, a risk of 1% is actually fairly high. If you compare this to the risk of vascular occlusion (VO) with dermal filler, for instance, which is roughly one in 100,000, it becomes more apparent that more patients will experience ptosis.

In my personal experience, I have found that the risk of ptosis often seems to be dose-dependant, so I practice with the assumption that the risk of ptosis will be lower if treating with the Baby Botox approach, where perhaps half the standard dose is utilised.

There are certain ways a practitioner can reduce the risk of ptosis occurring. This is mostly down to injection technique, such as the depth of the needle during the injection, the placement of each injection site and, again, the dose administered. Being able to pick up which patient is at particularly high risk during the consultation and assessment is also vital from a practitioner’s point of view. This is why it is so important to choose your practitioner carefully.

What should you do if ptosis happens to you?

Although this type of side effect is a significant nuisance if it does occur, it is reassuring to know that it isn't something dangerous or sinister to worry about, per se. In most cases, ptosis will affect you on a cosmetic level, with mild discomfort only. However, in a minority of cases a severe eyelid or eyebrow drop (pushing excess upper eyelid skin onto the eyelid) can actually cause an impairment in vision, which may temporarily affect someone's ability to drive or work.

The good news is that any toxin-related ptosis is completely temporary and will wear off eventually, usually within 2-3 months. You will, therefore, eventually go back exactly to how you looked and felt before the treatment. The issue lies in the fact that once the toxin is in, the practitioner can’t take it out (unlike fillers and Hyalase). I, therefore, always approach new patients with caution and make a point of getting to know their muscles by starting with a cautious dose, with the understanding that I will top-up as necessary after two weeks. This allows me to reduce the risk of overdosing for the sake of saving time.

If you compare the one in 100 risk of ptosis with toxin to, for instance, the much rarer risk of a VO in dermal fillers (one in 100,000) it puts things into perspective. Although rarer, vascular occlusions aren't as trivial and should be treated as a medical emergency.

If you have been affected by ptosis, you should immediately contact your practitioner for advice. They will ask you come in for a face-to-face assessment as soon as possible, and then regular reviews every few weeks until it has fully worn off. There are a number of ways to actually improve a drop in the eyebrows by injecting further toxin in a way that will cause a brow lift to slightly alleviate the problem until it wears off. For eyelid ptosis, there is an eye drop medication (apraclonidine) that your practitioner may prescribe for you, which acts by temporarily opening up the eyelids. This, too, can be useful in providing symptomatic relief while the toxin is wearing off.

There are some reports of the toxin potentially wearing off quicker with electric massage to the muscles, so your practitioner may recommend you to use the back of an electric toothbrush (non-bristle side) to manually massage the affected areas, daily.

How to avoid ptosis

As an injector, there are several ways to avoid ptosis - and this comes down to patient assessment, patient selection, dosage and injection technique. As a patient, the most important take home message is to choose your practitioner carefully in order to reduce the risk of these problems occurring in the first place, for them to be less severe if they were to occur and, most importantly, to go to someone who will be able to manage a complication and support you in the best way in the unlikely event of a complication.

It is important to inform your practitioner if you have ever experienced ptosis in the past, as this will be an important consideration when creating your treatment plan.

I often see patients in my clinic with ptosis from toxin treatment, or other practitioners asking for advice, which is somewhat expected. However, what really concerns me is that a lot of these patients had never been informed of this risk to begin with. I cannot stress enough to patients as consumers the importance of choosing a medically qualified, skilled, experienced but also open and honest injector, who will sit you down and discuss all of the risks (including ptosis) with you in detail in a way that you clearly understand and are able to go away, consider your options and then make an informed decision.

Thanks to Dr Ana Mansouri for this fantastic summary of how to recognise and deal with ptsosis. For more information about the treatment of lines and wrinkles, as well as the potential side effects, check out our handy Glowday treatment guide.

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