Iatrogenic Blepharoptosis: Multimodal Management and Treatment Technique With Botulinum Toxin Type A

Eyelid ptosis, or blepharoptosis, following esthetic treatment of the upper third with botulinum toxin Type A (BoNT-A) is a complication with a variable incidence depending on the injector's experience. Among unexperienced injectors, it ranges from 2.5% to 5.4% and approximately 0.51% to 1% in experienced injectors. Blepharoptosis is commonly defined as an eyelid located between 1.5 and 2 mm below the scleral-corneal limbus. It occurs because of the local spread of botulinum toxin, affecting the levator palpebrae superioris muscle, one of the principal muscles for elevating the superior eyelid. It typically becomes evident 3-14 days after BoNT-A application and resolves spontaneously after approximately 3 months, once the toxin's effect subsides. Even though it resolves with time, it can cause great distress for the patient and the physician.

In turn, knowing the anatomy of the face in high detail will help the physician treat and prevent this complication, which can be avoided with correct training and application. Once it has happened, it is important to recognize the severity of the blepharoptosis (which is classified as mild, moderate, or severe), in order to decide whether to use oxymetazoline or apraclonidine eye drops, muscle exercises, vibrating devices, radiofrequency, and the latest option described with pretarsal BoNT-A application. Even though the treatment is challenging, and evidence is scarce, here we present a literature review and some clinical cases of successful treatment with pretarsal BoNT-A in iatrogenic blepharoptosis following esthetic treatment of the upper third.

This review highlights the importance of facial anatomy knowledge to minimize potential complications associated with BoNT-A application. It also describes the clinical classification and management of iatrogenic blepharoptosis based on severity, with special emphasis on the pretarsal BoNT-A application technique.

A literature search was conducted using electronic databases (PubMed, MEDLINE, Embase, and Google Scholar), focusing on upper third anatomy, prevention of iatrogenic blepharoptosis secondary to BoNT-A application, classification, and therapeutic options based on severity.

Iatrogenic eyelid ptosis after BoNT-A application results from the neurotoxin spreading to the levator palpebrae superioris muscle. Current therapeutic options include sympathomimetic eye drops, vibration therapy, facial exercises, radiofrequency, and pretarsal BoNT-A application. This review emphasizes anatomical knowledge, risk factors' identification, and anatomical landmarks to minimize complications. The pretarsal treatment technique for iatrogenic ptosis using BoNT-A is also detailed.

The limitations of this review consist of the number of patients, which is very limited; another limitation is that none of the patients had severe ptosis to prove the treatment.

Blepharoptosis following esthetic BoNT-A treatment is a rare complication among trained injectors. Knowledge of therapeutic options, including pretarsal BoNT-A injection techniques, is crucial for managing this complication, which can have significant esthetic and functional impacts.