I've Been Using Botox for Four Years Now and As I Look at my Eyes, They Seem to Look Smaller and Smaller. Why is This?

If you use your forehead to keep your eyebrows up and your eyelids open, paralyzing the forehead with botox can result in the upper eyelids appearing heavy or more hooded.  An experienced injector will look at your natural facial movements/structure and accommodate for this.  

Of note, you can also use botox to open the eye and bring the brow up.  This is done by injecting botox into the muscle around the eye, called obicularis oculi, near the outer edge of the eyebrow.

Without ever having Botox, the areas of the forehead which are tight and in a naturally-elevated position in our twenties, start to lower in our thirties and forties.  With this, the sling support of the eyebrow / upper eyelid complex weakens and we develop "hooding" of the upper eyelids which makes the eyes looks smaller.  When my patients first saw me when they were much younger and did not exhibit lowering of the upper eyelids they underwent forehead muscle Botox injections with good results. Now that they're 10 to 20 twenty years older, the aged forehead muscle has sagged and they can't undergo the same forehead treatment to smoothen out their horizontal creases.  The Botox can be injected in the glabella between the eyebrows to decrease the vertical frown lines and this helps to lift the forehead, but not enough to compensate for the drop that the Botox injections of the forehead would create. As we age, we need to use the forehead muscle to actively elevate the droopy upper eyelids.Some patients, who never have Botox need a surgical brow lift to lift the forhead so their eyes can open more again (they also may undergo a blepharoplasty).  Without the brow lift, some patients may get a non-surgical benefit of a brow lift from Ultherapy.

It would be very helpful to look at your pictures (and pictures of your eyes from years ago).  Most likely you are referring to the aging process as your brows descend over time, your eyes start to look heavy, your upper eyelids seem fuller.  But once again, without pictures, this is just a speculation.

Sincerely,
Martin Jugenburg, MD

Hi TO.  There is more than one explanation, but without photos it's difficult to say what is happening.  

One answer is that this is just part of the natural aging process.  As we age, gravity pulls our facial features downward.  This may be happening naturally with your brow, which puts more downward pressure on the lids, which can make the eye appear smaller - less of it is visible.  As we age, the skin on the upper eyelid becomes less elastic.  This excess tissue can also make your eyes appear smaller.

Alternatively, the ongoing Botox injections, because they can relax the forehead muscles, may have contributed to the facial structure being slightly lower.  This can have the same affect as the natural again process described above.  

Finally , if your injector is using too much Botox in the forehead, he could be dropping your brow with each injection.  Again, before and after pictures would help.  

It may be time to consider a Botox browlift, surgical browlift and/or blepharoplasty (eye surgery) as another option.

The frontalis muscle is the main elevator of the eyebrows.  BOTOX treatment in the forehead weakens this muscle.  This means the forehead relaxed and the eyebrow fall.  The upper eyelid fold gets heavier as this muscle relaxed.  

Botox, if injected in the wrong place, can cause temporary droopoing of the eyelids.  That will reverse as the botox wears off.  I suspect what you are seeing is a gradual descent of your upper eyelids and brows due to the aging process.  The treatment for that is surgical re-lifting of the brow ( brow lift) and sculpting of the eyelids (blepharoplasty).

Consider lifting eye brows and minimize dosage on forehead will help make the eyes look better.  Consider skin tightening (ThermiSmooth)  or surgery if eye is getting smaller due to excess skin. 

Overtreatment of the frontalis muscle in the forehead can cause brow heaviness and upper eyelid hooding that may appear to make the eyes look smaller.  Thoughtful placement of the Botox (using small amounts) in the forehead, glabella, and lateral brow, and lower eyelid can often "widen" the appearance of the eyes.  

Aging is a dynamic process.  Part of what you are describing may be due to volume loss.  Volumizing agents and/or fat may be able to address some of the changes you describe.

You probably are getting some descent from aging which is being exaggerated by the Botox lowering your brow a little. I suggest you reevaluate after the Botox has completely worn off. You may need a lid or brow procedure at this time.

You need to loo at the older pictures and compare them to pictures now. the eyes will age like other parts of the face. The best thing would be to get a consultation with a board certified plastic surgeon.