Three Botox Injections in Crows Feet Area, Bunny Lines and Under the Eyes

Question

I Now Have a Very Prominent tear trough on the left side where the ridge protrudes. I can only put it down to the botox. Can botox cause this and if so will it rectify itself as it wears off? The other tear trough is fine and Ive never had any issue with them before the botox. I also get slight tingling near the ridge.

Brent Moelleken, MD · Answer

Botox will relax the muscles where it is injected.

	If injected into the middle of the orbicularis muscles, this relaxes those muslces and can allow the cheek to descend.

	This can affect the outer eyelid-cheek junction (commonly) or the tear trough area (less frequently)

	This effect goes away with time.

Philip Solomon, MD, FRCS · Answer

I have occasionally seen this. In the few cases that ive seen the patients all had prominent tear troughs to start. In these cases we believed it was due to injecting laterally on the nose to correct bunny lines. Avoid bunny line injections or ask your injector to avoid lateral bunny line injection. I rarely inject botox under the eyes. This probably is best to avoid in your case. Review your pre treatment photos.

Ron Shelton, MD · Answer

No One can state unequivocally what happened to you without knowing the exact areas of insertion of Botox and examining your current condtion. However, if before the Botox you didn't have an asymmetric tear trough and now you do, without having had any fillers, then it may be related to some muscle relaxation of the infraorbital areas. If this is the case, it will go away by itself in three to four months. No Botox effect is permanent.

Harold J. Kaplan, MD · Answer

All good feedback from panel members as to possible causes and/or solutions.

	Most importantly, we recommend that you return to your practitioner to address and photograph your concerns.  A review of your photos prior to treatment will also indicate if your outcomes are directly related to your treatment.

	It may be helpful to consider the possibility of using dermal filler (ex: Restylane) in the tear trough depression to provide more symmetry and to add volume to camouflage what you are describing.

	We are very selective and conservative as to who is a candidate for under eye Botox injections as this area may lead to a negative outcome if there is skin laxity, fat bag, etc.

Kenneth D. Steinsapir, MD · Answer

Eliza Mae

	A photograph of your concerns would be very helpful.  In general, yes crowsfeet BOTOX injections can diffuse and have an effect on the appearance of the lower eyelid.  One of the surprising results occur when the treatment smooths the lateral lower eyelid wrinkles but leaves the inner lower eyelid muscles untreated.  Paradoxically, this can actually make the over all lower eyelid much more tired looking.  The treatment for this situation is just a time bit more of BOTOX in these inner eyelid wrinkles.

Martie Gidon, MD, FRCPC, FAAD · Answer

It is possible that this result was caused by the Botox injections. You should return to your injector for assessment. A small amount of Botox on the other side might be appropriate or just waiting a few months for the effect to wear off.

Emily Altman, MD · Answer

Botox injections can result in asymmetry of the lower eyelids with more descent on one side if either more units were injected or the muscle is somewhat weaker on one side.  The orbicularis oculi immediately below the lower eyelid margin requires 1-2 units of Botox for relaxation.  The bunny lines require about the same amount of Botox.

	In time this should resolve as the action of Botox wears off.

George J. Beraka, MD (retired) · Answer

Hi.

	We have seen this occasionally.  The good news is  the bad effect is usually gone in three or four months.  There is no treatment.

Francis R. Palmer, III, MD (retired) · Answer

No, I do not believe that the Botox injections to the Crow's Feet and "bunny lines" could have created your prominent tear troughs. You should stop all future Botox for 1 year and see if things change. IMHO, Botox is not meant to be placed into the lower eyelid muscle as this can cause drooping of the lower eyelid.

Kevin C. Smith, MD (retired) · Answer

I suppose it is possible that unequal relaxation [in particular of the levator labii superioris alaeque nasi = "LLSAN"] after treatment of bunny lines might affect tear troughs, in particular when the LLSAN is contracted. If this is the case, then a tiny bit more BOTOX&reg; on the stronger side might be all that is needed to restore the symmetry of your tear trough area.

	The best way to sort this out is by referring to pre-treatment photos, which ideally were shot relaxed and at full contraction, without flash, under symmetrical lighting by your doctor.

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