Is this eyelid or eyebrow ptosis or Botox? 2 months after Botox (photo)

Question

see before wnd after pictures. It has been two months since botox. 4 units for both sides for browlift. One week later my eyes got that sleepy look (one looked even worse the first month). lately i am not seeing improvement and i cannot get my eyes to open much (a lil improvement w naphon A but short lasting and irritates my eyes). did my eyebrow drop or my eyelid or both? why is it nlt gone at 2 months?

Michael A. Zadeh, MD, FACS · Answer

Your brows are not showing in the before picture, but from what I can see it looks like you have eyelid ptosis and not a brow drop. 4 Units of Botox is not much, but if improperly placed can be enough to cause a ptosis. Iopidine drops may help, but either way things should go back to normal once the Botox wears off in 3-4 months. Make sure you find an experienced injector next time. Best wishes.

Mehryar (Ray) Taban, MD, FACS · Answer

It appears you have upper eyelid ptosis, asymmetric.  See an oculoplastic specialist for evaluation.

Brent Moelleken, MD · Answer

It's best to allow 3-4 months for the Botox to dissipate completely and then reassess, especially when important decisions are being made about future treatments.  4 units for a brow lift sounds suspect.  Botox provides targeted relaxation of muscles.  These muscles are in an intricate balance with opposing muscles, so the results from different injectors are wildly different.

Jason Emer, MD · Answer

This can be improved with Iopidine drops, venus legacy and thermage treatments. Botox results resolve in 3-4 months. See an expert. Best, Dr. Emer

Nelson Castillo, MD · Answer

Thank you for sharing your question and photographs.  Unfortunately without an in-person examination it is difficult to offer definite advice but this appears more consistent with eyelid ptosis.  This can be improved with eye drops until the Botox fully wears off after 3-4 months.  Hope this helps.

Daniel Barrett, MD · Answer

Dear Xangelika,Botox is generally an on off switch for muscle activity. It depends on the amount of Botox and area where it is injected but it usually last for 3-4 months so you will probably have to wait a bit more. Next time finding an experienced physician injector is your best bet.Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

James R. Gordon, MD, FACS, FAAO · Answer

Thank you for sharing your question and posting your photograph. It appears that you have mild ptosis of both upper eyelids. Usually, this resolves within two months following BOTOX injections, but might take a little longer. Make sure experienced physicians perform all medical treatments. If the problem is caused by Botox, then it should fully recover. Good luck.

Michele S. Green, MD · Answer

It is difficult to tell from the photos but it appears to be a ptosis from the Botox which will take at least a month to resolve.  Please consult an expert in Botox for the best cosmetic results. Best, Dr. Green

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your
photographs Xangelika. 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.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.Sometimes after a Botox treatment a peaked
appearance of the eyebrow is seen. This is sometimes called the Spock or
Mephisto look, which makes a person appear surprised or sinister. It is also
called the Jack Nicholson look, after the appearance of his eyebrows. This can
occur if the muscles that pull the eyebrow down are relaxed with Botox. It can
also occur if the upper forehead only is treated. In this case the inner
portions of the muscles are relaxed preferentially over the outer portions of
the muscle. This allows the outer portions of the muscle to pull up on the tail
of the eyebrow. While some people desire this appearance, others do not. This
effect can be corrected by placing a small amount (1-2 units) of Botox in the
upper forehead approximately midway between the eyebrow and the hair line at
the peak of the brow. This relaxes the muscle that pulls up on the tail of the
eyebrow, thereby restoring a natural appearance.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!

Nicholas Gentry, MD · Answer

it is difficult to say for certain without an exam but it seems like you have some ptosis. You might just try Visine (only for a few days) if naphthalon irritates your eyes. It is uncommon to cause ptosis with only 4 units for brow lift. Did you have any forehead Botox?

Is this eyelid or eyebrow ptosis or Botox? 2 months after Botox (photo)

Answers (13)

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