Can Botox cause facial muscles to weaken and then result in my face sagging?

Hi, over time can Botox cause weakening of facial muscles, which can cause the face to sag and lose elasticity? I'm worried about continuing having Botox if this is the case. I have hooding on my eyelids and this could potential cause my forehead muscles to be become weak. And having Botox around my eyes can cause cheeks to sag. Please advise as I'm not sure what to do.

Doctor Answers 14

Facial sagging due to Botox

Hi Butterfly1983:

This is a very perceptive and interesting question. Yes, Botox will relax muscles and allow complementary muscles to rebalance facial expression. The idea of this balance is to lift facial skin and not allow it to drop so the concern over Botox-muscle-relaxation causing skin laxity and loss of elasticity, I believe will not play out. 

Hypothetically, Botox could cause reduction in sebum production in oil glands of the skin and reduce the inflammatory response which tends to thicken the dermis and therefore keep it firmer or tighter. 

Skin elasticity and laxity are genetically and environmentally controlled. Retinoids such as tretinoin and retinol are used to stimulate the cells vitamin A receptors stimulating cell turnover and structural molecule formation to firm and tighten and thicken the skin. 

The skin and muscles of the face slide over each other with tethering filaments which allow the changes in muscle balance to relax or pull on the skin. With aging, this sliding continues downward and with less ligamentous tendrils to pull on the skin from the muscle, the skin and underlying soft tissues sag. 

Your concerns of overuse of Botox are unfounded. Continue with Botox to achieve the best muscle balance results you can and retinoids to firm and tighten your skin until the next "miracle cure" for aging comes along.

I hope this is helpful. All the best! 

Baltimore Plastic Surgeon
4.8 out of 5 stars 69 reviews

Botox can weaken muscles with repeated treatments.

You’re correct in thinking that BOTOX may cause your facial muscles to become weaker. Botox relaxes the facial muscles by inhibiting neurotransmitter function in the muscle tissue, preventing them from receiving electrical impulses and contracting normally. While this neurotransmitter function can be regained after a typical Botox treatment, many patients elect to have repeat procedures in the same area immediately after each other. This can, in some cases, cause the facial muscles to atrophy and lose some of their function. While this is certainly not a concern for most people, if you’re worried about this outcome, make sure you give your body enough chance to recover in between treatments.

No, BOTOX Reduces Sagging

Hi Butterfly1983. Questions about long-term use of BOTOX are common at my practice. BOTOX works by relaxing facial muscles, but that won't lead to sagging or the loss of elasticity. In fact, the opposite is true. The constant contraction of facial muscles causes our skin to move. Think of skin like a rubber band that is constantly being stretched and then relaxed. Ultimately, the rubber band begins to lose its elasticity. BOTOX helps minimize that stretching. The key is to have injections performed by an experienced specialist who understands facial anatomy. I hope this helps!

Susan M. Stuart, MD
San Diego Dermatologist
5.0 out of 5 stars 2 reviews

Can Botox cause facial muscles to weaken and then result in my face sagging?

Thank you for your question. In smaller muscles such as the muscles you have described, no. Botox will not cause sagging of the skin. Your best option would be to speak in person with an expert injector and discuss your problem areas.

All the best,

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 415 reviews


No, gravity and time cause the face to sag, not the muscles.  You will be fine and the Botox will continue to help decrease the fine which also cause signs of facial aging!

Mark T. Boschert, MD
Saint Louis Plastic Surgeon
4.9 out of 5 stars 17 reviews


Botox will not cause weakening and sagging of the muscles, only the process of aging can cause this.
Botox relaxes the muscles, softening fine lines and wrinkles.  The hooding of the eyelids can be lifted with
proper use of Botox, but as the Botox wears off, the same hooding reappears.
A proper consultation with a Board Certified Plastic Surgeon will help you decide whether Botox is enough,
or at some point, would an Endobrow Lift be advantageous.

Charles A. Wallace, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 4 reviews

Facial sagging is an age and gravity problem.

Provided you have an experienced individual perform your Botox injections, you'll see a pleasant improvement in lines and hyperactive muscles.

Muscles that provide vital support and elevation of the soft tissues of the face should NOT be injected/overinjected.  Even if that were to occur, the tissues will return to their "usual" position once the Botox wears off in 3-4 months.  At that point, you're really just experiencing the changes that are due to gravity and aging.

There are areas that we can inject that can see some temporary unfavorable sagging.  If your forehead is overinjected, you are correct to assume that your eyebrows could sag - again, this is less likely if you being treated by an experienced injector.  

Per your question regarding your cheeks and eyes, the usual muscles injected around the eye do not provide any elevation to the cheeks.  Provided the injection is done properly, that should be very unlikely to occur and would most certainly be a temporary event nonetheless.

Best of luck.


It is the opposite, Botox is used to decrease the action of specific muscles that create fold or wrinkles. There are many facial muscles that will pull down some facial structures like the brows and jaw line, and then give an older or tired look on a patient. By using Botox wisely, you can avoid sagging on your brows, or along the jawline and neck, preserving a youthful appearance.

Botox Vs Aging

Botox does not cause progressive weakening of muscles or sagging of soft-tissue. Botox only relaxes the wrinkle-causing muscles for a limited time. These muscles regenerate completely in a few weeks. Several people have been using Botox for years together.
But you must understand, that while you relax the muscle to eliminate the dynamic wrinkles, your facial soft tissues and skin continues to age. So the overall sagging that you may notice after a few years is more attributable to your aging, rather than Botox.

Milind Naik, MD
India Ophthalmologist
5.0 out of 5 stars 1 review

Botox and Aging

Botox doesnt cause the skin to worsen, if anything it improves the complexion due to improvement in oiliness.  The muscles can atrophy if you use it too much with too high does , which is why I do very conservative doses especially on the forehead.  Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.9 out of 5 stars 159 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.