Everything You Need to Know About Ptosis

Bottles of neuromodulators surrounded by syringes

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Scrolling through TikTok and Instagram, perhaps you’ve come across Whitney Buha, a Chicago-based influencer who had an unfortunate run-in with ptosis as a result of a Botox injection gone wrong. But wait, back up. What’s ptosis? How does it affect the eyes? We consulted with Dr. David Shafer, a board-certified plastic surgeon and founder of Shafer Clinic Fifth Avenue in NYC, cosmetic dermatologist Dr. Michele Green, and aesthetic nurse practictioner Anush Movsesian to help explain the condition. Read on to learn more.

Meet the Expert

What Is Ptosis?

Diagram of pstosis

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According to Shafer, ptosis can occur in the upper eyelid, as well as in the brow area. “Ptosis is simply the dropping of the upper eyelid," he says. "I'm not referring to the extra skin of the eyelid, but rather, the actual eyelid, which descends downward so it covers more of the pupil than normal.”

He notes that there is a difference between eyelid ptosis and brow ptosis. “With brow ptosis, the weakened muscles of the forehead—mainly the frontalis—can’t hold up the eyebrow, so the position of the brow lowers making the patient look tired with full eyelids.”

Who Can Get Ptosis?

In short: Anyone. “Ptosis can occur in both adults and children,” says aesthetic nurse practitioner Anush Movsesian. “It may simply be a part of the person's anatomy.”

That said, Movesian points out that ptosis can also be caused as a side effect of a neuromodulator such as Botox or Dysport. More on that, below. 

Most Common Causes of Droopy Eyelids 

Before delving into neuromodulators, let’s talk about natural factors. According to cosmetic dermatologist Dr. Michele Green, ptosis can develop as a result of an eye injury, disease, or tumor that affects the function of the levator palpebrae superioris, the muscle used to lift the upper lid. “It is also possible that ptosis is present at birth, or that someone may experience ptosis as a part of the natural aging process.”

That said, neuromodulators are a notable cause for ptosis—albeit a rare one. “Neuromodulators such as Botox, Dysport, Xeomin, and Jeuveau all work by blocking the neurological junction to the muscle,” explains Shafer. “When the injections are placed too close to the eye, the medication can temporarily weaken the lifting muscles of the eyelid leading to eyelid ptosis or the muscles of the forehead leading to brow ptosis.”

It’s because of this possibility that plastic surgeons, dermatologists, anaesthetic nurse practitioners alike stress the importance of only placing cosmetic trust in the hands of a licensed and trained medical professional—preferably someone who has ample experience specifically with neuromodulator placement.  “[You want someone] who not only has years of experience providing treatment but also teaches and continues training on best practices and techniques,” Shafer adds. “As a trainer myself for Allergan Medical Institute, the company sends me to different parts of the country and overseas to train providers. Part of the training is product application of on-label areas so we can avoid cases of eyelid ptosis.”

Ptosis can also occur if the amount of neuromodulator is too high. “Sometimes, [if too much is used] the Botox may migrate into the levator muscle and produce a drooping effect,” Green explains.

How to Treat Ptosis 

Get prescription eye drops. “For iatrogenic eyelid ptosis with neurotoxin, there are eye drops such as Upneeq which help stimulate the muscle to lift the eyelid,” Shafer says.  “The good thing about neurotoxin-induced ptosis is that it’s always temporary but can be distressing for the patient until it wears off.”

Consider more neuromodulators. If a neuromodulator is the cause of your ptosis, you might be frightened by the idea of injecting even more. That said, Movesian says that sometimes a provider may inject more neuromodulators to surrounding muscles to help relax and lift the affected lid. (This is also true for brow ptosis.)

Discuss medication. In addition to eye drops, Movesian says that prescription medications exist to activate the Mueller's muscle which is located under the paralyzed levator palpebrae. This can help speed up the reversal process. 

Be patient. While eye drops and carefully-placed neuromodulators can help speed up the process, Movesian admits that if ptosis is the result of a neuromodulator in the first place, nothing will fully reverse the droop. “It will resolve on its own within about 11 weeks,” she assures.

Surgery is an option. If your ptosis is congenital, however, Shafer says that surgery is often the best bet for those looking to fix it. “The patient should seek consultation with a board-certified plastic surgeon or oculoplastics-trained ophthalmologist,” he adds.

When to See a Doctor

If you notice severe drooping following a neuromodulator appointment, it’s important to seek consultation from a trained medical professional, ideally a board-certified plastic surgeon or ophthalmologist, Shafer says. Even though neuromodulator-induced drooping will resolve on its own after a couple months, it helps to have a medical opinion when facing something that is, obviously, a quite shocking side effect. 

If, however, you’ve already seen a doctor, are in the waiting period, and notice that your vision is beginning to shift, then it's essential to book a follow-up appointment. “If the condition is interfering with your daily activities, see a physician who can recommend the best treatment for you and provide you with methods for correcting or managing symptoms,” Green says. “If you are experiencing ptosis as a side effect of having Botox injections, alert the injector of your Botox so that they can promptly resolve your situation.”

The Takeaway

Ptosis can be something you’re born with or a rare side effect of neuromodulator injections.  “If you notice that you are experiencing ptosis after having Botox, know that the droop will go away in a number of weeks, even without any treatment,” Green reassures us. “While a droop may seem apparent immediately after your Botox treatment, you should always wait two weeks before getting any additional Botox injections in order to ensure that you are truly experiencing a droop. The reason being that the full effects of Botox injections can take up to 14 days to be observed. Therefore, it is best to wait two weeks after treatment before deciding if you need additional Botox injected to correct the appearance of a droop."

Article Sources
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  1. Bacharach J, Wirta DL, Smyth-Medina R, et al. Rapid and sustained eyelid elevation in acquired blepharoptosis with oxymetazoline 0. 1%: randomized phase 3 trial results. Clin Ophthalmol. 2021;15:2743-2751.

  2. Cotofana S, Pedraza AP, Kaufman J, et al. Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique. J Cosmet Dermatol. 2021;20(6):1625-1633.

  3. Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg. 1986;17(6):354-360.

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