Diab N, Bou Farah E, Berjawi A, Ghorayeb T, Beydoun K, Ghanem S, Hamou A, Tarchichi A, Tlaiss Y. Methodology for preventing Botulinum toxin-A eyelid ptosis: Risk index derivation, safety rules, and evidence-graded management algorithm. World J Methodol 2026; 16(3): 116523 [DOI: 10.5662/wjm.116523]
Corresponding Author of This Article
Yehya Tlaiss, MD, Department of Ophthalmology, University of Balamand, Hazmieh, Beirut 1100, Beyrouth, Lebanon. yehyatlaiss@hotmail.com
Research Domain of This Article
Methodology
Article-Type of This Article
review-article
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Diab N, Bou Farah E, Berjawi A, Ghorayeb T, Beydoun K, Ghanem S, Hamou A, Tarchichi A, Tlaiss Y. Methodology for preventing Botulinum toxin-A eyelid ptosis: Risk index derivation, safety rules, and evidence-graded management algorithm. World J Methodol 2026; 16(3): 116523 [DOI: 10.5662/wjm.116523]
Nadira Diab, Elie Bou Farah, Amira Hamou, Department of Dermatology, University of Balamand, Beirut 1100, Beyrouth, Lebanon
Ahmad Berjawi, Safaa Ghanem, Department of Dermatology, Clémenceau Medical Center, Beirut 1100, Beyrouth, Lebanon
Tasha Ghorayeb, Karen Beydoun, Department of Dermatology, Saint Georges University of Beirut, Beirut 1100, Beyrouth, Lebanon
Alaa Tarchichi, Yehya Tlaiss, Department of Ophthalmology, University of Balamand, Beirut 1100, Beyrouth, Lebanon
Author contributions: Diab N, Bou Farah E, Beydoun K, and Hamou A contributed to investigation; Diab N and Bou Farah E contributed to data curation; Diab N, Bou Farah E, Berjawi A, Beydoun K, Ghanem S, Hamou A, Tarchichi A, and Tlaiss Y edited and reviewed the manuscript; Ghorayeb T and Hamou A contributed to original manuscript draft; Berjawi A contributed to formal analysis; Berjawi A, Ghanem S, and Tlaiss Y contributed to methodology; Ghorayeb T, Tarchichi A, Ghanem S contributed to visualization; Beydoun K contributed to validation; Tarchichi A and Tlaiss Y contributed to supervision; Tlaiss Y contributed to conceptualization. All authors reviewed and approved the final manuscript.
AI contribution statement: Grammarly was used only for limited translation support and minor editorial grammar correction. No images were AI-generated. However, Adobe AI-assisted features may have been used only for figure enhancement/formatting purposes and not for generation, manipulation of scientific content, or creation of novel image elements. We confirm that all intellectual content, scientific reasoning, methodology development, and conclusions are solely the work of the authors. The limited use of AI-assisted tools was restricted to translation/language editing and non-substantive figure enhancement.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Yehya Tlaiss, MD, Department of Ophthalmology, University of Balamand, Hazmieh, Beirut 1100, Beyrouth, Lebanon. yehyatlaiss@hotmail.com
Received: November 13, 2025 Revised: December 14, 2025 Accepted: January 23, 2026 Published online: September 20, 2026 Processing time: 239 Days and 11.2 Hours
Abstract
Eyelid ptosis after cosmetic use of Botulinum toxin A, though uncommon, can impair function and patient satisfaction. We aimed to develop a methodological framework that standardizes prevention and management via a derivation-based risk index, explicit safety rules, and an evidence-graded, onset-anchored treatment algorithm. We conducted a structured scoping approach to map existing evidence and anatomical insights, then used consensus-style item generation to derive a practical risk index and codify ten safety rules. Treatments were organized into an onset-anchored algorithm with indicative effect windows and contraindications. The framework introduces a Levator Diffusion Risk Index combining anatomical, technical, and patient factors; a codified ten-rule injection protocol specifying distances, depths, dilution, and needle orientation; and a graded management algorithm for symptomatic ptosis. A standardized, reproducible methodology - risk stratification, measurable technique rules, and a graded treatment pathway - can reduce complication rates and harmonize reporting and care.
Core Tip: We propose a methods-first framework to prevent and manage Botulinum toxin A–related eyelid ptosis. Using an evidence-mapped scoping synthesis, we derive the Levator Diffusion Risk Index to stratify diffusion risk, codify ten measurable injection safety rules (distance, plane, volume/dilution, and needle vector), and provide an evidence-graded, symptom-onset–anchored management algorithm with effect windows and contraindications. A minimum reporting checklist is included to standardize outcomes and enable prospective validation.
