April 21, 2022

eyelid ptosis eyeEyelid ptosis or a droopy upper eyelid can be an upsetting complication for your patients after cosmetic botulinum toxin or Botox® injections, but are you identifying it correctly, and is there more to the story, as well as your options for correction?

In this blog, Dr Tim Pearce talks about how to make sure you are not confusing eyelid ptosis with eyebrow ptosis or existing, congenital asymmetry, alongside three treatment options to help you to deal with this condition, ensuring you are in control and stress free for your patient as well as yourself.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

What is eyelid ptosis?

Eyelid ptosis is the medical term for a droopy eyelid; it is especially important if it is a new symptom, is asymmetrical, or affects vision.

It is vital to note that we are looking at the eyelid with reference to the pupil, and not the eyebrow, or the skin above the eyebrow, something which often confuses new aesthetic injectors.

Most of the cases of eyelid ptosis that Dr Tim sees reported on online forums are in fact eyebrow ptosis. A drooping frontalis muscle can rest on the eyelid and create a sense of heaviness in the area that to the inexperienced or less well-trained eye looks as if the botulinum toxin has affected the eyelid. With misdiagnosis, the patient gets the wrong treatment, and the aesthetic clinician is prone to repeating the same mistakes in diagnosing between eyelid and eyebrow ptosis.

What causes eyelid ptosis?

There are multiple causes of a true eyelid ptosis, and it is wise to consider all of them if a patient presents to you at any stage with a ptosis.

The first scenario, the one that we are expecting in 1% of botulinum toxin treatments is when the neurotoxin makes its way into the orbit of the eye affecting the levator palpebrae muscle.

Dr Tim notes that a risk of occurrence of 1/100 is not his personal understanding, as it is far less frequent than that in his experience in clinic; however, if the incidence is that high in wider practice, he surmises that it is probably because injectors do not understand the anatomy and are injecting too deeply and to near to the orbit.

Why not download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin treatments.

The primary muscle of elevation is the levator palpebrae muscle. It runs all the way from its origin on the lesser wing of the sphenoid bone, over the top of the globe, and over the superior rectus muscle until if fans out and becomes a tendon sheath called the levator aponeurosis. It passes over a transverse suspensory ligament, the Whitnall’s ligament which is part of a pulley system allowing the horizontal levator muscle to exert more of a vertical force on the levator aponeurosis, that pulls the eyelid upwards.

Eye anatomy muscles

Posterior to the levator aponeurosis is the superior tarsal muscle, also called Müller’s muscle. This is a smooth muscle that also elevates the eyelid, but it is not under conscious control, it responds to the sympathetic nervous system when you are acutely stressed or excited.

Did Botox cause the eyelid ptosis?

A lot of aesthetic practitioners immediately blame themselves for any side effects, symptoms, or complaints that occur after a procedure, and patients also reasonably connect what they see to procedures they have had done, but there are many causes of asymmetry in this area that are not related to botulinum toxin treatments, which you should rule out before blaming yourself.

Did Botox cause the eyelid ptosis?

A lot of aesthetic practitioners immediately blame themselves for any side effects, symptoms, or complaints that occur after a procedure, and patients also reasonably connect what they see to procedures they have had done, but there are many causes of asymmetry in this area that are not related to botulinum toxin treatments, which you should rule out before blaming yourself.

Congenital eyelid ptosis

There are people with congenital eyelid ptosis, usually mild and asymmetrical. It is present life long, but often gets worse as you age. In fact, Dr Tim himself has a slight asymmetry in his eyelids, check out the photo below to see if you can spot it.

His advice is to ALWAYS check your before photographs of the patient. It is very common for patients to spot old or existing facial anomalies for the first time after having a new cosmetic procedure because they analyse themselves in much more detail afterwards and this is most often the case with mild ptosis.

Brow ptosis not eyelid ptosis

Aesthetic injectors are commonly confused when encountering a brow ptosis, especially on patients whose skin runs uninterrupted to the eyelid.

A slump in the forehead tissue can transmit some energy into the upper eyelid area, usually this narrows the space between the eyebrow and the lid line, much more so than it drops the eyelid itself. This is what you must look for on examination, as the way you may treat a drooping eyelid is very different to treating a drooping eyebrow.

Myasthenia Gravis

There are several notable medical conditions which could look very similar to a side effect from botulinum toxin treatment, presenting with a droopy eyelid; one of which is myasthenia gravis.

diplopia myasthenia gravis
Source: Wikipedia https://en.wikipedia.org/wiki/Myasthenia_gravis#/media/File:DiplopiaMG1.jpg


This disease affects the neuromuscular junction and is caused by autoimmune destruction of the acetylcholine receptor. The more active the area, the more likely it is that symptoms will occur, so it is common for the eyelid to droop early in the disease, and this can also be asymmetrical.

Horner syndrome

Horner syndrome is another condition which can cause an eyelid ptosis, it results from disruption of the sympathetic nerve innervation to the face which can be for various reasons, the most serious of which is an apical lung cancer affecting the sympathetic nerve plexus in the chest. This causes a drooping eyelid, a loss of sweating on the affected side of the face, and constriction of the pupil.

Ways to treat eyelid ptosis caused by Botox injections

Having ruled out existing medical causes of eyelid ptosis, there are several options to be aware of for treating eyelid drooping caused by botulinum toxin treatment, even if you refer the patient onwards and seek help outside your own clinical practice and skillset.

Iopidine (apraclonidine) or oxymetazoline hydrochloride

If your patient has a botulinum toxin side effect, or a mild congenital ptosis, you can use medication (in the form of drops) that stimulates the smooth muscle in the eye – the tarsal muscle or Müller’s muscle – which responds to sympathetic stimulation. The fight or flight response causes widening of the eye, and drugs like Iopidine® (apraclonidine) or oxymetazoline hydrochloride mimic the sympathetic response and can be used to temporarily lift the eye for between 4-6 hours. These prescription medicines would be used off label in the UK, and may not be suitable for all patients, but a licensed product called Upneeq® is available in the USA.

Further botulinum toxin treatment

The next option for correction, which surprises many patients, is that you can treat an eyelid ptosis, even one caused by botulinum toxin injections, with MORE botulinum toxin!

The eyelid, like most moving structures in the body has muscles which oppose each other.  Eyelid retractors – the tarsal muscle and levator palpebrae muscles – are opposed by the palpebral part of orbicularis oculi – the protractors. This means that if you inject the upper eyelid, the orbicularis oculi muscle, anterior to the tarsal muscle, with 1-3 units of Botox®, it can lift a drooping eyelid by a millimetre or so.

Many aesthetic clinicians managing an eyelid ptosis complication as a side effect of botulinum toxin treatment will use both options, as the drops work in minutes, but need constant reapplication, and the botulinum toxin takes a couple of weeks to work, but once activated, the result is consistent.

Ptosis surgery

Dr Tim highlights that it is worth understanding and being aware of the surgical options available for congenital asymmetries and eyelid ptosis, even as an educational point for non-surgical aesthetic practitioners. These are obviously not used for correction in the case of a botulinum toxin side effect; however, pre-existing, or age-related ptosis often require surgery.

Ptosis surgery is not the same as a blepharoplasty and requires the skills of an oculoplastic surgeon who operates on the eyelid itself. There are two main options for this kind of surgery.

The first is to target the levator aponeurosis tendon – the levator palpebrae muscle inserts into this tendon – and shorten it by the required amount to create a lift. This type of surgery is often reserved for older patients with functional problems due to severe drooping of the eyelid obstructing their vision, and it is less likely to give a perfect aesthetic result. The second is a less powerful, but more aesthetically predictable type of surgery to create a more controlled aesthetic result whereby a section of the tarsal muscle is removed through the posterior side of the eyelid.

If you are interested in learning more about the dynamics of such surgical interventions for eyelid ptosis, to help when you consult with your patients, Dr Tim recommends following Dr Guy Massry who has several videos on his Instagram feed.

What are your thoughts on and experiences with managing eyelid ptosis? Why not drop Dr Tim a comment or question on social media, you can find you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

3 Ways to Fix Eyelid Ptosis After Botox

Dr Tim Pearce talks about how to identify eyelid ptosis, which is often confused with eyebrow ptosis or existing asymmetry that the patient didn’t notice prior to treatment. He also covers 3 treatment options so that you can feel in control and stress free when dealing with this condition.

The show has over 10k views and some great feedback from aesthetics professionals. Some of the latest comments include:

“Dr Tim, you are IMO the best educator an speaker in the field. I always enjoy so much your videos and the way you present the information. Thank you for the amazing work you upload “

Catalina G

“You are incredible you teach us how to prevent then you teach us even more ways in different techniques to prevent even more and now you teach us when we do mess up exactly how to fix it you’ve got to be the most well-rounded and well-schooled doctor in this beautiful art thank you so much and may God bless you and your beautiful wife all of us really appreciate this so much you could have just spent all of your time indulging in your practice in making actual money instead of making these fantastic videos that’s what I call a true humanitarian and a true professional in anesthetics”

Jennifer Craig

Read more and add your own comments on our YouTube channel.

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If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

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In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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