What can be done to counteract brow drop after Botox? Day 9 post Botox for forehead, Glabella and crowsfeet. Day 3 brows dropped

Question

Severely hooded eyes, constant feeling of pressure in frozen forehead, can’t move left eyebrow & right eyebrow only a little at the tail. eyebrows now asymmetric, left even lower than right. plastic surgeon says she used very conservative amount as it was my first time. will see me in 2 weeks. can still frown between eyebrows so presume Glabella still active & only small difference in crows feet. Would injecting more in those areas potentially raise eyebrows or do I risk even more frozen face?

Stephen E. Small, DO · Answer

Hello. Keep in mind that it can take up to two weeks for the product to fully settle and for any swelling to diminish after getting BOTOX injections. For these reasons, it’s recommended that you wait at least two weeks before assessing your final results. If you’re still having trouble around the two-week mark, consult with your provider to discuss possible options. Unfortunately, BOTOX cannot be removed once it is injected, but in some cases, carefully adding more in the right places may be able to correct minor issues. Otherwise, the product will wear away on its own within 3 to 6 months. Hope this helps.

Jeffrey D. Hopkins, MD · Answer

It is reasonable to give the Botox a little bit more time to take effect to see the final results.  Unfortunately, there is no antidote for Botox.  The effects of the medication will probably wear off after 4-6 months.  I do not recommend injecting more Botox into the areas due to the risk of worsening the problem.  A minor brow lift procedure may be indicated if you had some droopy eyebrows to begin with, that were worsened by the Botox injection.  Hopefully, this response of the answer some your questions.  I wish you all the best.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question Pioneering1750. 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 in the absence of consistent photographs before and after in the same lighting and angles for comparison. However, I hope the information provided here is useful.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 two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary. 
When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.
Despite having a natural appearance when performed correctly, many people are afraid of the results of their Botox treatment, in particular before their first treatment, which is natural. In these cases, a lower dose can be used. For example, sometimes I use 10 units in the glabella region instead of the recommended 20 units. In these cases, I advise my patients that the full results will be seen approximately two weeks after the treatment and have them return at that time to take after photographs. At this point, more Botox can be added if further enhancement is desired. I find that when lower doses are used, patients do not enjoy their results for as long; six to eight weeks as compared to three to four months. Therefore maintenance treatments must be performed more frequently.
In addition to addressing various wrinkles, Botox can also be used to adjust the position and shape of the eyebrows. It works the same way as it does when addressing wrinkles, namely by relaxing muscles. In the upper forehead, there are muscles that move the eyebrows up and other muscles that move the eyebrows down. The muscle that moves the eyebrows up is on the upper forehead; this is called the frontalis muscle. It is responsible for the horizontal lines seen on the upper forehead when one raises the eyebrows. The muscles that pull down on the eyebrows are located between the eyebrows and at the corners of the eyebrows. The muscle group between the eyebrows is called the glabellar complex. There is another muscle that goes around the entire eye called the orbicularis oculi muscle. The portion of this muscle under the tail of the eyebrow is responsible for pulling down on the tail of the eyebrow. When any of these muscles is relaxes with Botox the position of the eyebrow can be adjusted. When treating the horizontal lines on the upper forehead seen when one raises the eyebrows, if the dose is too high or if the placement of the product is too low it can lead to the feeling of a heavy eyebrow, difficulty raising the eyebrow, or downward movement of the eyebrow. This can also lead to downward movement of the eyelids, making a person appear tired. It also can make it difficult to apply eye makeup. To correct this Botox is placed in the antagonistic muscles, those in the glabella and orbicularis oculi which pull down on the eyebrows. This will raise the position of the eyebrows. These two areas can be treated with Botox to provide a brow lift. To do so 4-20 units of Botox are used in the glabella between the eyebrows and 2-12 units of Botox per side are used at the tail of the brow and/or the entire crow’s feet region.
When Botox is used in the upper forehead, if the dose is too high or the placement is too low it can result in the feeling of heaviness in the eyebrow or even lower the position of the brow. In order to reduce the risk of this possibility, I use a conservative dose in the area and place the product high on the forehead, sometimes near the hair line. Additionally, I recommend that my patients simultaneously receive a small amount Botox between the brows and at the corners of the brows. This will relax the muscles that pull down on the brows to counteract this effect and provide a harmonious balance to the position of the brow. The results are assessed two weeks after the treatment. If there is any asymmetry a small amount of Botox can be placed in the upper face for correction.
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 carefully follow the simple aftercare instructions described below. This may be a reason for the low incidence of side effects in my practice.
If I had a patient with the concern described here I would want to see the before and after photographs. I would also recommend waiting two weeks to see the final results. Patience is important. At that time additional units may be added depending on what it looks like.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!

What can be done to counteract brow drop after Botox? Day 9 post Botox for forehead, Glabella and crowsfeet. Day 3 brows dropped

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What can be done to counteract brow drop after Botox? Day 9 post Botox for forehead, Glabella and crowsfeet. Day 3 brows dropped

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