How can I avoid Botox Side Effects?

I read that Botox has some side effects like droopy eyelids. Is Botox safe?  Any tips for making sure my Botox (first time!) has no bad side effects?

Doctor Answers 141

Side effects result if Botox is not done properly

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Botox injections can cause side effects if not done properly. A good plastic surgeon will start with a lower dose and adjust the dosage to get the desired results. The skill part of injecting Botox is understanding the anatomy of the facials muscle, especially around the eye. It is also critical to inject the right amount of Botox in the right places to avoid side effects. If too much Botox was injected above your eyebrows or if some Botox migrates into the levator palpebrae muscle that elevates the upper eyelid, you will get a lid droop.

Your plastic surgeon should examine your eyes to determine if you have a compensated preexisting eyelid ptosis. In this case, Botox in the frontalis will reveal your eyelid ptosis. If there is no preexisting ptosis then Botox can cause paralysis of the levator palpebrae. 0.5% apraclonidine drops have been used to improve a Botox induced eyelid ptosis (~2 mm elevation) by contracting the Mueller muscle inside the eyelid.

If you are concerned about the possible side effects from Botox, I recommend that you consult with a Board Certified Plastic Surgeon for all plastic surgery on soft tissues around the eye. This includes Botox, Juvederm, Restylane, Eyelid surgery, Browlift and other surgical procedures. Board Certified Plastic Surgeons have over 2 years of comprehensive formal plastic surgery training on the aesthetics, anatomy and function of the soft tissue, muscles and bone around the eye.

Newport Beach Plastic Surgeon
4.9 out of 5 stars 50 reviews

Botox Safety

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Botox is pretty safe. Having said that, if injected by someone that is inexperienced, poor results can occur.  The droopy eyelid you are referring to is known as ptosis. This can occur for multiple reasons. To avoid ptosis, ensure that your injector stays at least 2cm outside of the orbital rim when injecting. Also, ensure that you do not massage the injected areas around your eyes. Similarly, take it easy after being treated with Botox. I tell my patients to avoid exercise the evening after being injected with Botox.  The reason for these precautions is to prevent the Botox injected around your eyes from descending and having an effect on the muscles that lift your upper eyelids.  If Botox comes in contact with these muscles, ptosis will result. 

Also, notify your physician if you are on any aminoglycoside medications, have a family history of neuromuscular or peripheral muscle disease, are pregnant, are lactating, or have a history of inflammatory skin conditions.

I hope this helps.


Asif Pirani, MD, FRCSC

Asif Pirani, MD, FRCS(C)
Toronto Plastic Surgeon
5.0 out of 5 stars 35 reviews

Botox Side Effects and Complications

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I agree with posters that the experience of the injector is critical to achieving good results in a consistent fashion, avoiding potential pitfalls.  Several things I encourage my patients to avoid after Botox: 1) avoid rubbing the treated area for 24 hours, 2) avoid facials, facial massage, Microdermabrasion for 24 hours after the procedure, 3) avoid aspirin, fish oil, excess vitamin e for 1 week before and 24 hours after the procedure.  From a technical perspective, use of Botox should be very conservative in the lower mid to lateral brow area to minimize risk of eyelid ptosis.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.9 out of 5 stars 103 reviews

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Keeping Botox Safe

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The most important factor in safety is choosing the right provider.  The provider is responsible not only for purchasing the genuine Botox Cosmetic product, but also for sterile technique, needle safety, and the proper preparation and dilution of Botox. The person you choose to perform your treatment should be an experienced aesthetic professional with proper training and a thorough understanding of facial anatomy, technique and the risks of treatment. I recommend that you avoid the Groupon offers and the so-called "bargain" Botox clinics. The small amount of money that you might save doesn't justify the risks imposed by an inexperienced or unqualified provider. I would also avoid any Medspa or clinic where the Medical Director is not onsite and fully engaged in training and oversight. Finally, I would be cautious with the"occasional" Botox injector, such as your dentist or gynecologist. Perfect Botox requires a dedication to the art and cannot be taught in a weekend course.

Brock Ridenour, MD
Saint Louis Facial Plastic Surgeon
5.0 out of 5 stars 126 reviews

There are a lot of ways to make Botox safe and avoid complications

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Botox can be done in a safe way to avoid problems. First off, diluting the botox with less solution can go a long way. I typically use only 2cc of botox where some other physicians use up to 4 cc of saline. When you use more saline, you end up needing more volume for the same number of units. What this means is that the more volume you use the more the botox will be spread out. When the botox is spread out, it can affect other muscles around the area and cause unwanted effects.

In your specific question, having droopy eyelids can occure when the botox reaches the muscle that lifts up your eyelid. With a smaller volume with the same amount of botox, the botox is less likely to reach that muscle. Also to avoid reaching that muscle its important to stay away from the eye or the orbital part of the eye. As you inject botox as it approaches the middle part of the eyebrow you need to move the injections further away from the eye.

Knowing where to inject makes a big difference as well. For the forehead, you don't want to inject the botox too low. When you inject too low it can lead to your eyebrows descending as well. I usually try to stay at least superior to the halfway point in terms of the height of the forehead. Consulting a person specializing in the face is always an important thing to consider.

Philip Young, MD
Bellevue Facial Plastic Surgeon

Botox Side Effects

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The most import decision regarding Botox is to go to a physician or injector with a long vast experience.  The quality of your result and possible side effects are a direct result of the technique used:  the dilution of saline to botox, direction of injection, and the anatomical areas injected.  Drooping of the eyelid (ptosis of the eyelid) occurs infrequently.  The cosmetic literature reports an incidence of around 1-2%.  In our experience this is reduced even further with newer injection techniques that use higher concentrations (1cc/100U Botox).  Ptosis is temporary and can be helped with eye drops prescribed by your physician.  

Best Wishes,

Neil Zemmel, MD

Botox is safe as ever

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The recent stir about the safety of Botox has nothing to do with the cosmetic use of the anti-wrinkle miracle drug. It is still as safe as ever to have a few of your wrinkles erased by Botox. We have used Botox over the past 30 years without any of these recent adverse effect reports.

The FDA is reviewing botulinium-based drugs used to treat cerebral palsy and other ills. There have been reported cases of breathing and swallowing problems in pediatric cerebral palsy patients, and even a reported death in a CP child who subsequently died of pneumonia. These patients are receiving Botox in doses that are many, many times larger than the small dose that is used for cosmetic treatments. Botox is used in these unfortunate CP patients to relieve muscle spasms in their legs, arms, and necks. Even the physicians who use Botox to help CP patients are saying that the overdoses are likely from injectors who don't know how much to use and are using the wrong dosing of the drug.

A few years ago there were unscrupulous labs and injectors who, respectively, manufactured and injected botulinium toxin that was for "experimental animal use only." Four people, including the injector, ended up in the ICU for many months. One must make sure that the Botox they use is from Allergan corporation, or from the company that manufactures Myobloc.

This news is a reminder that Botox is a potent drug and that injecting it is a medical procedure that should be performed by a board-certified physician in a medical setting, not in a salon, spa, hotel room, or friend's house.

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 39 reviews

Botox has excellent safety profile. Experienced injectors mean less bad outcomes

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Botox has an excellent safety record in terms of medical complications. The effect however, is designed to work in some areas and not others. Therefore, it's the experience and training of the injector that really leads to optimal results in terms of patient satisfaction. The number one concern seems to be eyelid drooping. In our practice, we boast ASOPRS-certification. This is the society of oculofacial plastic surgeons, that is surgeons who are double-trained in eye surgery and facial plastic surgery.

Therefore, the way that we use Botox around the eyes is extremely precise. There is a less-recognized issue of dry eyes following injection around the eyes. This, too is best evaluated by someone who understand the ocular surface, and we check all patients for dry eye findings and symptoms prior to injection. Other specialties are excellent at using Botox as well, but even if you choose to have a non-eye surgeon inject you, you may wish to have the eyes evaluated prior to injection to ensure the highest level of safety. This is the most beneficial advice I can offer in addition the excellent comments made by my colleagues.

David M. Mills, MD, FACS
Pensacola Oculoplastic Surgeon

Most side effects of Botox can be avoided with the right technique.

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The best way to avoid unwanted side effects from Botox is to visit a board-certified dermatologist who has experience performing Botox injections and knows how to precisely place the injections for the best effect, as well as how many units are appropriate. Most side effects of Botox can be avoided with the right technique.

Experience and training is key to avoid Botox side effects

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Botox has a better safety record than aspirin so it is very safe.

To avoid the potential side effect of droopy eyelids make sure your practitioner is well trained and experienced in the use of Botox. He/she should have performed hundreds (preferably thousands) of injections. Ask what training your practitioner has undergone and how often he/she updates their training with Allergan sponsored seminars.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
4.4 out of 5 stars 7 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.