Journal of Clinical and Aesthetic Dermatology

APR 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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49 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 C A S E S E R I E S A Although eyelid ptosis has various positional definitions, it is often defined as a margin reflex distance (MRD) below 2.5mm or an asymmetry of more than 1mm between the two eyes. 1 There are, however, grades of ptosis ranging from severe (with obstruction of the pupil) to mild with barely noticeable asymmetries. Near the mild end of the spectrum, micro-ptosis and the accompanying compensatory mechanisms (e.g., recruitment of the frontalis muscle in an effort to elevate the ptotic eyelid can in turn lead to asymmetry of the eyebrows) often result in aesthetic asymmetry) might motivate patients to seek treatment. Facial symmetry is particularly obvious in the periorbital region, and even mild ptosis can heighten the perception of facial asymmetry. 2 In patients with such mild or micro-ptosis, surgery is rarely indicated from a functional perspective and can lead to secondary aesthetic complications, such as contour asymmetry or crease abnormalities. 2 Nonsurgical treatments might be desirable in these situations. One such treatment is botulinum neurotoxin. 3 Through our review of three cases, we describe the use of pre- tarsal botulinum toxin injections to elevate the lid margin height in patients with mild ptosis. METHODS In this small case series, we review three patients with mild ptosis. The patients received pre-tarsal botulinum toxin injections via a transdermal approach. Botulinum toxin (diluted 1u/0.02cc, using a 1.0cc insulin syringe on a 30-gauge needle) was injected transdermally 2mm above the lash line in the medial and lateral third of the pre-tarsal orbicularis (Figure 1). Ptosis was evaluated by measuring MRD values before and several weeks (6–11 weeks) after the injection to assess improvement. Tarsal platform show was also measured in both eyes to assess symmetry. Measurements were made using ImageJ software (a public domain, Java-based, image-processing software program developed by the National Institutes of Health) on frontal photographs perpendicular to the camera plane with standard lighting. The central corneal diameter was used as a reference for measurements based on the normal values of 11.77 for men and 11.64 for women. 4 The efficacy of the treatment was defined by improvement in ptosis to less than a 0.5mm difference in MRD between the two eyes, as well as a reduction in the difference between the tarsal platform show. Informed consent and photoconsent was received from the patients. RESULTS The average increase in MRD was 0.914mm, with an average pre-tarsal botulinum toxin dose of three units. The average change in TPS between the two eyes was 0.89mm. A B S T R A C T Background: Lid margin asymmetry and its associated compensatory mechanisms might cause patients to seek treatment to improve aesthetics. Surgery might not be indicated and can potentially worsen the asymmetry in these cases. Methods: A case series of three patients was organized to illustrate the use of botulinum toxin administered to the pre-tarsal orbicularis for the correction of micro-ptosis and improved symmetry. The marginal reflex distance and tarsal platform show were measured on both sides. Measurements were made using ImageJ software on standardized frontal photographs taken pre- and post-injection. Results: The average increase in the marginal reflex distance was 0.914mm, with an average pre-tarsal botulinum toxin dose of three units. The average change in tarsal platform show between the two eyes was 0.89mm. Conclusion: Botulinum toxin application to the pre-tarsal orbicularis oculi muscle might be a suitable option for the management of small eyelid margin asymmetries. KEYWORDS: Botulinum toxin, ptosis, eyelid asymmetry Use of Botulinum Toxin for the Correction of Mild Ptosis by HAMZAH MUSTAK, MD; MICHAEL RAFAELOF, BS; ROBERT ALAN GOLDBERG, MD; and DANIEL ROOTMAN, MD Drs. Mustak, Goldberg, and Rootman and Mr. Rafaelof are with the Stein Eye Institute, Division of Orbital and Oculoplastic Surgery at the University of California, Los Angeles in Los Angeles, California. Dr. Mustak is also with the Groote Schuur Hospital, Division of Ophthalmology, University of Cape Town in Cape Town, South Africa. J Clin Aesthet Dermatol. 2018;11(4):49–51 FUNDING: No funding was provided for this article. DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article. CORRESPONDENCE: Hamzah Mustak, MD; Email:

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