High‐Intensity Focused Ultrasound for Botulinum Toxin‐Induced Ptosis: A Retrospective Pilot Case Series

Background Botulinum toxin‐induced ptosis is a recognized complication of aesthetic injections that may adversely affect cosmetic outcomes and patient satisfaction. Pharmacologic management is limited and primarily aims to provide temporary elevation of the upper eyelid through stimulation of Müller's muscle. High‐intensity focused ultrasound (HIFU) has established applications in facial tissue tightening and may represent a potential non‐pharmacologic treatment option. Objective To evaluate the clinical outcomes of botulinum toxin‐induced ptosis treated with HIFU using the ULTRAcel Q+ system. Methods This retrospective pilot case series included five consecutive patients with botulinum toxin‐induced ptosis treated using a standardized HIFU protocol with the ULTRAcel Q+ system (3‐mm dot handpiece, energy level 0.7, 12 shots). Clinical outcomes were evaluated using standardized photographs obtained under controlled imaging conditions. Margin Reflex Distance 1 (MRD1), defined as the distance between the corneal light reflex and the upper eyelid margin in primary gaze. Eyebrow position was also evaluated by comparing brow height relative to the supraorbital rim and facial symmetry. Both were measured at baseline, immediately after treatment, and during follow‐up through Day 21. Results Five patients (4 females, 1 male; mean age 38.4 years) were included. All had received Dysport injections (130–150 units) to the glabella, forehead, and crow's feet regions. Ptosis onset occurred 3–7 days after injection. HIFU was performed 3–6 days after symptom onset. Mean MRD1 increased from 0.76 mm at baseline to 1.98 mm immediately after treatment, 2.30 mm at Day 7, 4.18 mm at Day 14, and 4.44 mm at Day 21. Three patients presented with isolated eyelid ptosis, whereas two had combined eyelid and eyebrow ptosis. All patients demonstrated complete clinical resolution by Day 14. Mild transient procedural pain occurred during treatment, and no long‐term treatment‐related adverse events were observed. Conclusion In this retrospective pilot case series, HIFU using the ULTRAcel Q+ system was associated with complete clinical resolution of botulinum toxin‐induced ptosis by Day 14 and was well tolerated. Unlike pharmacologic agents such as oxymetazoline, which temporarily elevate the eyelid through Müller's muscle stimulation, HIFU may act through a different mechanism involving tissue contraction and remodeling; however, the contribution of spontaneous recovery cannot be excluded. Larger prospective controlled studies are needed to determine efficacy and clarify the underlying mechanisms.