Eyelid Drooping, Ptosis from Botox. What Can I Do to Fix the Problem?

Question

I had botox injected into my forhead about 2 weeks ago and now it seems that my right eyelid is not opening up as wide as my left. At first I was mortified and thought I had a seizure and developed a lazy eye but thank fully to internet research I found out that this could be ptosis and is a comman side effect of botox. The Dr only injected the top 1/3 of my forehead (torwards hairline) and I wanted to know if I go back to have between or above my brows injected, would it fix this issue?

Richard H. Tholen, MD, FACS · Answer

Aizza, I am sorry that you are having this problem, caused by inadvertent migration of Botox molecules to the eyelid elevators, or loss of tone of the brow and eyelid muscles. It will indeed wear off over time, but in the meantime, your injecting physician can prescribe one of several eyedrops that strengthen other eyelid elevator muscles and partially (hopefully near-completely) improve the eyelid droop.

Your description of the injection site near the hairline is an unusual cause for eyelid droop, and in your case may be due to the fact that your basic eyelid position is affected by your frontalis muscle tone. If you look closely at your photograph, the eye that is more "open" also has a brow that is "higher!" Perhaps a bit too much Botox in the right side has decreased your frontalis muscle tone asymmetrically, causing your right brow (and eyelid) to be positioned lower.

Thus, another (not really recommended, but one to consider if all else fails) possible trick would be to inject a bit more Botox on the left side to allow that brow and eyelid to drop as well. You might look tired or sad for a few months, but your brow and lids would match better. Then, get less Botox, regardless of location, next time!

Mark K. Markarian, MD, MSPH, FACS · Answer

Thank you for the picture.Before I discuss the etiology of eyelid droop after Botox and its treatment, I will say that it is highly unusual for eyelid drooping to occur if only the top third of your forehead was injected.   I would carefully evaluate the pre-injection pictures that your physician took before you received your injection.  If pictures were not taken, I would look at some of your own "close-up" pictures to carefully assess if your right eyelid isn't normally slightly lower than your left.  If, however, this is not the case and your eyelids were indeed even before you injected, read on...A droopy eye-LID may occur if the Botox is injected too close to your eyelid-elevating muscle, the levator palpebra superioris.  In such a scenario, the Botox will diffuse inadvertently onto the levator muscle and cause an eyelid droop. Typically, a lower dose diffuses onto the levator muscle and so the GOOD NEWS is that the eyelid droop will typically NOT last as long as the full Botox duration of 3-4 months. However, if the eyelid droop occurs shortly after injection (i.e. within 3-4 days), then your eyelid levator muscle likely received a significant dose of Botox and your eyelid droop may not resolve for 1-2 months...Apraclonidine (Iopidine) eye-drops for Botox-induced eye-LID droop can provide a small (2mm) improvement -- Apraclonidine 0.5, 1-2 drops, 3 times per day. Make sure you put in one drop at a time, tilt your head back, and close your eyes to make sure none of the eye-drop leaks out. Be sure your prescribing physician discusses all the potential side-effects of the drops, such as "adrenaline-like" symptoms like anxiety or heart pounding; you may also experience eye irritation, eye dryness, and eye pain, amongst other symptoms. If these symptoms occur, you will likely need to take some lubricating eye drops, lower the dose, switch the eye-drops, or stop the drops altogether...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.Dr Markarian

Harold J. Kaplan, MD · Answer

Hi aizza.  In looking at your picture, we do see that the right eyelid appears to cover more of the iris then the left.  With that said, we often see patients that have a slightly different lid elevation before they have any Botox injected.  We capture this in the "before" pictures.  Were any taken of you that you could reference back to?

	While it's certainly possible that the injections you received cause eyelid ptosis, it is more difficult to envision this if your MD was injecting only the top 1/3 of the forehead near the hairline.  We suggest going back for a visit to review the "before" photos.  If it does turn out the the injections caused this, the issue should resolve itself in a matter of about 6-8 weeks.  Hope this helps and good luck.

Mohammed F. Ahmad, MD · Answer

Hello Pizza,thank you for your question.  I am sorry that this occurred to you as this can happen from injection technique and/or high dose. 
This occurs mainly from injecting the glabella area past the mid pupillary line and migration of botox to the muscle that elevates the lid. Good news is this will not last very long but I would still recommend following up with your injector.

Monika Soni, MD · Answer

Thank you for your question! Eyelid droop can be corrected with a prescription eye drop (Iopidine 0.5%). This can help alleviate the droop within a few weeks to a month. You can also wait a couple of months for the effects of the Botox to wear off, at which point the droopiness will also go away. Best of luck!

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photograph aizza17. 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 pivotal studies used 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. 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.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.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 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.Please consult with a doctor for specific recommendations. Good luck!

Eric Rosenberger, MD · Answer

Apraclonidine 0.5% is a common prescription eyedrop used to treat ptosis caused by neuromodulator induced weakening of the eyelid elevator muscle. I recommend returning to your injector and seeking treatment/monitoring of this result. This effect will wear off with time, however, I would strongly advise AGAINST more botox to the glabella. You may make the situation worse and for a longer duration of time!
Thank you for sharing your photo and question.

Hardik Soni, MD · Answer

Eyelid droop can be corrected with a prescription eye drop (Iopidine 0.5%). This can help alleviate the droop within a few weeks to a month.You can also wait a couple of months for the effects of the Botox to wear off, at which point the droopiness will also go away.

Renato Saltz, MD · Answer

It usually improves after a couple of weeks, see your surgeon immediately for other options in treatment

Michael H. Gold, MD · Answer

Ptosis is an adverse event of having Botox or any toxin injection. Sometimes it occurs even with the mostskilled injectors. As much as we do not want to see it, this does in fact occur – but rare with experienced injectors. If you have ptosis, and no matter what the cause is, this ought to be treated. I always recommend going to a board-certified dermatologist or plastic surgeon’s office because we can prescribe eye drops that can be used to minimize the ptosis and help its course perhaps be shorter. The good thing to know is ptosis is not permanent and will go away over time, as the toxin will as well.

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