Author(s): Ramey, Nicholas A. M.D.; Woodward, Julie A. M.D.

Chemodenervation with botulinum toxin type A has gained widespread use in various cosmetic procedures. Its long-lasting but impermanent effects make it attractive for several reasons. First-time and repeated consumers alike are drawn by convenience, cost, and efficacy. For relatively risk-averse patients, repeated chemodenervation is a viable alternative to the permanence and complications associated with incisional cosmetic surgery.1,2 Facial muscles of expression, especially those in the periorbital region, offer high-impact results.3 Although inevitable, unexpected results including brow and lid ptosis are frustrating for patients and providers.

A human cadaver was injected with colored latex to define arteries (red) and veins (blue). Methylene blue (1%, 1 cc) was injected into the right and left corrugator muscles, at the level of the supraorbital foramina. On the right, the injection needle was inserted deep to the bulk of the muscle belly, approaching the periosteal plane. On the left, the needle was inserted into the muscle belly, with a trajectory toward the supraorbital foramen. The superior orbital tissues were dissected and inspected for tracking of dye along relevant lid and orbital structures.

In this study, two mechanisms of blepharoptosis from corrugator chemodenervation have been proposed. First, toxin may reach the levator muscle as it traverses the preperiosteal plane. Second, toxin may track along tributaries of the superior ophthalmic vein, which travels along the levator for part of its course. Blepharoptosis may be avoided through careful superficial positioning of the injection needle, using appropriately low volumes. Deep injections, particularly those overlying the bulk of the supraorbital nerve or near branches of the superior ophthalmic vein, should be avoided to prevent perineural or perivascular infiltration around the levator palpebrae superioris.

Plastic and Reconstructive Surgery: November 2010 - Volume 126 - Issue 5 - p 248e-249e doi: 10.1097/PRS.0b013e3181ef822a

For medical disclaimer, privacy policy, and system requirements click here.