« FDA Approves "Sculptra Aesthetic" | Main | Topical Toxin? The Effect of Botox Without the Needles »

July 30, 2009

First Complication with Dysport--But is it Dysport's Fault?

Ms. LM has suffered the first significant complication that I have ever had with an injectable botulinum neurotoxin (i.e., Botox or Dysport)--ptosis, or drooping of the upper eyelid.

Ms. LM is just 48 years old, and she has been a faithful Botox patient in my Ventura, California, office for over two years.  She has loved...

  • fewer wrinkles at the glabella (between the eyebrows)
  • softer crow's feet
  • reduced bunny lines (on the sides of the nose)
  • elevated eyebrows, with more arch 

Despite her youth, Ms. LM has not always been healthy.  She had suffered a stroke 5 years ago, which had temporarily paralyzed her entire left side, including her face, arm, and leg.  Although she has recovered nearly completely, she has admitted to persistent left-sided weakness.

Quarterly Botox has always been terrific, and has never resulted in an untoward effect.  However, this past session, I used the other botulinum neurotoxin type A--Dysport.

Two weeks later, she definitely has a left upper eyelid ptosis--a drooping of the left upper eyelid.

  • Ptosis is a known complication of both Botox and Dysport.
  • According to most research studies, ptosis occurs in 1-5% of patients.
  • However, none of my patients have ever suffered such a complication before.  And I have injected Botox thousands of times.
  • Is Ms. LM at particular risk for ptosis because of the stroke and the residual left-sided weakness?
  • Then, why didn't Botox unmask the problem?  Why was it Dysport that led to the ptosis?
  • Does Dysport "spread" too much?  Is it uncontrollable?
  • A single case does not create rule.  However, should I temper my enthusiasm for Dysport?

For now, I have prescribed an eye drop that will minimize the drooping, and I will wait patiently with Ms. LM.  Supposedly, the eyelid will be droopy for 2-6 weeks, rather the full 12-16 weeks that the botulinum neurotoxin type A will be effective elsewhere.  In the future, at least in her case, I will use Botox rather than Dysport.

|

TrackBack

TrackBack URL for this entry:
http://www.typepad.com/services/trackback/6a00e008dc7c8c8834011571572a21970c

Listed below are links to weblogs that reference First Complication with Dysport--But is it Dysport's Fault?:

Comments

Brigette-Cherie

Goodafternoon, great to read your article i am 43yrs old have had botox injections 5 years ago, and have recently tried Dysport, within 2 days i received on the right eye a very droopy eye, so much so it has been uncomfortable with children and people commenting, i went the doctor who did they Dysport injections and she apologised to me and said a had a droopy eye, prescribed me some drops which ive been taking 3 times and as the week has gone on with no difference 4 times if the strain and soreness, when she injected my on that side on the right it hurt a lot and i new straight away something was not right, she told me to relax, im very concerned that the drops will not work, your saying 2-3 weeks i have not seen any improvement with the drops in at the stage and that concerns me i would never ever use dysport again i think it is a cheaper version of botox kind regards
Brigette-Cherie - Austraila

Michael Pickart


Dear Brigette-Cherie,

You are correct. Dysport is a less expensive version of Botox. However,Dysports lower price shouldnot imply that it is an inferior product.

Let me reassure you that your droopy eyelid (termed ptosis) will resolve. Neither Botox nor Dysport is permanent. As you already know, glabellar frown lines are softened for only 3-6 months, and complications such as ptosis (which occurs in 2-3% ofpatients with either Botox or Dysport)typically last just 2-4 weeks. Iopidine eye drops do ameliorate the droopiness while you wait for the levator palpebrae superioris muscle to recover.

Do realize that Botox and Dysport are essentially the same thing: botulinum neurotoxin type A. They work the same way, and their side effect profiles are identical.

However, the dosing for the two products is different. One unit of Botox does not equal one unit of Dysport. Since Botox has been the only cosmetic neurotoxin available in the USA for years, the vast majority of the dosing regimens have been created for a single product--Botox. And since we physicians are still working out the optimal ratio for converting Botox treatments to Dysport treament, there are going to be hiccoughs as we gain more experience with the second cosmetic neurotoxin (Dysport). Ourgoal, of course,is to provide the same (or better) results with a nearly identical product that happens to be less expensive.

I have now used both productsfor about 9 months.I now realize that my initial ptosis complication with Dysport was secondary to mild over-dosing. One way that I have minimized complications is to use less product and to placeboth BotoxandDysportfarther away from the levator muscle.

Certainly, some patients will obtain a better result from either Botox or Dysport, but I suspect that the vast majority will gain results equivalent from either product.

In your case, please dont beat yourself up! You did not make a bad decision by opting for Dysport rather than Botox. Next time, just ask for less product, or perhaps insist on Botox. Im sure that your plastic surgeon will not be offended.

Sincerely,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811


To: info@pickartplasticsurgery.com

virginia

I just experienced terrible ptosis after dysport. Had one prior experience with botox, no problem there. In your experience, how long will this last? At rest my eye is shut, if I really try to open it it will open about 30%. It has been a week. I am totally devastated, I look like Igor. The iopidine drops may help minimally, but the eye never opens more than half way. In your experience, how long does this degree of ptosis tend to last. Also, I do wonder if the larger volumes required with dysport cause leakage. thanks.

Michael Pickart


Dear Virginia,

I am sorry that you have had a complication with Dysport. Ptosis is very annoying.

Heres the good news:


Ptosis tends to resolve in just 2-3 weeks;
you do not need to wait for3-4 months.
Iopidine drops do help; use them 3 times per day.

The bad news:


The next 2-3 weeks are going to be very frustrating.
Other than the iopidine, I dont know of another good antidote.

Does ptosis occur more frequently with Dysport than with Botox? Unknown. There are no comparative research studies. However, the FDA-approval studies were very similar for both products, and the ptosis rates were comparable for both products.

Because of a theoretical risk of greater spread with Dysport, I have adjusted my technique:


I use a smaller volume of saline when reconstituting the product, so that the Dysport is relatively more concentrated. Hence, greater volumes of injection are NOT necessary.
I raise my injection points by 2-3 millimeters to stay further away from the levator palpebrae superioris--the muscle responsible for lifting the upper eyelids.

For now, I can only express my frustration with you and for you. Just use that Iopidine and try to be patient. Call me at 805-648-4567 if you have specific questions.

Sincerely,
Mike Pickart

Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811


To: info@pickartplasticsurgery.com

Jennifer

I've been getting Botox injections for a few years. A small dose in between my eyebrows and also in the inner corner of each eyebrow mainly to relieve migraines, with the benefit of less squinting and wrinkling also. This last time my Doctor gave me Dysport, without telling me he was changing my injection. I experienced severe Ptosis in my upper eyelid (the worst he said he's ever seen). I couldn't open my eye at all for 3 weeks. I am using the eyedrops (Iopidine) 3x a day. At 4 1/2 weeks I'm only at 30% open and have constant cramping and pain in my eye. Neither injection is worth the risk for me to try this again.

Michael C. Pickart, M.D., F.A.C.S.

Dear Jennifer,

What a bummer! I wish that you had had a better experience with Dysport.

As I have gained more experience with both Botox and Dysport, I can state with certainty that both are excellent for reducing wrinkles and for mitigating headaches.

However, sometimes, one product works better than the other. The ptosis may have been from a greater "spread" supposedly associated with Dysport.

However, the more likely culprit is inappropriate dosing. Most of the research studies validating treatment regiments with neurotoxins used Botox, not Dysport. So, generalizing those results from Botox to Dysport (and soon Xeomin, Purtox, etc.) requires "conversion factors." Since the conversion factors themselves have not been optimized, Dysport can be over- or under-dosed.

In your case, I bet that you were over-dosed, and, hence, the ptosis. I might be wrong, and I'd be happy to consider other possibilities.

At least for now, you have done the right things: started iopidine and patiently waited for spontaneous resolution.

While I don't expect you to embrace Botox and Dysport ever again, do at least consider trying one or the other again, but with incremental dosing. Get a half dose first; if no side effects, then get a quarter dose (for 3/4 total); if still no side effects, then get the last quarter. Incremental dosing can stave off problems.

Hope that you return to health soon.

My warmest wishes,
Mike Pickart

Charlotte

I had Dysport in October and a few days later noticed the change in my eyelids. It is now December and there is still no change in how my lids are drooping.

Michael Pickart


Dear Charlotte,


I am sorry that you have suffered a complication associated with Dysport. Droopiness of the upper eyelids is known as ptosis, and it is an unusual (but not rare) complication of Botox and Dysport.


I am a Board Certified Plastic Surgeon, and I use both Dysport and Botox in my office to treat dynamic wrinkles of the upper face. I do tend to inject Dysport slightly higher (by about 3-5 millimeters) than Botox, because I do think that Dysport spreads more. Otherwise, Dysport has been a safe product. In fact, many patients prefer it over Botox, since Dysport definitely has a faster onset of action.


In the future, you may be a better candidate for Botox rather than Dysport. I would recommend lower doses, such that you may need to accept more residual wrinkles in order to avoid complications.


For now, I do have some good news....


Your plastic surgeon can prescribe an eye drop (called Iopidine) to raise your droopy eyelid. While the eye drop should not be used continuously for more than a week or two, it would be OK to use it intermittently for a month or so.Yes, you read correctly. You may have to wait another month or two for the droopiness to resolve spontaneously. Botox and Dysport do last 3-6 months. However, both toxins are only temporary; any untoward effect (and salutary wrinkle reductions) will resolve. I have NEVER heard of a permanent impairment from Botox or Dysport.

I hope that this information helps. Please call your doctor so that you can discuss these suggestions with him, especially whether Iopidine would be helpful for your case.


Sincerely,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811

To: info@pickartplasticsurgery.com

Gwen

I have successfully used Botox for 8 years without any problems. My doctor used Dysport for the first time and I have suffered from eye droop five days after the injection.I believe it spreads more than Botox and Doctors don't understand this since it is a new product. I have been researching this and it seems more women suffer eye droop with Dysport than with Botox. I will never use either product again, it's not worth the embarrassment of the eye droop. Also, I have been using the iopidine for a week and it barely makes any difference! This is so frustrating!

Michael Pickart


Dear Gwen,


I am sorry that you have had an unfortunate side effect of treatment with Botulinum Neurotoxin Type-A (BoNT-A) (more commonly known as either Botox or Dysport). Ptosis (or drooping) of the upper eyelid occurs in about 1-3% of BoNT-A treatment sessions. The rate of this complication appears to be about the same for Botox and Dysport, in expert hands.


Note that additional phrase in expert hands. Dysport is probably no more likely to cause ptosis than Botox if the health care provider is an expert with the use of Dysport. If he or she is just learning how to use the product, then all bets are off.


I have now been using Botox for 5 years and Dysport for 2 years. I have trained other physicians in the use of Dysport. So, I feel confident that I can call myself an expert on both products.


I dont think that Dysport truly spreads more than Botox, with my current technique. The only scientific study documenting an increased spread for Dysport relative to Botox examined sweating (which is also minimized by BoNT-A injections) rather than muscle activity, and the study was funded by the makers of Botox (who, of course, would want to discredit their competition). Moreover, in this study, the dilution of the Dysport was much greater than what I currently recommend.


Bottom line: Did the Dysport cause the ptosis because...?


Dysport is a poor product?Absolutely not!the injector is not an expert with Dysport (even if he/she is good with Botox)?Maybe.the injector used the wrong dilution of Dysport?Maybe.you are unlucky?Most likely.


Regardless, you seem fed up with both of the BoNT-As. I certainly would not try to convince you to get a treatment for which you lack confidence. However, I would reassure you that a future Botox/Dysport treatment remains unlikely to cause a repeat ptosis event (97-99%).


Also, more BoNT-As are about to be released. Merz Pharma already has FDA approval for Xeomins use for spastic muscle diseases; a cosmetic indication awaits an FDA verdict, which will, almost certainly, be positive. The Mentor Corporation is in clinical trials with Purtox, which also looks promising.


So, even if Botox and Dysport are not for you, Xeomin or Purtox might be. Im hoping that youll keep an open mind.


Sincerely,
Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

1746 S. Victoria Ave., #250, Ventura, CA 93003
(805) 654-8800 | fax (805) 654-8802

To: info@pickartplasticsurgery.com

clara

I just experienced eyelid ptosis after dysport. Had one prior experience with botox, no problem there. In your experience, how long will this last? I am using iopidine drops , but its effect lasts 2 or 3 hours. In your experience, what should I do and how long I will use the drop. Thanks...

Michael Pickart


Dear Clara,


I recommend using the iopidine drops every 8 hours for no more than 1 week. I am not an ophthalmologist, but I have been told by my eye colleagues that long-term use of iopidine (more than 1 week) can predispose a patient to glaucoma. So, definitely curtail your iopidine use soon.


Usually, droopiness (better known as ptosis) lasts just 2-3 weeks, even though the anti-wrinkle effect of Botox and Dysport lasts 3-6 months.


I am so sorry that you have had an unexpected outcome. Please remain patient. It will resolve. Promise!


Sincerely,
Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

1746 S. Victoria Ave., #250, Ventura, CA 93003
(805) 654-8800 | fax (805) 654-8802

To: info@pickartplasticsurgery.com

Angel

I had injection on july 7th and started suffering BAD headahes, and both eyes drooping on sunday. It is now wed and still no relief....I have only used Botox in the past and have had no problems til now.....Now im concerned that mayb my doc switched to Dysport and didnt tell me

Michael C. Pickart, M.D., F.A.C.S.

Dear Angel,

What a bummer! I am sorry that you have had an unfortunate side effect of treatment with Botulinum Neurotoxin Type-A (BoNT-A) (more commonly known as either Botox or Dysport). Ptosis (or drooping) of the upper eyelid occurs in about 1-3% of BoNT-A treatment sessions.

There has never been a head-to-head comparison of Botox to Dysport, so I don't know whether Dysport causes more ptosis than Botox. However, I think that the rate of this complication appears to be about the same for Botox and Dysport, in expert hands.

Note that additional phrase "in expert hands." Dysport is probably no more likely to cause ptosis than Botox if the health care provider is an expert with the use of Dysport. If he or she is just learning how to use the product, then all bets are off.

Please contact your doctor regarding your dissatisfaction. Ask him what he used? Was it Botox? Was it fresh? Was it reconstituted normally?

Unfortunately, ptosis can occur even amongst good doctors with the same Botox on loyal patients. It is a real bummer.

Also, I would like to reassure you that a future Botox/Dysport treatment remains unlikely to cause a repeat ptosis event (97-99%).

Sincerely,
Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

1746 S. Victoria Ave., #250, Ventura, CA 93003
(805) 654-8800 | fax (805) 654-8802

Deborah Hall

Have had Botox for glabellar furrows for many years with excellent outcomes. Had first Dysport treatment on August 25th. I could feel that the needle on the left seemed to be going in lower. Then on September 2 the left eyelid dropped. It has gotten worse since then. Saw the practitioner today. He prescribed the Iopidine drops. I feel quite certain that my ptosis resulted from too low a placement of the Dysport. The right side is fine. Nonetheless if I decide to do this procedure again I will go back to Botox.

Christine Mosley

I had Dysport treatment done on a cruise ship. A week later my eyelids are drooping and feel heavy. I tried to contact the Doctor on the ship and have not received a call or anything. I read online that exercise can cause this...Is that true? I have also started a body cleanse...would this cause it? Any information you could offer would be appreciated.

Michael C. Pickart, M.D., F.A.C.S.

Dear Ms. Mosley,

While it is impossible for me to diagnose and to treat you via email, I'm going to hazard a guess and a treatment plan....

1) You are likely suffering from "ptosis."

2) Usually, this droopiness lasts just 2-3 weeks, even though the anti-wrinkle effects of Dysport (and Botox and Xeomin) lasts 3-6 months.

3) Since ptosis is temporary, it can usually be mitigated by using iopidine drops every 8 hours--but for no more than 1-2 weeks. (I am not an ophthalmologist, but I have been told by my eye colleagues that long-term use of iopidine can predispose a patient to glaucoma.)

I am so sorry that you have had an unexpected outcome. Please find a local Board Certified Plastic Surgeon who can check you out and give you a proper evaluation. And then remain patient. I bet that your drooping will resolve.

Sincerely,
Mike Pickart

Angel

I've used Botox for a few years without any complications, but 7 days ago I was injected with Dysport.Three days after the treatment I woke up with incredibly swollen eyelids and blood shot red eyes. I am not allergic to anything that I know, and my ophthalmologist told me it looked like a reaction to toxic chemicals exposure. He prescribed eye drops and pills containing steroids. Also my voice sounds raspy and rough. Are this effects likely to be caused by Dysport? Either way I will never again inject poison into my face, it is similar to playing the Russian roulette.

Sharon

The instructions said to not lie down for 6 hours after injection. Could there be a connection between to the setting up and the drooping eyelid not appearing for several days? I'm afraid to sleep lying down. I also did not tell or was asked about medication I'm taking. I take prosom to fall asleep and get puffy eyelids from it. I use a warm cloth or cold tea bags that does reduce the puffiness. What are your thoughts on this? My first time with dysport, have never used Botox. I'm afraid to lay down and now at midnight I'm awake because I'm afraid to take sleeping pill.

The comments to this entry are closed.

Blog Design & Consulting by flyte new media