I got the dreaded Botox eyelid droop. Can more Botox lift it?

Question

I had Botox done 2 weeks by my regular dermatologist that I've been going to for years. One of my eyelids is drooping. I am going to go back to show them next week but wanted to ask here in advance if more Botox to lift the corner of the brow can help or if I should wait it out. I got a droop one other time many years ago & if I recall, they put more Botox to fix it, but I can't recall if it helped.

Harold J. Kaplan, MD · Answer

Hi NSS.  Yes, what you have suggested is possible, but it depends on the treatment that was performed previously.  We offer a treatment called the Botox browlift where we relax the area between the eyes and the crow's feet area at the sides of your eyes.  If the crow's feet were not dosed the last time you were in, it's very possible to correct some of the ptosis by dosing this area.To learn more about the Botox (Dysport) browlift and see before and after photos, check the link below.

Jason Emer, MD · Answer

This is difficult to answer without pictures. However, additional Botox may give improvement. Venus legacy, thermage and Iopidine can also help soften Botox results. See an expert. Best, Dr. Emer

Kenneth D. Steinsapir, MD · Answer

If the inner eyelid is drooping, a drop called iopidine can help open the eyelid.  The drop is not perfect.  Generally when the eyelid is very heavy, it will not work at all.  In fact, when the drop does work it forecasts that the ptosis will wear off in 4 to 6 weeks. When it does not work, the ptosis will take much longer to wear off.  If what is drooping is not the actual eyelid but the upper eyelid fold, that means the eyebrow is heavy from being frozen by botox.  This can be helped by superimposing a correcting treatment.  Generally I would recommend waiting about 6 weeks to do this if we are talking about a heavy eyebrow. Consider posting a photograph for more concrete recommendations.

Mitesh Kapadia, MD, PhD · Answer

Sorry you had this happen. A picture would be helpful to distinguish between two possible scenarios. If the full eyelid is drooping, then you need to wait it out. There are eyedrops that can help elevate the eyelid which may help. The drooping usually gets better over a few weeks.If the eyebrow is pushed down from too much botox in the forehead, it usually makes sense to wait it out. The eyebrow droop will improve as the botox wears off.

Shaun Patel, MD · Answer

The first thing to do is determine whether it is the eyebrow or eyelid that is drooping. If it is the eyelid that is drooping, certain eyedrops can help keep the eyelids open until the effect of the Botox wears off. If the lateral eyebrows are drooping then injecting the orbiculares oculi muscle at the tail of the eyebrow may help raise the brow. If the medial eyebrow is drooping, you may need to wait for the Botox to wear off although injecting the depressor supercilii muscle may help some. Followup with your injector to see what needs to be done.

Tim Sayed, MD, MBA, FACS · Answer

In general, if the droop after Botox treatment is in the EYELID muscles, then some drops to stimulate one of the eyelid muscles that opens the eye may be helpful until the Botox effect wears off. If it is the BROW that has descended - which is TYPICAL, by the way, with Botox to the mid forehead frontalis muscle since that is the muscle that raises the brow -- then you may need additional Botox to the brow depressor muscle which may help lateral brow drooping. It may not be possible to "reverse" the drooping of the medial (closer to eyebrows) part of the frontalis muscle as there really is no brow depressor in that area. You may have to wait for the effect to wear off but in-person exam in the office is the only way to properly assess you.

Sanjay Mukerji, MD · Answer

Having a droopy eyelid after Botox is because some of the injection migrated from above the brow to below, and affected the muscle that lifts up the eyelid. I try to avoid this by staying at least 1 cm above the eyebrow, and not going deeper than the muscle in my injections to this area. If the lid is drooping, more botox below the brow is not going to fix, because that works only for a sagging brow, not a sagging eyelid. 
The only treatment for this are eyedrops, that strengthen a different muscle, which counteracts the lid muscle that has been affected by botox. All the lid activity returns back to normal by 4-5 months after injection, and the drops are to help you until then.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your
photographs nssvintage. 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 without a
formal exam in the office where I can view the skin in multiple angles and observe
wrinkles formed with facial expression. However, I hope the information
provided here is useful.The safety record of Botox is well established.
The product has been used for over 20 years for a variety of treatments with
minimal side effects. Botox is amongst the safest treatments for treating
facial wrinkles.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 (discussed below) or a temporary
asymmetric smile.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.Sometimes the brow becomes droopy or heavy after a Botox treatment. 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.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!

Mark L. Mazow, MD, FACS · Answer

Thank you for your question. A droopy lid after Botox is an unfortunate, but well known side effect. It can happen anytime Botix is injected, even if you have had it many time before and even if dome by an experienced injector. Fortunately it is rare in the hands of an experienced injector. If the droop is in the lid itself then drops can help. If the brow is droopy then you need to be re-evaluated. More Botox will not help either scenario. Fortunately the effect is temporary and will wear off as the Botox wears off. Go back to your injector.

Andre Levesque, MD · Answer

Thank you for your question.
It is difficult to say which scenario you are describing for sure without pictures.  One scenario is that the eyebrow is dropped or lower which can sometimes be improved with additional Botox to the “brow depressors” in the crows feet or glabella areas.
The alternative scenario is drop of the eyelid which results from migration of toxin to the levator muscle.  Additional Botox would be contraindicated in this scenario and eye drops can sometimes help to temporize until the Botox wears off.
Best Dr. L

I got the dreaded Botox eyelid droop. Can more Botox lift it?

Answers (12)

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