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.

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