Ultrasound-guided preseptal hydrodissection with 5% dextrose in water for persistent botulinum toxin-associated ptosis: a technical protocol.

Background: Botulinum toxin type A (BoNT-A) injections for glabellar rhytides can rarely lead to persistent blepharoptosis. Current management, including observation and α-adrenergic agonists, is often temporary, highlighting a need for definitive minimally invasive interventions. Methods: This article presents a novel, systematic protocol for ultrasound-guided preseptal hydrodissection. The technique utilizes high-frequency ultrasound with color Doppler to access the sub-orbicularis plane superficial to the orbital septum, where 20 mL of 5% dextrose in water (D5W) is delivered as low-pressure irrigational hydrodissection to establish a confined fluid layer. Results: Application of this protocol in two patients with persistent BoNT-A ptosis refractory to conventional care resulted in progressive improvement. The Marginal Reflex Distance 1 (MRD1) increased from 0 to 4 mm in one patient and normalized in the other, with gains maintained at 3-6 months without additional treatment and no adverse events. Conclusion: This work standardizes a technical protocol for a potential adjunctive intervention in persistent BoNT-A-associated ptosis. The findings are descriptive and hypothesis-generating, positioning the technique for consideration only after standard measures fail. Prospective controlled trials are required to establish efficacy and safety.