Not so long ago, Botox was thought of as a procedure reserved for middle-aged women – usually high profile celebrities desperate to keep the edge against younger competition.
But Australians, it seems, have a large appetite for the non-invasive cosmetic procedure, and it’s now far more common for men and younger women to submit themselves to the needle.
With ptosis – or drooping of the eyelid – one of the more common complications of Botox, eye care professionals may need to think outside the box, if patients present with this symptom.
Western society’s obsession with regaining – or retaining youth – is perhaps best seen in the transformation of wrinkle filler injections such as Botox and Dysport from secretive, closed-door procedures, to something that is rapidly becoming a routine cosmetic procedure, and not just for women “of a certain age”.
The problem is no-one knows exactly where the point of injection is that will produce ptosis, and so no-one quite knows how to keep away
Reality television’s Kim Kardashian has admitted to using Botox – she’s 29. Another reality star and aspiring actress, 23-year-old Heidi Montag was recently featured on the front page of the gossip mags boasting about the 10 cosmetic procedures, including Botox, that she had received in one day. Other young actresses who have been rumoured to use Botox include Megan Fox, Lindsay Lohan, Hilary Duff and Jessica Simpson, who are all in their 20s.
Perhaps its because of our exposure to the harsh Australian sun, that we seem to have embraced cosmetic procedures. Figures released by the Cosmetic Physicians Society of Australasia (CPSA) in 2009-10, showed an estimated AUD$448.5 million was spent in Australia on non-invasive treatments – such as Botox injections.
CPSA President Dr. Gabrielle Caswell said patients feel more comfortable with ‘walk in, walk out’ treatments with short recovery periods and are more willing to give them a try.
Botox, or its alternative Dysport, which works in a similar way, involves small, precise injections of botulinum toxin into the muscles. They work by latching on to the end of the nerve endings which normally activate the muscle, and prevent the nerve from releasing the chemicals which cause the muscle to contract.
New nerve endings grow over time and then the nerve can activate the muscle again. This process takes a variable amount of time, depending on where the muscles are, how much of the toxin is used and individual variations, but the procedure usually lasts between three and eight months.
According to one medical website spruiking the benefits of the procedure, the result of removing or reducing ‘dynamic wrinkles’, which are those wrinkles caused by facial expressions and muscle movement, can “dramatically change a person’s appearance from one of continual anger or sadness to one of contentment and restedness”.
However, there can be quite severe side effects from the drug, and one of the more common ones is eyelid ptosis.
Incidence of Eyelid Ptosis
Associate Professor Greg Goodman, the principal dermatologist of the Dermatology Institute of Victoria, has been a practising dermatologist for more than 20 years. He says experienced practitioners are well aware of the potential for eyelid ptosis, or brow ptosis.
He believes the rate of reported incidence of ptosis when Botox is used for the treatment of frown lines used to be about 4 to 5 per cent, but he said that has dropped to about 1 per cent.
“The problem is no-one knows exactly where the point of injection is that will produce ptosis, and so no-one quite knows how to keep away.
“We used to inject inwards and downwards. We now inject upwards and outwards and that led to the first diminution in the cases of ptosis,”. Goodman said.
He said practitioners now believe there is another injection point that could lead to ptosis, and recent trials on patients who had previously suffered from Botox-induced ptosis, and who were injected into this point, have shown good results.
American actress Dana Delany (Desperate Housewives, Body of Proof) has become an advocate for ageing gracefully after revealing that she ended up with a hematoma and ptosis after Botox several years ago.
In an interview with Prevention magazine last year, Ms Delany said she was urged by her dermatologist to try Botox.
“He injected my forehead, hit a nerve and created a huge hematoma. The nerve has been dead ever since,” she said.
The damaged muscle in her right eye left her with a slight droop that – from photos, at least – seems hard to detect.
“I notice it more than anybody else, but I was symmetrical before, and now I am not. I stopped going to him right then.
“Doctors are human – they make mistakes,” she added. “But I never went back, especially after he wouldn’t own up to it.”
It doesn’t take much digging on the Internet to find others with similar complaints.
MS”, a contributor to an online cosmetic enhancement forum, said she would “give anything to have my lines back and my eyelids back to normal”.
“This was my third treatment in about a year and a half… after the second treatment I had one eyelid droop slightly. It went away in about two weeks. The third time (and believe me I hesitated about trying it again), I told my dermatologist he needs to be careful and not get it any closer than one centimetre to my eyebrow. Now, not only do I have the other eye that droops this time but on the one that drooped last time my eyebrow is raised up! I look like a freak! I am sick about this and it’s been two weeks and it’s not changing,” she wrote in her post.
On the same site, “G” said she was hoping her ptosis was “not a forever deal”.
“I will never again go through this treatment. I too would like to know if there is anything that can be done to treat or at least speed up the process of drooping eyelids. I look disfigured and am extremely depressed about it.”
Associate Professor Goodman said the good news about eyelid ptosis caused by Botox is that it is a temporary condition.
“It doesn’t last long. Because you’re not deliberately injecting into that point, you’re not getting full strength of the injection to that injection point, it will wear off faster than the rest of the Botox.
“Some people are more susceptible. These people need to be injected in totally different ways. You’ve got to be very careful of people with a ‘sleepy eye’. Their muscles perhaps already have a touch of ptosis,” Professor Goodman said.
He said apraclonidine drops, used a few times a day, provide a partial treatment for the condition, making other muscles in the eye work harder to open up the eye.
mivision spoke to Julie,* a woman who experienced ptosis after Botox, who said she used the drops, but “the dose would only last an hour or so and then the eyelid would drop again and I’d look like a stroke victim again”.
Julie said the clinic she attended never advised her about the potential for ptosis, and did not tell her about the drops after she developed the condition.
“If it does happen as often as it seems to, they should be advising about availability of drops… but I guess it depends on who you go to. I certainly won’t go back to the clinic I went to, ever again,” Julie said.
“It’s the eyes. The eyes are a crucial part of your life. Since it happened to me, I researched this on the Internet and found cases where people couldn’t even open their eye. It affects everything – your driving, your work – absolutely everything.”
A/Prof. Goodman said people who develop ptosis should go back to their Botox clinic, or visit their eye care professional, for advice on how to handle the condition.
“It is a very well-regulated profession, at least in Australia. Drug companies Allergan and Dysport will only provide the drug to professionals who are properly trained. Of course, there are problems if people are getting the drug off the Internet or overseas,” he said.
Botox-induced ptosis can sometimes take up to two weeks after the injections to appear. As an eye care professional, if patients present with the onset of ptosis, it may be worth asking questions about whether or not they’ve recently had Botox injections … even if they don’t seem the type to need them.