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2015 ASPS
Nonallergic Eyelid Edema After
Botulinum Toxin Type A Injection
Case Report and Review of Literature
Chao-Ming Wu1, Yin-Shuo Chang 1, 2, Chang-Cheng Chang1, 3, Jen-Hsiang Shen 1, 4, Yu-Tsung Chen 5
1 Aesthetic
Medicine Center, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
2 Department of Medical Education, MacKay Memorial Hospital, Taipei City, Taiwan
3 Department of Cosmetic Science, Chang Gung University of Science and Technology, Taoyuan, Taiwan
4 Department of Medical Education, Tzu-Chi General Hospital, New Taipei City, Taiwan
5 Department of Dermatology, Taipei Municipal Wang Fan Hospital, Taipei City, Taiwan
** Nothing to disclose **
Introduction
Botulinum neurotoxin type A (BoNTA)
0 Aesthetic medicine as treatment for glabellar lines
0 Reduce muscle activities, decrease muscle tension, smooth
facial wrinkles
Ascher B, et al. J Eur Acad Dermatol Venereol. 2010;24:1278–1284
Ascher B, et al. J Eur Acad Dermatol Venereol. 2010;24:1285–1295
0 Adverse events after BoNTA injection: only 3.73%
Kim BW, et al. J Dermatolog Treat. 2014;25:331–336
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0 Most adverse events: minor and transient, and
composed of eye disfiguration and vision blockage
0 No consensus on incidence of adverse effects
0 Ptosis: frequent side effect, eyelid edema uncommon
Kim BW, et al. J Dermatolog Treat. 2014;25:331–336
0 Few studies etiology, clinical course, and treatment
outcomes
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CASE REPORT
0 59-year-old woman
0 History of well-controlled asthma
0 BoNTA therapy to smooth wrinkles: forehead, glabella,
corners of her eyes (crow’s feet)
Physical examination revealed thick, triangular-shaped eyelids with infolding of the upper
eyelid
0 BoNTA (BOTOX1, Allergan, Inc, Irvine, CA,
100 U in 4mL normal saline)
0 Forehead, glabella (12.5 U), and eye corners (12.5/12.5 U)
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0 Local allergic reaction to BoNTA 3-day follow-up
0 Painless, nonpruritic, bilateral periorbital swelling and erythema
0 A topical corticosteroid BID x 3days
No symptom relief
0 Hypothesis: impaired venous and lymphatic return by
reduced muscle tone rather than allergic / infection
0 Hot pads, blink frequently, and massage
Eventually resolved 2 weeks later
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0 At 4-month follow-up, an additional course
0 Blink frequently, especially in the early morning
0 Massage the periorbital area increase venous return
No adverse effects and satisfactory outcome
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DISCUSSION
0 Most common complications: bruising, dry eye, corneal
exposure, diplopia, ectropion, lid retraction, other lid
malpositions, and an asymmetrical smile
Klein AW. Dermatol Clin. 2004;22:197–205.
0 Little known about periorbital eyelid edema: 0.04%
Kim BW, et al. J Dermatolog Treat. 2014;25:331–336
0 Median onset time of eyelid edema: 5
0 Median duration: 15 days
0 Asian populations at greater risk than Caucasian
Brin MF, et al. J Am Acad Dermatol. 2009;61: 961–970.
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0 Eyelid edema: allergy, infection, trauma, poor venous
or lymphatic return
0 Procedural and possibly even local adverse effects
0 Related to injector experience, decline with cycles
0 Repeated treatments: lower incidence of eyelid ptosis,
eyelid sensory disorder, and eyelid edema
Brin MF, et al. J Am Acad Dermatol. 2009;61: 961–970
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0 Multiple muscles involved in the blinking reflex.
0 Levator palpebrae superioris, Mu ̈ller’s (superior tarsal) muscle
0 Pretarsal and posttarsal plexuses: venous drainage of eyelid
0 Ophthalmic vein: drain the forehead and temple.
0 Preauricular and parotid nodes: lateral segment,
Submandibular: medial side
Paul RE JP. 17th ed: McGraw Hill Professional; 2007.
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0 Local spread of toxin Eyelid edema
0 Propose the mechanism:
0 Venous or lymphatic stasis, Decreased muscle tone
0 Different from ptosis
Brin MF, et al. J Am Acad Dermatol. 2009;61: 961–970
0 Impaired mechanical venous return: more common in
Asians than Caucasians
Brin MF, et al. J Am Acad Dermatol. 2009;61: 961–970
0 Fewer fibrous attachments
Kikkawa DO. Int Ophthalmol Clin. 1997;37:193–204.
Nguyen MQ. Semin Plast Surg. 2009;23:185–197.
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0 Fusion of levator aponeurosis and orbital septum
0 Closer to eyelid margin puffiness in Asian
Nguyen MQ. Semin Plast Surg. 2009;23:185–197
Jeong S, et al. Arch Ophthalmol. 1999;117:907–912.
Puffiness compresses the vein and obstructs venous return
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0 Asian eyes: eyelid hooding (dermatochalasis)
0 elastic fibers and  breakdown of collagen networks
 Secondary lymphostasis and eyelid edema
Nagi KS. Ophthalmology. 2011;118:1205–1210.
0 Examination of function and tone
0 Orbicularis oculi and levator palpebrae superioris muscles
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0 Doses and injection points in patients at risk
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CONCLUSION
0 Periorbital edema: Rare, Self-limiting, ✖medical treatment
0 Hot pads, frequent blinking, self-massage for venous
return
0 Preventive strategies: Examination of orbicularis oculi and
levator palpebrae superioris
0 Patients at risk: Asian, dermatochalasis, and poor
periocular muscle tone half dosage
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