Drooping Eyebrow After Botox

Dear Dermaqueen
It is my experience that the effects of BOTOX begin to be evident at 2 to 3 days but are not at their maximal effect until about three weeks after treatment. Then the effect is sustained for about 3 months and then begins to rapidly diminish. Unwanted side effects may not persist nearly this long because generally, these are typically caused by only a tiny fraction of the total treatment.
However, brow drop is a 100% predictable result of injecting BOTOX into the forehead. The muscle up there makes the forehead lines but also lifts and supports the eyebrows. The position of the eyebrow is determined by a tug of war between the brow elevators and the eyebrow depressors. I actually due a treatment I call MicrodropletTM BOTOX where I extensively only treat the eyebrow depressors. My technique allows me very precise control over the placement of the BOTOX. By just treating the eyebrow depressors and leaving the forehead lifter alone, a significant, naturally looking lift in the eyebrows results. I am applying for a patent for this method.
As your treatment sets in the asymmetry may or may not persist. Your doctor can adjust the asymmetry with a little more BOTOX in the forehead. The doctor is welcome to review my technique but should be careful of using it on you. The treatment method is often counter intuitive to doctors who are use to paralyzing things and are uncomfortable with using small doses of BOTOX to balance things.

Hi DQ.  A droopy brow is one of the side effects of Botox injections.  Although it does not happen often for experienced injectors, it can happen when the solution migrates from the muscle group that the drug is intended to relax to an adjacent muscle group.  With eyebrow droop, we can sometimes fix it if we relax the crows feet but it seems you had that done at a previous injection.  You should visit your injector for feedback, but you may have to wait 1-2 months for the area to improve. 

Eyebrow drooping after neuromodulators like Botox, Dysport or Xeomin is a rare but well described issue, usually resulting from product placement or the amount used. 
The first thing that needs to be determined is whether it is a droopy eyebrow or a droopy eyelid. Droopy eyebrows are much more common and result from over-immobilizing the only muscle on the forehead that is able to lift up our eyebrows - choosing the right amount and placement in the right patient is key to good forehead results. Droopy eyelids come from the product getting into the wrong muscle that elevates the eyelid. 
Management of them is quite different, but both have strategies to help expedite resolution while waiting for them to resolve with time, and any experience injector should be very familiar with how to deal with them: drops for the eyelids and precise placement of Botox in the brow depressors when it is an eyebrow issue. 
To ensure you are receiving the highest level of care, seek out a modernly trained, new-school dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these "core four" cosmetic specialties. Membership in organizations like the American Academy of Facial Plastic and Reconstructive Surgery help to identify a highly trained surgeon.
Cameron Chesnut#realself500 Physician

So, the good news is that Botox is NOT permanent and although the full effects of Botox typically last 3-4 months, muscles that are inadvertently affected (as in your case) typically receive less of a dose and I predict your brow will likely return sooner to its pre-injection state...The key is what do now…A droopy eye-BROW from Botox can sometimes be improved with Botox injected into the outside part of the eye (the lateral aspect of the orbicularis oculi muscle) to generate a bit of a brow lift in that area – by paralyzing the orbicularis muscle that normally acts to depress the brow, you may get a slight compensatory brow lift with Botox to that area.  In the future, be sure to 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, 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 and see the actual muscles themselves. For me, this helps guide where to inject and where not to. However, with that said, I know many Dermatologists who know the anatomy well despite not operating in that area, and get great results.Good luck.

One of the risks of botox treatment is that muscles other than those targeted can be affected by the treatment. That risk is less likely when your treatment is performed by an experienced doctor. Botox treatment's effects are temporary. Because non-targeted muscles do not receive the full dose of your botox treatment, the effects in non-targeted muscles typically resolve well before the effects in targeted muscles. There is no way to immediately reverse the effects of botox. In some cases, unintended asymmetry may be amenable to improvement by performing a touch up treatment on the other side. Always discuss your concerns with your doctor. Good luck.

Notify your doctor but do nothing for two weeks.
I have seen Botox over correct for the first two weeks and settle down after that.
If after two weeks your eyebrow still droops there are a few options:

If your eyelid is also drooping, there are eye drops (one is alphagan) which can stimulate the eyelid to elevate but this will not effect the eyebrow.
If your eyebrow still droops, injection of Botox below the tail of the eyebrow may ease the depressor effects for the orbicularis oculi
Alternatively, you may choose to lower the opposite eyebrow to make them more even.

Hi Dermaqueen,
Drooping eyebrow after Botox is not correctable with more Botox. Wait 7 to 10 days and return to your physician for evaluation. Usually the brows recovery within a few weeks.
Please take a swim for me in those beautiful South Beach waters.
Good luck and be well.
Dr. P

Dear dermaqueen,
Botox injected into the frontalis muscle to treat forehead lines can cause the eyebrows to droop. You can see the maximal effect of the Botox typically at around 2 weeks after the injections and then the effect fades over time. I would recommend waiting until around the 2 week mark to see what the result is from the injections. Sometimes, the eyebrow can be raised slightly by injecting the orbicularis muscle by the lateral brow or the corrugator muscle by the glabella. If your biggest concern is the asymmetry between the two brows, the left brow can be lowered slightly with injections to the frontalis forehead muscle to match the right brow more closely as well. 
Best,
Dr. Liu

Thank you for your question dermaqueen. I am sorry to hear about your situation and 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. The appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines. 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 2 weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary.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 2 weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take 2 weeks for full resolution. I recommend that my patients apply cold compresses such as ice packs and sleep on an extra pillow if not uncomfortable to reduce swelling.In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Most importantly are muscles required to perform various functions. The muscles that are treated with Botox around the eyes are close to the muscle that lifts the upper eyelid. If this muscle is affected it can lead to a temporary droopy eyelid (blepharoptosis). The duration depends on the placement of the product and the dose used. Usually it resolves in 2 weeks, but it can last up to 4 months. Blepharoptosis can be treated with apraclonidine 0.5% ophthalmic solution (also known as iopidine) and various other medications. For my patients, I recommend 2-3 drops to the affected eye 2-3 times per day. When the blepharoptosis begins to wear off patients notice less of a droop when waking up in the morning after the last dose of apraclonidine has worn off. The incidence of blepharoptosis is reported to be approximately 1% but in my experience, I find it to be about 0.1%. This is likely due to the fact that when these studies were initially performed injectors may have not been as aware of this adverse effect nor been taking extra precautions to avoid it.Blepharoptosis occurs when Botox is placed near the eye and it diffuses to the muscle that lifts the upper eyelid (levator palpebrae superioris). This is located inside of the orbital rim above the globe. To avoid this side effect, I place the product at least 1 cm from the orbital rim. When placing product between the brows I pinch the area to be treated and lift it so that the product is placed in the muscle and is less likely to diffuse around the bone into the orbital space. Diffusion into this area may also be caused by other preventable things. For this reason, I recommend that my patients follow the aftercare instructions below. This may be a reason for the low incidence of side effects in my practice. I encourage my patients to contact our office and return for a follow up visit with any questions or concerns. In addition to such treatment Botox can be placed in the corners of the brows. This will relax the muscle that pulls down on the brow, allowing for a slight elevation of the brow. Sometimes this also helps pull up on the lid and can address blepharoptosis.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 4 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 as described above. 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.Botox is what we call a neuromodulator. This means that it controls nerves to prevent the muscles from contracting. Botox is the most popular neuromodulator available, has been the most studied, and is cleared for the most number of indications. Other neuromodulators available in the United States include Dysport, Xeomin, and Mybloc. Overseas many others are also available. Each product has slight differences, but all of them work. The majority of our patients find that they like the results of Botox the best. Additionally, Allergan, the maker of Botox, offers the Brilliant Distinctions Program. This is a rewards program where patients receive points from their Botox treatments which can be used toward discounts at subsequent treatments. Points are also received when patients purchase other treatments in the Allergan portfolio including Juvederm Ultra, Juvederm Ultra Plus, Voluma, Volbella, Vollure, and Kybella or products such as Latisse or Skin Medica products.I find that combining Botox with other treatments or skin care regimens enhances the results and allows patients to enjoy their results for longer. One specific topical product our patients have found to be outstanding in conjunction with a Botox (and filler) treatment is our Hydrating Serum, which contains hyaluronic acid. Hyaluronic acid draws water into the skin and helps to fill in fine lines and wrinkles.Please consult with a doctor for specific recommendations. Good luck!

Thank you for your question.
In my opinion, it is still early to tell how the final outcome is going to be. You had Botox injected 1 day prior to your symptoms, so it is very early to tell how your brows will settle. I recommend that you follow with your surgeon in a 2 week period as the effect would maximal by then. At that point your surgeon will perform a touch up if need be.
I hope this helps. Best wishes.