Neuromodulator for Mild Eyelid Droop: What Research Shows

A short 2018 report from eye specialists at UCLA described three people with very mild upper eyelid droop who were treated with tiny doses of botulinum toxin type A just above the lash line. Each eyelid rose by a little under one millimetre, enough to make the two eyes look more even. It is a very small case series, so it shows a possibility in carefully chosen people, not a routine treatment, and any eyelid droop needs a proper eye assessment first.

Why this was studied

Ptosis means a drooping upper eyelid. It can be present from birth, develop with age as the lifting muscle stretches, or be linked to other conditions such as thyroid eye disease, nerve problems or muscle disorders. Significant ptosis is usually treated with eyelid surgery.

Some people have only a slight droop, or one eyelid sitting a little lower than the other. Surgery may feel like too much for such a small difference. The researchers wanted to see whether a simple injection could offer a modest, temporary improvement.

What the researchers did

Dr. Hamzah Mustak and colleagues at an academic eye institute treated three patients with mild or "micro" ptosis and uneven eyelid height. They injected very small amounts of botulinum toxin type A into the part of the orbicularis oculi muscle that lies over the eyelid plate, about two millimetres above the lashes, at the inner and outer thirds of the lid. Doses were around two to three units per eyelid. One patient also had a single unit in the forehead.

The orbicularis oculi is the ring-shaped muscle that closes the eye. The idea is that gently relaxing the part sitting on the eyelid shifts the balance toward the muscles that open the eye, allowing the lid margin to rise slightly. The authors describe this as a hypothesis.

Standard photographs were taken before treatment and again six to eleven weeks afterward, and eyelid position was measured with image software.

What they found

In all three patients, the distance from the centre of the pupil to the upper lid edge increased, by an average of just under one millimetre. The difference between the two eyes became smaller, which the authors used as their measure of success. In the patient with the largest change, the visible eyelid crease also became more symmetrical. No side effects were reported in these three people.

How strong is this evidence?

This is about as early as clinical evidence gets. Three patients is a case series, not a trial. There was no comparison group, no statistical testing, no information on how long the effect lasted and only one follow-up point per person. The three patients also had different underlying causes of ptosis, and one had additional forehead treatment, which may have contributed. The paper contains small inconsistencies in its reported averages.

The authors themselves note that the change was under one millimetre, that the effect on more significant ptosis is unknown and that larger studies are needed. They also point out that higher doses, or toxin spreading into the deeper eyelid-lifting muscles, could in theory make ptosis worse or interfere with eyelid closing.

What it means for you

The most important point is that a drooping eyelid should be assessed before anything cosmetic is considered. New or worsening droop, droop that changes through the day, droop with double vision, a change in pupil size, headache or weakness elsewhere can signal a medical problem. See your family doctor or an eye specialist, and seek urgent care if the droop is sudden.

For someone with a stable, mild, already-assessed difference between eyelids, this report suggests very small neuromodulator doses might offer a subtle, temporary lift. It is not standard practice and should only be considered after careful assessment by an experienced physician. In many cases, observation, surgery or treating a contributing brow position are more appropriate. Our articles on brow and eyelid heaviness after injections and facial asymmetry and neuromodulator give related background.

Botulinum toxin type A is not used during pregnancy or breastfeeding, with infection at the injection site, or in people with certain neuromuscular conditions. Around the eyes, possible side effects include bruising, dryness or watering, temporary difficulty closing the eye fully and, uncommonly, a worsened droop that wears off over weeks.

Why a millimetre matters, and why it does not

Eyelid position is measured in millimetres because small differences are easy for the eye to notice, especially when one side sits lower than the other. That is why a change of under one millimetre could look meaningful in these patients. At the same time, it is a reminder of how limited the effect is. It will not lift a heavy lid, correct a significant droop or remove excess skin. For many people, the more useful first step is simply finding out why the eyelid sits where it does.

Questions to ask at your consultation

• Has the cause of my eyelid droop been properly assessed?
• Is my brow position, rather than my eyelid, part of the issue?
• What is the evidence for this approach, and what could go wrong?
• Would referral to an eye specialist or oculoplastic surgeon be better for me?

Frequently asked questions

Isn't eyelid droop a side effect of neuromodulator?

It can be, when product affects the muscle that lifts the eyelid. This report targeted a different muscle with very small doses, which is why precise placement and an experienced injector matter.

How long would any lift last?

The study did not measure duration. Neuromodulator effects generally fade over a few months, so any benefit would be temporary.

Can this replace eyelid surgery?

No. The change seen was under a millimetre. Moderate or significant ptosis is usually managed surgically after specialist assessment.

If you have a mild difference between your eyelids and want to understand your options, HealthPark Medical Aesthetics in Sydney can discuss it at a consultation and help arrange an eye assessment where needed.

Source

Mustak H, Rafaelof M, Goldberg RA, Rootman D. Use of botulinum toxin for the correction of mild ptosis. Journal of Clinical and Aesthetic Dermatology, 2018. Read the study