Inconsistently Drooping Eyelids After Botox

Dear Regina,

Your transient eyelid droop may be from Botox injected over the area of the eyebrow that is important for elevation of the eyelid itself.  Although we can inject Botox or any neuromodulator to the lateral part of the eyebrow (the tail of the eyebrow) to produce an eyebrow lift, it is important not to inject directly over the midportion of the eyebrow as this can lead to a droop.  Since your droop is transient, it is likely that you are consciously or unconsciously compensating for the lid droop by recruiting other facial musculature.  When done correctly, a "Botox Browlift" should appear like the picture on my before and after gallery and can provide several millimeters of lift.  

 

With regards,

Kian Karimi MD

 

 

 

Most likely what is happening is that some of the Botox is drifting into the eyelid muscles,  in addition to the forehead muscles.  The forehead  is composed of both elevator and depressor muscles  which function to raise and lower the eyebrows.  Placing Botox in the forehead is always a dynamic balancing act

Hi Regina
First your loyalty to this doctor is commendable.
In evaluating your photo, I assume this is the after treatment position of the eyelid. You don't comment if this is the eyelid position at its worst but for sake of discussion here, lets assume it is. The photo demonstrates and overly elevated eyebrow. The upper eyelid fold is thin and rests low on the eyelid platform but does not rest on the eyelashes. The upper eyelid margin (portion of the eyelid with the eyelashes) also rest low on the eyelid and this effect is particularly pronounces laterally.
The before photo would have been extremely helpful to analyze what is going on. First the time frame of 4 days to develop lid drop after BOTOX is well described. Usually it is noted within the first 3 to 6 days. Upper eyelid ptosis with some of the so-call browlift techniques can be seen in up to 10% of cases. This is related to how you doctor is placing the BOTOX which is permitting some quantity of BOTOX to drift into the eyelid. The quantity is not great or you would not be able to open the eye whatsoever. However, the droop is bad enough that despite whatever forehead treatment you have had, you are intensely activating your forehead muscles to compensate for the fall in the upper eyelid.
The picture suggests to me the the orbicularis oculi muscle in the upper eyelid has also been weakened as this skin appears to have a type of crepey texture related to mild neuroparalytic weakening of this muscle.
In analyzing cases like yours, I have found that it is associated with injections of fairly large aliquots of BOTOX place low and deep along the orbital rim. If you get your entire treatment done with less than 10 shots of BOTOX by the doctor, this would be consistent with the size of aliquots associated with this complication. By way of comparison, when I treat this area with my patent pending MicrodropletTM BOTOX method, I may use 100 tiny BOTOX injections placed very superficially to trap the BOTOX between the skin and the muscle of facial expression that inserts into the skin (check out lidlift.com for more information about this technique).
The fact that your treatment is not completely dropping the upper eyelid for an extended period of time, means that the doctor has so far avoided inserting the needle behind the orbital septum. However, BOTOX is drifting low into the upper eyelid weakening the orbicularis oculi muscle and at the eyelid crease there is enough diffusion to slightly weaken the muscle that opens the eye.
Your ptosis is not severe but if it bothers you enough, ask your doctor for a prescription of Iopodine which is used twice a day and will help lift the eyelid. If the drops are initially effective, then it is unlikely that the lid droop will last more than 6 weeks. I would encourage you to have your doctor read this email and see if you can persuade him to change his technique. It is improbable that you are his only patient with this problem. However, most BOTOX patients would not go back to a doctor who causes this type of problem so he may be unaware that he is causing the issue.