Droopy Eyebrows and Puffiness After Botox

Question

I was injected with Botox 4 days ago and noticed puffiness and slight drooping 2 days later. Now, it becomes worse and worse each day. My upperlids are very puffy and hang over my lower lids. I have little to no movement of brows and have lost the natural arch and sit low over my eyes. I have increasing headaches and large bags under the eyes which I never had before. Any remedies to speed recovery? How long can drooping eyebrows last?

Mark K. Markarian, MD, MSPH, FACS · Answer

The good news is that what you are experiencing is NOT likely to be permanent and your face should improve to its pre-injection state.With that said, let us discuss these three rare, but known complications of Botox that you are experiencing.(1) Headaches -- as discussed by my colleagues below, Botox is sometimes used to treat migraine headaches, yet can cause some headaches as well.  Please be seen by your primary care physician or a Neurologist for some long-term treatment, as you headaches, if truly recalcitrant to treatment, may last as long as the full duration of the Botox -- 3-4 months.(2) A drooping eye-BROW may happen in the following scenarios:-- When the brow-elevating muscle in the forehead, the Frontalis, receives too high a dose of Botox.-- The Botox is sub-optimally placed too low in the forehead -- it should typically be placed at least 1 cm above the Brow. -- Over-injection of the glabella area (between the brows). -- It may also happen if you have a low set eyebrow to begin with, in which case any Botox to the Frontalis increases the likelihood of a brow droop. Ironically, a droopy eye-BROW from Botox can sometimes be improved with MORE Botox -- this time, the Botox is typically injected into the outside (top of the crow's feet) part of the eye (aka the lateral aspect of the orbicularis oculi muscle) to generate a bit of a brow lift in that area -- by injecting more Botox and paralyzing the orbicularis muscle that normally acts to depress the brow in that area, you may get a slight compensatory brow lift...If the extra Botox does not improve the brow droop, it will likely last as long as the full duration of the Botox -- 3-4 months.(3) A droopy upper eye-LID may occur if the Botox is injected too close to your eyelid-elevating muscle, the levator palpebra superioris. In such a scenario, the Botox will diffuse inadvertently onto the levator muscle and cause an eyelid droop. Typically, a lower dose diffuses onto the levator muscle and so the other good news is that the eyelid droop will typically NOT last as long as the full Botox duration of 3-4 months, and may in fact resolve in less than a month. Note however that if the eyelid droop occurs shortly after injection (i.e. within 3-4 days), then your eyelid levator muscle likely received a significant dose of Botox and your eyelid droop may not resolve for 1-2 months...You may have an increased risk of eye-LID drooping if you have a weakened upper eyelid muscle for neurological reasons, or a deeply set eye-BROW that would be more prone to drooping and result in skin gathering over the eyelid making the eyelid appear like it was drooping. A droopy eye-LID due to Botox can be treated with Apraclonidine eye-drops which can provide a small (2mm) improvement -- Apraclonidine 0.5, 1-2 drops, 3 times per day. Make sure you put in one drop at a time, tilt your head back, and close your eyes to make sure none of the eye-drop leaks out. Be sure your prescribing physician discusses all the potential side-effects of the drops, such as "adrenaline-like" symptoms like anxiety or heart pounding; you may also experience eye irritation, eye dryness, and eye pain, amongst other symptoms. If these symptoms occur, you will likely need to take some lubricating eye drops, lower the dose, switch the eye-drops, or stop the drops altogether...Again, please seek the services of an experienced physician injector. I think the key with Botox lies in truly understanding the anatomy of the injected area, and more importantly the variability in the anatomy between patients -- for brows, the forehead, and anywhere else you plan on receiving a Botox injection. This includes having a firm understanding of the origin, insertion, and action of each muscle that will be injected, the thickness of each muscle targeted, how deep beneath the skin the actual muscle resides, and the patient variability therein. As an aesthetic-trained plastic surgeon, I am intrinsically biased since I operate in the area for browlifts and facelifts, and have a unique perspective to the muscle anatomy since I commonly dissect under the skin, see the actual muscles themselves, and learn "first-hand" the incredible variability between patients -- live, "on the OR table" -- as opposed to via lectures or a cadaver dissection. For me, this helps guide where to inject and where not to. However, with that said, I know many non-aesthetic trained plastic surgeons and other physicians who know the anatomy well despite not operating in that area, and get good results.Good luck.Dr Markarian

Otto Joseph Placik, MD · Answer

I would recommend that you contact your injecting physician and notify him or her of your results. They would certainly want to know as this sounds very unusual. Occasionally, this response may be more pronounced the first time that you have Botox injected but the severity of your response is greater than would be expected.

Arnold R. Oppenheim, MD (retired) · Answer

This sounds as if you have had some really bad luck. Most patients who have a problem after Botox have a single problem but it looks like you developed three. This will take some perseverence on your part but I assure you that there is a light at the end of this tunnel.
   First, headaches ironically can occur with Botox. I say ironically because it is a remedy for headaches and I have a number of patients who tell me that their recalciatrant headaches resolved following Botox treatments. If your headaches persist, however, you best see your family physician or a neurologist. 
  Your droopy lids or double quaz ( eyelid ptosis) resulted from the Botox leaking into the Levator Palpebrae muscles. These are the muscles that lift your eyelids up. Iodipine drops can activate a muscle ( Muller's) that will help lift your lids. Visine will also help with this problem. At any rate this situation should last about 4-6 weeks, but could last longer depending on the number of units that were placed and how close to the affected muscles the injections were done.
   Brow drop ( ptosis) is less easily remedied though the appearance in not as drastic as the dreaded quaz. Your physician can inject the glabellar area, and sometimes the lateral brow, depending on the location of the brow drop. Obviously, this should be done gingerly ( and frankly probably  by a more experienced physician) in light of your other problem. These injections will help, but you probably will have to wait this out. 
   Don't give up on Botox. As I said it is very unusual to have all three problems at once.

Droopy Eyebrows and Puffiness After Botox

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