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Botulinum toxin is the most popular non-surgical procedure worldwide. Although the procedure is considered safe and associated with a favorable complications profile but any medical intervention carries inherent risks. We classify the adverse effects into 3 categories: procedure associated and idiosyncratic reactions, functional and esthetic. Procedure-associated reactions include injection site pain, bruising, 1-3 days headache. Idiosyncratic reaction characteristics are unknown mechanism, flu-like symptoms, intractable and severe headache lasting 2-4 weeks.

Eyelid ptosis is defined as MRD distance below 2.5mm or an asymmetry of more than 1 mm between the two eyes. MRD (margin reflex distance) is the vertical distance between the pupillary light reflex and the upper eyelid margin. BTXA-induced eyelid ptosis pathogenesis is the compromise of levator palpebrae function due to diffusion of BTXA through the orbital septum. These rules can help you to avoid eyelid ptosis:

  1. Always inject 1CM above the orbital rim
  2. Protect against orbital leak
  3. Medial point deep, lateral-superficial
  4. Avoid rubbing and exercising for a few hours after injection
  5. Consider 3 point injection scheme (off label)

For treating eyelid ptosis you should:

  1. Stimulate activity of Muller muscle (adrenergic)
  2. Exercise the levator muscle
  3. Decrease the sphincteric activity of the pretarsal portion of orbicularis oculi (plays a role in lid margin tone)
  4. Consider oral pyridostigmine 60 mg*2/d

Mephisto eyebrows will be seen mostly at eyebrows elevation when lateral fibers of frontalis become hyperactive due to insufficient injection of the lateral frontalis when treating forehead wrinkles. While pseudo-Mephisto eyebrows will be seen both at rest and eyebrow elevation due to high-positioned injection, affecting lower frontalis and causing drooping of eyebrow head when treating glabella.

Other complications of Botulinum toxin like eyebrow ptosis, loss of ability to pull mouth corner while smiling, and complications during “off label” use of BTXA will also be discussed in detail.

BTXA associated complications do happen, most of them are avoidable and treatable and all of them are self-limited.