Under eye and cheek drop after Botox in crow's feet; permanent or temporary? (photos)

Question

I just had 7 units of Botox injected in the crow's feet area, for the first time. 6 days later, I developed the "chipmunk" effect in the apple of the cheek upon smiling. More concerning, I have about 1cm drop under my eyes, and upper cheek. The natural volume loss and dark circles I had prior now look worse. A lot of patients online reported the same effects, claiming they became permanent and that Botox caused actual volume loss at the top of cheek and under the eyes. Thoughts/opinions? Thanks.

Jason Emer, MD · Answer

Botox results last up to 3 to 4 months and can be softened with Venus Legacy and Thermage treatments. If you're still experiencing the same issues after 3-4 mos, I would recommend getting a formal evaluation with an experienced cosmetic dermatologist. Best, Dr. Emer

N. Bill Aydin, MD · Answer

Thank you for your question, notideal. Luckily Botox only lasts around 3-4 months. After that time your under eye and cheek area should improve. Good luck!

Camille Cash, MD · Answer

I'm sorry you are having issues after your Botox treatment.  If Botox is injected too low when treating crow's feet the cheek drop or "shelf" appearance can occur.  Botox effects are not permanent.  The product effects will gradually wear off over three to four months on average.  I've included a video about neuromodulators that I hope you find helpful.

Center for Aesthetics and Plastic Surgery - Grand Rapids · Answer

Hello there! Botox is not permanent, and everything should return to normal within 3-4 months. What you are seeing is probably due to the muscle-relaxing affect of the neurotoxin.  Good luck! Sarah RN BSN

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photographs notideal. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.
It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.The pivotal studies used 24 units of Botox (12 units per side) to address the crow’s feet. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary. 
Some people have a deficit under the eyes due to loss of or downward movement of the fat pad in the tear trough area. In some cases, the muscle around the eyes serves to hold up the upper cheek fat pad. If this muscle is relaxed with Botox (as it is when addressing crow's feet), this volume deficit can be exaggerated. In these cases, restoring the lost volume with fillers such as Volbella or Vollure under the eyes or Voluma in the cheeks can correct the deficit.
If I had a patient with the concern described here I would say that this side effect will resolve in three to four months and that it is not permanent. Patience is important. Also, this patient may benefit from filler treatment in the upper cheeks or tear trough area.With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.
  
After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.
  
Please consult with a doctor for specific recommendations. Good luck!

Robert J. Paresi Jr., MD, MPH · Answer

Thanks for the question.  Botox only lasts 3-4 months so the effects are temporary.    You should be back to normal in that time period.

Anteneh Roba, MD · Answer

You do not have to worry about any permanent changes after Botox injections. Botox effects are gone within 3-4 months.

Horizon Plastic Surgery · Answer

Hello,
The side effect you are describing tends to be caused from having the toxin injected lower than the lateral canthus of the eye. It is generally recommended to have minimum amounts injected here as it can paralyse the muscles in areas of the cheek giving a "shelving" appearance. This is only temporary and should only last a short time. Don't worry!
Regards,
Sophia RN

Kristine Brecht, MD (license suspended) · Answer

Dear Chicago,Thank fully in your case Botox typically lasts 2.5-4 months. Swelling from the actual Botox mixing fluid may often last a couple weeks.Try massaging of the swelling area to help mobilize the fluid.Best. Dr Brecht

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