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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51 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 C A S E S E R I E S be made that the elevation of the brow might also play a role in the upper lid margin position. The results from Case 3 might provide some evidence for the role of specifically targeting the pre-tarsal orbicularis. In this case, botulinum toxin was administered to the right frontalis region in order to drop the right eyebrow. Intuitively, a drop in the brow should lower the ptotic lid further; however, we saw an improvement in the lid margin position, presumably from the pre-tarsal botulinum toxin treatment. One adverse effect of botulinum toxin application is the inadvertent induction of ptosis, which occurs at a rate of approximately 0.5 to 1 percent. 8 Inadvertent induction of ptosis can be mitigated by careful injection of the toxin in a standardized location; however, there is no way to completely eliminate the risk. 3 Patients should be counseled regarding this. CONCLUSION In patients with mild or micro-ptosis, corrective surgery might not be indicated but cosmetic improvement might be desired. In such cases, botulinum toxin application to the pre-tarsal orbicularis oculi muscle might be a suitable option for the management of small eyelid margin asymmetries. REFERENCES 1. Ahmad K, Wright M, Lueck CJ. Ptosis. Pract Neurol. 2011;11(6):332–340. 2. Lew H, Goldberg R. Maximizing symmetry in upper blepharoplasty: the role of microptosis surgery. Plast Reconstr Surg. 2016;137(2):296e–304e. 3. Fagien S. Temporary management of upper lid ptosis, lid malposition, and eyelid fissure asymmetry with botulinum toxin type A. Plast Reconstr Surg. 2004;114(7):1892–1902. 4. Rufer F, Schroder A, Erb C. White-to-white corneal diameter: normal values in healthy humans obtained with the orbscan ii topography system. Cornea. 2005;24(3):259–261. 5. Lander T, Wirtschafer J, McLoon L. Orbicularis oculi muscle fibers are relatively short and heterogeneous in length. Invest Ophthalmol Vis Sci.1996;37(9):1732–1739. 6. Sinha KR, Rootman DB, Azizzadeh B, Goldberg RA. Association of eyelid position and facial nerve palsy with unresolved weakness. JAMA Facial Plast Surg. 2016;18(5):379–384. 7. Francisco GE. Botulinum toxin: dosing and dilution. Am J Phys Med Rehabil. 2004;83(10 Suppl):S30–S37. 8. Chen AH, Frankel AS. Altering brow contour with botulinum toxin. Facial Plast Surg Clin North Am. 2003;11(4):457–464. JCAD FIGURE 2. A1) Pre-injection photograph of a 38-year-old man with left relative ptosis; A2) The botulinum toxin injection pattern includes 2u into the lateral pre-tarsal orbicularis; A3) The six weeks post-injection photograph shows improvement in left lid margin height and overall symmetry; B1) Pre-injection photograph of a 71-year-old woman with left relative ptosis; B2) The botulinum toxin injection pattern includes 2u into both the lateral and medial pre-tarsal orbicularis; B3) The eight weeks post-injection photograph shows improvement in left lid margin height and overall symmetry; C1) Pre-injection photograph of a 55-year-old woman with right relative ptosis with brow compensation; C2) The botulinum toxin injection pattern includes 2u into the lateral and 1u into the medial pre-tarsal orbicularis; C) The 11 weeks post-injection photograph shows improvement in right lid margin height and overall symmetry.

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