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You may have seen TikToks and Reels of a Chicago-based beauty blogger - Whitney Buha - who was left with a droopy brow (ptosis) after having anti-wrinkle injections.
But what is ptosis? What causes it? How do you treat ptosis? And how can you prevent it in the first place?
Ptosis is a known 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's a known risk when you have wrinkle relaxing treatment with Botulinum toxin, so you should be clearly informed about it prior to treatment as part of the consent process.
If you're 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. And the bad news...you have to ride it out until the treatment wears off!
There are loads of muscles in the forehead and aarouns the eyes. Ptosis can happen if the toxin spreads into nearby muscles, or it it was injected too deep or too close to these muscles, or if the dose was too high.
The toxin then affects muscles it shouldn't - those either responsible for lifting the eyebrow or the eyelid. These then becomes weakened or paralysed as the toxin takes effect, resulting in ptosis.
The eyelid feels "heavy" and the brow can't be lifted nor the eyelid opened fully.
It's important to remember, that whilst a ptosis might be concerning and you may not like how it looks, it isn't a harmful complication.
That said, in a very small number 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 great news is that any toxin-related ptosis is temporary and will wear off. The bad news is that this can take 2-3 months. You will, therefore, eventually go back exactly to how you looked and felt before the treatment.
Unlike dermal fillers, there's no "reversal agent" for Botulinum toxin. Once the toxin is in the muscle, there's no way to take it out. This is why your practitioner will treat conservatively.
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.
- 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.
The risk of brow or lid ptosis is estimated as one in 100 for an experienced practitioner (1%) , and this rises to approximately five in 100 (5%) 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 most experienced hands.
In the world of medical aesthetics, 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. So be aware of this when you're booking your appointment.
As an injector, there are several ways to avoid ptosis - and this comes down to patient assessment, patient selection, dosage and injection technique.
It's really important that your injector REALLY assesses your anatomy. They should spend time asking you to frown, smile, raise your brows, scrunch your eyes as they observe and palpate your muscles and mark up your injection points.
Most practitioners will also be very cautious when they treat initially, potentially underdosing you, and will adjust the dosage in the 2 week review appointment, if necessary.
An expereinced practitioner will inject carefully In the forehead (frontalis muscle), if the dose is too high or is 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, if there is 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.
So understanding individual anatomy, careully identifying injection sites, ensuring the correct injection fepth depth and toxin dosage are all important considerations to avoid ptosis. This is why it is so important to choose your practitioner carefully.
As a patient, you must 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.
If you've had ptosis in the past, let your practitioner know, as this will inform your treatment plan.
Follow any post-treatment advice carefully. Avoid rubbing and massaging the treated area, to reduce the risk of the toxin spreading where it shouldn't.
For more information about the treatment of lines and wrinkles, as well as the potential side effects, check out our handy Glowday treatment guide.
