Too deep set eyes for Botox? Is Botox no longer an option? (photo)

Question

I’ve had Botox since 28. Now at 52, I have benefitted greatly from long term results ( very little eye wrinkles for my age) ; however, I can’t get the eye“ lift “ I used to anymore. I have very deep -set eyes and I’m unsure if it’s my injector’s technique ?. At what point do I opt for eyebrow lift ? ( I’m currently due for Botox again) and seeing my eyes, if Botox is no longer an option, forehead lift or endoscopic brow lift?

Monica Boen, MD · Answer

The effects of aging do not stop with Botox treatments, so it is possible you are seeing more advanced signs of aging that are not responding to Botox injections alone any longer. I encourage you to schedule an appointment with a board-certified cosmetic dermatologist that can perform a comprehensive, in-person assessment to identify your current needs and the best treatment plan for you. It may be time to add treatments to your regimen, such as non-surgical skin tightening with laser devices such as RF microneedling or Ulthera and Thermage.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photograph Omaisbeste. 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.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.
In rare cases, some people are resistant to a certain neuromodulator such as Botox. In this case the treatment can be repeated using a different neuromodulator such as Dysport or Xeomin.
Botox (onabolutimun toxin) is what we call a neuromodulator. This means that it controls nerves to relax the muscles by preventing them from contracting. Botox is the most popular neuromodulator available, has been the most studied, and is cleared for the most number of indications. Other neuromodulators available in the United States include Dysport (abobolutimun toxin), Xeomin (incobolutimun toxin), and Mybloc (rimabolutimun toxin). Botox, Dysport, and Xeomin are type A toxins while Myobloc is a type B toxin. This means the structure of the protein is slightly different. Overseas many others are also available. Dysport is the most commonly used neuromodulator other than Botox in the United States. The dosing for Dysport is different than that for Botox. Approximately 2.5 to 3 units of Dysport are required for every unit of Botox. For example, in the glabella 20 units of Botox is most commonly used. If Dysport were to be used in this area 50 to 60 units of Dysport would be required. The investment per unit of Dysport is approximately 2.5 to 3 times less than that of Botox. While the manufacturer states that the units of Xeomin are a one to one equivalent of Botox, many doctors find that a higher dose of Xeomin is required to produce the same effects as Botox. Each product has slight differences, but all of them work. Dysport, for example, is known to spread more than Botox. This makes it useful in places like the underarms where it can be used for excessive sweating. However, if it spreads near the eyes it can lead to side effects such as a droopy eyelid. Xeomin is also called a naked protein, because it does not contain the accessory proteins that are included with Botox or Dysport. It is thought to have a slightly faster onset (by one to two days faster) than Botox or Dysport. It is also thought to have a decreased likelihood for allergic reactions, although allergic reactions to Botox and Dysport are incredibly rare. In the United States Myobloc is not FDA cleared for cosmetic use and is primarily used for muscle pain in those with cervical dystonia. The majority of our patients find that they like the results of Botox the best. Additionally, Allergan, the maker of Botox, offers the Brilliant Distinctions Program. This is a rewards program where patients receive points from their Botox treatments which can be used toward discounts at subsequent treatments. Points are also received when patients purchase other treatments in the Allergan portfolio including Juvederm Ultra, Juvederm Ultra Plus, Voluma, Volbella, Vollure, and Kybella or products such as Latisse or Skin Medica products.
If I had a patient with the concern described here I would want to see the entire face and review all previous treatments. The patient may be a candidate for Botox possibly placed in different areas or a higher dose. Additionally, other cosmetic treatments such as laser skin tightening and fillers may be of benefit.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!

Lindsay Sturm, DO · Answer

Great question, thank you!  Unfortunately Botox cannot stop the aging process and as one ages, their brows can grow heavy.  So the lift that you receive from Botox in your 20's may not be as evident in your 50's.  If you are starting to notice that the lift is not as great as it used to be it may be time to discuss with your provider other surgical options which may help you.  I would recommend that you schedule an in-person consultation with a provider to discuss your goals so that he/she may determine which procedure is best for you! Thank you again for the question.  Best wishes, Dr. Lindsay J. Sturm

Camille Cash, MD · Answer

If you are no longer seeing the "lift" from Botox and your injector has tried increasing the number of units, it may be time for you to consider surgery.  Visit with a board certified plastic surgeon near you for an evaluation to determine the best procedure to consider to help you achieve your surgical goals.

Kristine Brecht, MD (license suspended) · Answer

Dear California,Facial Rejuvenation involves many pieces.Botox is just one piece.Deep set eyes is a combination of genetics and bone changes as we age.A consult to discuss fillers and eye Rejuvenation would be a great step to help educate yourself on all your options.Best. Dr Brecht Seattle, Wa

Too deep set eyes for Botox? Is Botox no longer an option? (photo)

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