Droopy, Saggy, Swollen Eyelids from Botox Still Present 1 Month Post Injection- is This Permanent? (photo)

What you need is a different BOTOX injector.  The botox treatment you got paralyzed the frontalis muscle which is the main elevator of the forehead.  That in turn caused the brows to fall, bringing with it the sub brow fold.   When the botox wears off, the brows will return to their pretreatment levels and the upper eyelids will look much better.  Be aware that microdroplet BOTOX is an alternate method of doing periocular BOTOX treatment that actually lifts the eye brows and preserves forehead movement.  Properly done it could be done over your current treatment to improve the over all aesthetic result.  You can look up the method online to learn more.  Also please avoid coercive surgeons.  Please be aware that this treatment effect can last up to 4 to 6 months but it does wear off.

Thank you for the pictures -- it appears that you have drooping eye-BROWs that have resulted in skin gathering over the eyelid making the eyelid appear like it was drooping.  The eyelids, themselves, are not droopy however...The good news is that this is NOT likely to be permanent and should improve -- I would not recommend any surgery to correct this...A drooping eye-BROW may happen in the following scenarios:(1) When the brow-elevating muscle in the forehead, the Frontalis, receives too high a dose of Botox.(2) The Botox is sub-optimally placed too low in the forehead -- it should typically be placed at least 1 cm above the Brow. (3) Over-injection of the glabella area (between the brows). (4) It may also happen if you have a low set eyebrow to begin with, in which case any Botox to the Frontalis increases the likelihood of a brow droop. Ironically, a droopy eyebrow from Botox can sometimes be improved with MORE Botox -- this time injected into the outside (top of the crow's feet) part of the eye (the lateral aspect of the orbicularis oculi muscle) to generate a bit of a brow lift in that area -- by injecting more Botox and paralyzing the orbicularis muscle that normally acts to depress the brow in that area, you may get a slight compensatory brow lift...Please 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, how deep beneath the skin the actual muscle resides, 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, see the actual muscles themselves, and learn "first-hand" the incredible variability between patients -- live, "on the OR table" -- as opposed to via lectures or a cadaver dissection. For me, this helps guide where to inject and where not to. However, with that said, I know many non-aesthetic trained plastic surgeons and other physicians who know the anatomy well despite not operating in that area, and get good results.Good luck.Dr Markarian

Surgery for brow ptosis due to Botox is inappropriate.  Find a qualified surgeon.  The Botox will wear off and you will return to your normal self in a few months.  By experimentation, a skilled surgeon can find the location and dosage that will soften your wrinkles and minimize brow ptosis (droop).  You may well need lid surgery, but it should be judged off Botox not on it.

BOTOX® molecules attach to a nerve ending membrane.  They are then internalized into the cytoplasm of the nerve terminal. One molecule of Botox® then cuts one molecule of SNAP-25.  SNAP-25 is one of three molecules than must attach (docking) in order for acetylcholine to be released across the cell membrane to a muscle receptor for it to contract.

Imagine you have 10 SNAP-25 molecules in a glass.  You add ten Botox® molecules in the glass and all the SNAP-25 molecules will be cut.  Now imagine you put 100 Botox molecules in the glass of 10 SNAP-25 molecules.  You have now wasted 90 molecules of Botox®.  Some theorize that a single Botox molecule can continue to cleave more than one SNAP-25 molecule, which would be more wasteful.

At higher concentrations, cell-to-cell transfer of active Botox® has been demonstrated, which raises questions about the toxin affecting cellular targets that are distant from the injection site.

The objective is to use the least amount of Botox® that will cleave the SNAP-25 molecules in the treatment area and not overload the treatment area with wasted Botox.  Botox that may migrate to affect distant targets.

While Acetylcholine is blocked by Botox®, new nerve buds are forming.  If Botox® permanently blocked the treated nerve endings, new ones would simply grow and replace the non-functional ones.  Therefore claims, that one product is longer lasting than the others, or higher concentrations prolong the blockage, are highly suspect.  The objective is to use the least amount to do the job. 

In the early 90’s we experimented by trial and error.  We diluted a 100 unit bottle of Botox® with 10 cc of normal saline, yielding 10 units per cc which we injected using a 1cc syringe and a 30 gauge needle.  We videotaped our patients before and after for muscle function.  We decided to inject the muscle though and across muscle bellies, and across lines of innervation rather than poke them directly from above, to lessen the pain and bruising.   We observed that in over 90% of patients, 10 units of Botox® would paralyze the frown lines for over three months.  10 units of Botox® across the forehead would weaken the muscle to soften the wrinkles but avoid the “bowling ball” effect of complete loss of facial expression and forehead droop.  5 units on each side of the crow’s feet avoiding the lower lid would improve the area without lid ptosis.  We then adjusted for patients with greater or lesser degrees of muscle mass.  In five days we could evaluate the effects and adjust accordingly.  We were pioneering in those days and had to figure this out for ourselves when treatment for wrinkles was off-label.   It now seems we evolved our technique on one of the Galapagos Islands.

Botox® Cosmetic recommends reconstituting a 100 unit bottle with 2.5cc of 0.09% sterile non-preserved sodium chloride which would yield 40 units of Botox® per 1cc syringe.  

In our twenty-one year experience, this is four fold the effective dose.  It may also explain reports of effects and complications beyond the site of injection.  Advances in immunostaining techniques reveal active Botulinum A can migrate cell to cell in high concentration. (jneurosci.org/content/31/44/15650.full.pdf).   We have just scratched the surface of understanding Botox®.

Perhaps our technique improves the effectiveness of our dosages, but we had similar results with the more common stabbing technique, which we also tried.  We encourage intellectually curious colleagues to experiment and find the lowest possible dosage that saturates the nerve endings and accomplishes the mission without wasting molecules of Botox® that are yet to be fully understood and may migrate to sites beyond local injection as noted in the warning label.

YOu may not have a result you desire, but if caused by Botox it should revert to your normal and it will not be permanent. You might benefit by a smaller dose the next treatment.

Sometimes, more lift of the droopy eyebrows / upper eyelids can be accomplished by injecting more units of Botox in the glabellar depressor muscle sites. Other times, the maximum lift has been accomplished and you have to wait for the botox to wear off. the droopiness will correct itself but it can take three or more months. The arched eyebrows can be corrected by using one unit avoe the peak but this can lower the eyebrow too.

From what you describe and looking at your photo's, the number of units you had injected to the glabella region is not excessive, and you should go back to the original provider for further assessment. You're likely experiencing eyelid ptosis and this is treatable with a prescribed drop. Botox effects will wear off and without proper evaluation and information, considering surgery is not in your best interest.

Please be patient and wait for 2-3 more months.  Your eyelids will return to the way that they were before your injections.  

If the sagging truly started to bother you after your Botox injections, you can feel good by knowing that this is only temporary. The Botox will ware off within 2-4 months. I would not let any one propose or do surgery on your eyelids or forehead until Botox has completely warn off. 

21 units of Botox to treat the glabella and forehead is not excessive…but it all depends upon how it was placed. Just to clarify -- your eyelids are not swollen. What you are experiencing is drooping of your brow from too much Botox being placed in the forehead.

In fact, the most common complication following treatment of forehead lines is probably brow ptosis; the eyebrows droop and patients may feel a heavy brow or heaviness in their upper eyelids. This is a more common occurrence than it should be, and results from physicians not performing a thorough enough evaluation before deciding how much neurotoxin to use, and where to place it, in the forehead.

An experienced and conscientious injector should evaluate the appearance of your static forehead lines (at rest), your dynamic forehead lines (when you raise your eyebrows), the amount of brow ptosis present, and the eyebrow position at rest and with muscle contraction. The dose of neurotoxin used, and the placement of the injections, is based upon everything listed above. In middle aged or older patients, the forehead may be over-treated because the physician fails to consider the degree of brow ptosis. Brow ptosis is not common in younger individuals, so over-treating the forehead shouldn’t occur as frequently.

The muscle relaxation of all botulinum toxins is not permanent, and therefore your problem will slowly improve. If you have had Botox injections before, you know how long the results last, and that should give you some indication as to how this will resolve. If you have not had Botox before then you will be learning as you go. I suspect that within the next 2-4 weeks you will begin to see some slight improvement. The full effect will have resolved within 3-6 months; and the average duration of action for Botox is about 4 months. So, there is not need for you to consider surgery. In fact, I’m shocked by what you were told by your surgeon! I can’t even imagine why someone would say that.

It sounds as if the person who performed your Botox injections is not the same plastic surgeon you saw about your dissatisfaction with your results. If so, you may want to consider looking for a new more experienced injector….maybe consider a different plastic surgeon who is experienced with injections.

Best wishes, Ken Dembny

Hard to believe 21 units of BOTOX could cause upper eyelid edema??? A before photo would be very helpful. And I believe you had heavy uppers before the injections. Especially I see lateral edema or excess skin so I doubt the Botox was the problem but it made you aware of the issue by smoothing out the in between of your eyes. Maybe an in person consult might demonstrate that you might need an upper bleph. Or you can wait the 3 to 4 months for the Botox to wear off, you are already into month 2. 

You do not need surgery.  You just need to let the botox wear off.  It should start to get better fairly quickly since its been a month or so already.  You didn't even get a lot of units, but with your anatomy of heavy upper lids, you might want to stay away from botox on the forehead again since it accentuated that issue.