Preventing and Treating Eyelid Ptosis

Prevent and Treat Eyelid Ptosis from Neurotoxin Injections

Do You Fear Eyelid Ptosis and Other Complications from Neurotoxin Injections?

Eyelid ptosis, otherwise known as blepharoptosis, can be a natural occurrence in the aging process. Eyelid ptosis can also be mechanically triggered by improper placement of neurotoxins such as Botox, Dysport, Xeomin, Daxi, and Jeuveau in the upper third of the face. Although medical providers, including aesthetic injectors, understand the medical terms eyelid ptosis and or blepharoptosis, the average person will understand this phenomenon as a droopy eyelid or a heavy eyelid. The word ptosis stems from the Greek meaning falling and is translated into medical terminology as droopy (King, 2016). This aesthetic problem can be not only physically damaging to patients but can be psychologically damaging as well. When an injector causes eyelid ptosis, knowing to correct the ptosis is equally as important as being able to nurture the relationship based on trust and respect. The goal is to provide injectors with the knowledge to prevent adverse events; however, if an adverse event should arise, aesthetic injectors must be able to manage the complication. When blepharoptosis occurs after an aesthetic treatment, it is most commonly attributed to the spreading of neurotoxin through the fascia of the orbital septum to the levator palpebrae superioris muscle in the upper eyelid often due to the application of neurotoxins outside the safe zone or due to marked dispersion of the neurotoxin from excessive manipulation of the region. Eyelid ptosis occurs in 5.4% of novice injector’s neurotoxin injections resulting from neurotoxin spread from the brow area to the levator palpebrae superioris muscle (King, 2016; Nestor et al., 2021). The rate of eyelid ptosis drops to less than 1% with treatment by an experienced aesthetic injector (Nestor et al., 2021). Education is paramount in patient safety in any field of medicine; however, it is even more imperative in aesthetic medicine, given that this niche field of medicine is highly unregulated.

Eyelid ptosis can impact patients, their love life, their ability to work, and even drive a vehicle. The condition mimics having a stroke or what some may know as Guillain Barre Syndrome. The overwhelming impact this condition can have on a patient’s entire life will likely have a negative impact on an injector’s business regarding the potential litigation due to medical liability. Injectors must understand the anatomical nature of the area they are treating to reduce the risk of this adverse complication. Beyond a comprehensive understanding of anatomy, injectors must also understand how to provide informed consent beyond the legal document the patient signs. Informed consent, patient selection, a comprehensive understanding of the drugs being used, and a comprehensive knowledge base of human anatomy, coupled with proper technique, are imperative for aesthetic injectors. Should a complication arise, one must possess an intimate knowledge of the human body beyond cosmetic medicine to be able to diagnose correctly and to be able to treat the adverse event successfully. Given the emotional impact one physical deformity can have on a patient’s mental well-being, an aesthetic injector must be able to nurture the relationship in order to stay in control of the patient’s physical and mental well-being.

There are five known classifications of eyelid ptosis: neurogenic, myogenic, aponeurotic, mechanical, and traumatic. Eyelid ptosis induced by neurotoxins classified as myogenic is due to impairment of the transmission of electrical impulses at the neuromuscular junction. The remainder of this section on eyelid ptosis will focus on the idea of a myogenic complication.

Learning Goals for Aesthetic Injectors to Mitigate and Manage Complications:

Learn how to reduce the risk of eyelid ptosis
Learn techniques and anatomy harmoniously to recognize how technology plays a role in outcomes
Learn how to treat eyelid ptosis and reduce the symptoms
Learn how to explain the diagnosis and the management plan to your patient to reduce stress and anxiety, creating a smooth transition to resolution.

Anatomy

The affected muscle in eyelid ptosis is the levator palpebral superioris (LPS). This muscle attaches to the superior tarsal plate and is responsible for lid elevation and closing. The LPS is one of the most important muscles when injecting neurotoxin. This muscle originates from the lower wing of the sphenoid bone, right at the posterior part of the orbit, slightly superior to the optic foramen. The LPS becomes broader and thinner, along with becoming more fibrous as it passes anteriorly, before becoming the levator aponeurosis. The LPS is a skeletal muscle innervated by the somatic nervous system acting under conscious control.

Within the lid structure, anterior to the body of the LPS, is the superior tarsal muscle (STM), also known as the Mullers muscle. This muscle receives innervations from the sympathetic nervous system, consisting of thin fibers of smooth muscle. The STM originates just beneath the LPS and reaches the insertion point on the superior tarsal plate of the upper eyelid. The Muller’s muscle assists the LPS by maintaining the elevation of the upper eyelid after the LPS has raised the lid. The LPS raises the lid, and the STM maintains the position of the LPS, but then the STM will elevate the eyelid another 2mm. The STM is a subtype of the extraocular muscles. Blood is supplied to the STM from tiny branches through the lateral muscular branch of the ophthalmic artery. This muscle does have acetylcholine receptors which makes it sensitive to the neurotoxin. As a reminder, neurotoxins are acetylcholine inhibitors; in other words, they prevent the release of acetylcholine, thus blocking the message to contract or relax the imposing muscle (Standring, 2016).

For the neurotoxin to get to this highly protected area, the neurotoxin must pass through several layers of tissue.

Hypodermis
Orbicularis oculi
Orbital septum

The orbital septum is considered a semipermeable structure, including several perforations that allow the passage of supratrochlear and supraorbital nerves, arteries, and veins to pass through from the orbit to the forehead. This perforation is called the superior orbital foreman.

Injection Technique:

Injectors must move beyond the static cookie-cutter approach to understanding only the dose and muscles intended for injection. A competent injector will also arm themselves with a global understanding of cause and effect by comprehensively understanding the anatomy in and around the targeted area for treatment. When treating the Glabella complex, injectors should understand that treatment aims to inject a neurotoxin into the lateral and medial corrugator and the procerus. In some cases, a patient will need treatment for the depressor supercilli. Areas to avoid when treating this zone are the LPS, STM, and the frontal lacrimal duct. Natural, safe zones for the face exist and can help injectors stay in the safest zone possible to prevent adverse events. Depth and correlation to the orbital body rim are essential landmarks to become familiar with when injecting neurotoxins.

When injecting, the medial and lateral corrugator is thought to be when an injector is at the most risk for causing eyelid ptosis. The most medial portion of the corrugator starts deep on the bone at the superciliary arch (Standring, 2016). As the muscle moves laterally, the lateral corrugator muscle becomes more superficial until the insertion point is just above the level of the orbicularis oculi in the skin above the mid-pupillary line. Inferior and posterior to the corrugator lies the supratrochlear and supraorbital notches, which perforate the orbital septum creating a portal to communicate with the LPS and the STM. Depth, dose, extrusion force, and angle all play a role in the ability of injection to reveal the intended results or an adverse event. Consider the fibers in the way in which they track. Attempt to inject in the same direction as the fibers using the fibrous nature as potential bumpers, not accidentally extruding the product from the intended areas. Injecting parallel with the corrugator is essential. An angle of 30 to 45 degrees will help to provide easy insertion and depth.

Diagnosis

One can only diagnose if one understands the anatomy and functions of these structures affected by the neurotoxin. Injectors must also develop differential diagnoses, moving beyond the notion that eyelid ptosis or palsy is related to the injection. Patients can have an actual stroke coincidently at the time of injections; therefore, behooving practitioners must understand the whole person. The first step in being a good injector is to be on call after injections. Developing a sound consult process and a thorough informed consent process will deter your patients from turning to the dreaded Google for diagnosis. Ensuring them that you will be there for them is the first step in decreasing anxiety and losing the patient down a habit of the whole of Google and the Emergency room. If your patient makes their way to the emergency room, they will be tested for a stroke with expensive and invasive testing, increasing the original injector’s inability. Patient selection will also assist in reducing this complication.

Be sure to take photos in the clinic at rest and in motion. A 3-second video of movement is also critical in the follow-up process. Notate any pre-existing asymmetry before starting treatment and kindly address this with the patient. Patients can be woefully unaware of their asymmetries before the treatment, and at times they have a sudden amnesia of remembering what they looked like just before the treatment. Eyelid asymmetry is prevalent in the vast majority of patients. Patients may have a lid or brow ptosis before treatment, which should be carefully noted and discussed before initiating any treatment to ensure the treatment does not exacerbate the ptosis. When assessing for asymmetries, start inward. Make your focal point the eye’s iris, see where the lid falls on each eye, and compare right from left. Perform the same assessment when the patient squints and raises their brows. Then look to assess the folds within the eyelid at rest and in motion. A key note to be mindful of when treating the frontalis muscle along with the glabella complex is the patient’s engagement of the frontalis muscle even at rest. When a patient has a baseline brow or eyelid ptosis, the frontalis is subconsciously recruited to raise the lids or brows to enhance peripheral vision. Asking about the patient’s visual acuity prior to injection can be helpful prior to treatment, along with a simple gaze test where you ask the patient to follow your finger left, right, up, and down to assess for an existing rectus palsy.

Definitions

Levator Palpebrae Superiors (LPS)
Origin-Lesser wing of the sphenoid bone. The levator palpebrae superioris muscle arises from the inferior part of the lesser wing of the sphenoid bone, superior to the optic canal.
Insertion– Superior tarsus and skin of the upper eyelid.
Action– Elevates upper eyelid.
Innervation– Superior branch of the oculomotor nerve (CN III)
Arterial Supply– Ophthalmic and supraorbital artery

Mueller’s Muscle/Superior Tarsal Muscle (STM)
Origin-From underneath the levator palpebrae muscle
Insertion– On the tarsal plate of the upper eyelid
Action- Structural muscle that maintains the function of the upper eyelid’s ability to become elevated and maintain an elevated status. This muscle can also raise the eyelid an extra 2mm after the levator palpebrae’s original lift.
Innervation-From the sympathetic nervous system
Arterial supply-Supplied by the lateral muscular branch of the ophthalmic artery.

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Tara Delle Chiaie

MSN, FNP-BC, APRN, ABAAHP

Owner/Master Aesthetic Injector

My name is Tara and I am the owner of Delle Chiaie Cosmetic Medicine. I have been in medicine since 2002 as a Registered Nurse. In 2011 I graduated from the accelerated program at the University of New Hampshire (UNH) as an Advanced Practice Registered Nurse (APRN) and immediately became nationally recognized through the American Nurses Credentialing Center (ANCC) as a Board Certified Nurse Practitioner. I grew up in the beauty industry and found it was a great union to blend beauty with medicine. I have an astute sense of safety, while my experience guides my practice to produce beautiful and natural results. My goal is to continually fine-tune the art of bringing one’s inner beauty to the surface.

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REFERENCES:

Carruthers, J. A., Lowe, N. J., Menter, M. A., Gibson, J., Nordquist, M., Mordaunt, J., Walker, P., Eadie,

N. (2002). A multicenter, double‐blind, randomized, placebo‐controlled study of the efficacy and safety of botulinum toxin type A in treating glabellar lines. Journal of American Academy of Dermatology; 46(6): 840‐849. https://doi.org/10.1067/mjd.2002.121356

King, M. (2016). Management of ptosis. The Journal of Clinical and Aesthetic Dermatology, 9(12), E1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300727/

Nestor, M. S., Han, H., Gade, A., Fischer, D., Saban, Y., & Polselli, R. (2021). Botulinum toxin-induced blepharoptosis: Anatomy, etiology, prevention, and therapeutic options. Journal of Cosmetic Dermatology, 20(10), 3133–3146. https://doi.org/10.1111/jocd.14361

Standring, S. (2016). Gray’s anatomy: The anatomical basis of clinical practice. Elsevier Limited.