"Carefully applying small doses of botulinum toxin to address eyelid malposition, ptosis or eyelid fissure asymmetry takes Botox to another dimension, including not only the standard areas of treatment and facial shaping, but also to eyelid shaping," says Steven Fagien, M.D., an aesthetic eyelid plastic surgeon based in Boca Raton, Fla. Dr. Fagien, who is also a Cosmetic Surgery Times editorial adviser, estimates he has treated a total of more than 300 patients with eyelid malposition problems.
Dr. Fagien adds that, since his first article on treating eyelid malposition with Botox appeared (Plast Reconstr Surg. 2004 Dec;114(7):1892-1902), "It's a treatment that is really starting to catch on."
"It's very common for an individual to have a big eye and a small eye. Most people like their big eye, and more often we're treating the smaller eye to make it the same size as the other," Dr. Fagien explains.
Regarding eyelid ptosis, he says that aging represents the most common cause. In his initial series of 22 cases, "Most were involutional — they had lid ptosis and mild eyelid fissure asymmetries. Others had lid ptosis for a variety of other reasons including mild unilateral blepharospasm or previous eyelid surgery," Dr. Fagien says.
Muscular yin and yang
For treating eyelids, he says that, as in most areas of the face, "One muscle is the protagonist and another is the antagonist.
When one performs a brow lift with Botox, for instance, one is weakening the brow depressors and typically bolstering the strength of the brow elevators with the net effect of brow elevation."
Likewise, he says that when one weakens the eyelid depressors, one strengthens the eyelid elevators.
"By selectively weakening the pretarsal orbicularis above the lashes," Dr. Fagien says, "one allows the elevator muscle and Muller's muscle to work more effectively to elevate the upper lid into a better position, especially if it's ptotic."
A related principle applies with alpha-adrenergic eyedrops that physicians use to contract Muller's muscle, to test preoperatively for lid ptosis and, in some cases, to treat the mild lid ptosis that might unintentionally occur as a result of Botox injections near the eyes, he adds.
"The drops work to lift the upper eyelid as they strengthen the eyelid elevators by contracting Muller's muscle; Botox does this by weakening the antagonists to the lid elevators," Dr. Fagien explains.