Botox of forehead wrinkles made my hooded eyes more prominent. Why did this happen? They look worse than before Botox (Photo)

Question

Botox made my hooded eyes worse. Now the skin hangs over a little more. It’s only a little bit it definitely makes me look older. I am considering upper eyelid surgery but I am afraid I may be doing too much I had different opinions one doctor says I’m ready another advises me to wait?

Ron Shelton, MD · Answer

upper eyelids can drop after Botox for different reasons.- Botox injected too close to the lower forehead and affects the upper eyelid ligament by spreading to that area- Botox injected into too much of the forehead muscle so that it can't support the lifting of the eyebrows and upper eyelid complexExpertly injected Botox of the right amount and into the right areas minimizes the chance of upper eyelid droop especially to be paid attention in those individuals who already show some hooding or sagging of the upper eyelid skin.Fortunately all this will resolve itself usually within three months, sometimes longer.The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice. The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs. If you are experiencing a medical emergency proceed to your nearest emergency room.

Steven H. Williams, MD · Answer

Hello, thank you for your question. This effect can be experienced with Botox treatments in patients that have heavy lids or excess upper eye lid skin. This is because botox relaxes your forehead muscles and does not allow you to lift your eyebrows as easily. Letting the botox wear off so you can raise your brows again (decreasing the hooding) will unfortunately continue to cause wrinkles. I would discuss this further with your physician for surgical and non-surgical options. I hope this helps!

Jason Emer, MD · Answer

many of my younger patients need upper eyelid surgery (blepharoplasty) early if they have hooding. often its genetic.  and there is a blanace between doing forehead botox and the eyebrows coming down. so id suggest you get them taken care of surgically this is a simple procedure, weekend downtime.  sometimes eyebrow lift is needed at same time. we do this frequently at same time in my practice with lasers to help fine wrinkles.A combination approach would give the most improvement. Movement lines and superficial wrinkles improve best with botox, dysport or xeomin.  Fine wrinkles need lasers like clear and brilliant, fraxel or erbium or co2; radiofrequency like venus viva or intensife microneedling RF; microneedling with PRP and stem cells; aquagold treatment; or soft fillers like belotero, restylane silk or refyne, revanesse versa, or juvederm volbella.  Deep wrinkles can be improved with a combination of Botox and/or fillers for the lines themselves and to build anatomical support with Sculptra for collagen building.  Agressive deep peeling like phenol/TCA and J plasma can be used for deeper scarring or wrinkles.  Ultherapy is great for lifting of this are and thermage is great for tightening and improving overall texture.  Montly facialis like silk peel, dermalinfusion, salt facial, and microneedling with retinol masks can really help fine wrinkles and pore size. You really need a combinaation apporach and proper daily skin care and sun protection for the best results.  Please consult with an expert.  Best, Dr. Emer.

Michael A. Zadeh, MD, FACS · Answer

The forehead is the muscle that lifts your brows. If you weaken the forehead too much with Botox then your brows will droop and eyelid hooding will look worse. This is likely what happened to you. Options are to get less Botox next time, Strategically place Botox to the outer brows to help lift them, or combine Botox with other procedures such as radiofrequency or ultrasound to help lift the brows and improve the eyelid hooding. Make sure you are under the care of an experienced physician provider. Best wishes.

Yael Halaas, MD · Answer

Because Botox relaxes the muscles of the forehead, any upper eye lid may seem more pronounced than before injections.  Once the Botox wears off, any increase of hooding should return to its pre-injection state.  There are, however, many minimally treatments to reduce and even eliminate upper eyelid hooding.

Monika Soni, MD · Answer

Thank you for your question. This effect can be experienced with Botox treatments in patients that have heavy lids or excess upper eye lid skin. This is because botox relaxes your forehead muscles and does not allow you to lift your eyebrows as easily. Letting the botox wear off so you can raise your brows again (decreasing the hooding) will unfortunately continue to cause wrinkles. I would discuss this further with your physician for surgical and non-surgical options.

Daniel Brown, MD, FACS · Answer

Hello and thanks for your questions and photo.  This commonly happens with Botox treatment in younger patients that have hereditary heavy lids/excess upper eye lid skin.  Botox relaxes your forehead muscles and does not allow you to lift your eyebrows - with heavy upper lids this inability to raise your brows (which you likely have been unconsciously doing constantly while awake) makes your eyes look and feel more closed down/hooded.  You have several options: 1. Botox can be utilized to relax the muscles pulling your brows down - allowing for a modest lateral brow lift which can correct that "heavy" feeling and reverse the hooding caused by forehead Botox.  2. An upper eyelid lift can be performed which will remove the excess skin of the upper lid and "open" your eye more - You are not at the age when this is typically necessary, though you do appear to have excess upper eyelid skin and would be a reasonable candidate and likely get a great result.  Heavy upper eyelids can be hereditary and as such, the youngest  patient that I have performed an upper eye lid lift (blepharoplasty) for was 26 years old and she got a great result.  3.  You can simply wait until the Botox "wears off" enough in a month or 2 so that your forehead muscles can again lift your brows slightly - unfortunately these muscles are also what causes your visible wrinkles.  I would encourage you to schedule a consultation with a board certified plastic surgeon in your area that can discuss all of the above surgical and non-surgical options with you to come up with the best treatment plan for you.  My office and I would be happy to assist.Best wishes!Daniel Brown, MD, FACSBoard Certified, American Board of Plastic SurgeryMember, American Society of Aesthetic Plastic SurgeonsMember American Society of  Plastic SurgeonsCastle Connolly Top DocReal Self Top 500

Jacqueline Calkin, MD · Answer

This is a great question and a common problem. When the horizontal forehead lines are treated, you can no longer lift your eyebrows using the forehead muscle. You are likely always lifiting them slightly (which is why you have the lines in the first place ) and so now that they are “at rest” your eyelids appear more hooded. You can ask your doctor to inject the brow to effect a lift at rest. In the future,  ask your doctor to do less Botox in the forehead lines and always treat the eyebtows. Make sure you’re seeing a board certified dermatologist, facial plastic surgeon, oculoplastic surgeon,  or plastic surgeon.  You don’t need eyelid surgery!

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photograph hotmommie. 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 and without knowing the dose used and the exact placement of the product. 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 pivotal studies for the horizontal lines on the upper forehead were published many years after doctors had been using Botox. In these studies, 20 units of Botox were used to treat this area. However, in my experience I find that anywhere from 10 to 20 units works well in this area. For patients with narrow foreheads a lower dose may be used and those with a broad forehead generally require higher doses. I have also found that the full results in this area are seen by two weeks. Therefore, we have our patients return two weeks after their treatment to assess the results via photographs. At that point additional units may be used if further enhancement is desired.When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.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.If I had a patient with the concern described here I would like to know the placement and dosing of the product. It may be possible for improvement by adding additional units in other areas as described above.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. 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!

Leonard Grossman, MD · Answer

Perhaps you did not make it clear to your treating physician as to what it was that you were really wishing for. An experienced plastic surgeon like myself can easily create a new look for the eye brow you desire including an eyebrow lift. In your case I think I would wait and let botox wear off, then go to a plastic surgeon near you and have your face reevaluated and make a decision if you require a blepharoplasty or additional, better administered administered Botox. Good luck from New York City

Botox of forehead wrinkles made my hooded eyes more prominent. Why did this happen? They look worse than before Botox (Photo)

Answers (12)

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