Doctor the Botox made my eyelids droop!

Dr Azoo Clinic, Ealing, London

This is a complaint that all providers of Botox, Azzalure or Bocouture will hear from an occasional patient. It feels true for the patient, but in reality, the statement is mostly false.

There is a very rare complication of true eyelid droop or ptosis and this results from the neurotoxin getting into the muscle that raises the eyelid (levator palpabrae superiorus). This muscle is shown in purple in figure 1 and if the neurotoxin is injected too close to this muscle, it will be weakened, and the eyelid cannot be opened. In some cases, there is a partial ptosis (drooping of the lid) or a complete ptosis where the lid is totally closed and cannot be opened until the neurotoxin wears off which can be months (figure 2). This is an extremely rare complication and is usually seen with novice injectors injecting into the wrong area or using too high a dose.

Figure 1. A true upper lid ptosis (drooping) can occur if the neurotoxin is injected in or near the levator muscle (shown in purple).

Figure 2. This patient has a true ptosis from levator weakness after neurotoxin which is a rare complication.

There are numerous muscles that depress or pull down the eyebrows and these are the most commonly treated muscles to decrease frowning and frown lines. There is only a single muscle that raises the eyebrows and this is the frontalis muscle (figure 3). Herein lies the problem.

Figure 3. This image shows the frontalis muscles (red) which are the only muscles that lift the brow.

Many females, especially those over their mid-40’s walk around all their waking hours with their eyebrows subconsciously elevated. They do this for several reasons. One is animation, but the more significant reason is that in the 4th decade, the upper eyelid skin begins to droop and becomes folded over. Young women have a discrete space above the eyelashes and the normal eyelid crease. This is called the eyelid shelf. This is the area where women apply eye shadow and other makeup. As we age, this shelf disappears and is hidden by redundant upper lid skin. Women with aging upper lids must extremely raise their brow (or manually lift it) to apply eye shadow, and after a certain age, many simply quit wearing it at all. This sagging upper eyelid skin makes them look older and sometimes obscures vision. To combat this sagging, many women raise their brows, and they keep them raised all their waking hours without even thinking about it. If you are in conversation with a woman in a relaxed environment and hand her a mirror virtually all females with subconsciously raise their brows when they look in that mirror. I see this many times a day in my consultation appointments. This continual raising of the brow may make your eyes look younger and may improve your field of vision, but it also accelerates the formation of horizontal forehead wrinkles; it is a win/lose situation.

Remember that the frontalis muscle is the only muscle that elevates the brow. When susceptible women (usually those that have eyelid aging) have neurotoxin injections in the frontalis muscle or even near it, it will reduce or prevent that muscle from lifting the eyebrows. When the eyebrows are not able to be elevated in a patient with aging upper lid skin, the skin bunches and it makes the patient look older (figure 4 and 5). What patients most frequently confuse with a true ptosis is the inability to elevate the brow after neurotoxin injection due to decreased function of the frontalis muscle.

Figure 4. This image shows a patient that is a set up for post neurotoxin brow drooping. The patient needs an eyelid tuck and compensates by elevating her brows. If she is over treated with Botox, the skin will appear to be more excessive.

Figure 5. This picture illustrates the effect of brow elevation on eyelid skin. When the brows are raised (top picture) the eyelids look better because the lid skin is lifted. When the brow is relaxed, the skin looks more excessive. If the forehead is overtreated with Botox it would have a negative cosmetic effect and the patient may feel that the brow has dropped.

This is the exact phenomenon that happens to older patient that causes them to think that their eyelids are drooping. In reality, this had nothing to do with the eyelid muscle or poor injection technique. It simply means that this patient needs cosmetic eyelid surgery or needs to stop having neurotoxin injected in or about the frontalis muscle. It is not the cosmetic doctor’s fault or the patient’s fault; it is simple anatomy.

There are various solutions to this. Either the patient should have cosmetic eyelid surgery, not treat the frontalis, or their cosmetic doctor can customize the injection pattern to preserve necessary frontalis function to elevate the brows. Unfortunately, this is not an exact science since some patients are very sensitive to neurotoxins and a little bit may knock out the entire frontalis. I prefer to use a “frontalis sparring” technique to preserve some frontalis function and allow some lifting activity in the brow.

Experienced injectors recognize this potential problem in patients with excess upper lid skin (it can be present in younger patients as well) and will advise the patient about the potential problem and attempt to customize the injection pattern. This problem is most common the first time a patient is injected or the first time by another provider. Evaluating the problem and patient’s sensitivity to the neurotoxin can usually allow a more natural treatment the second time around with injections.

So, if you feel that your lids droop after Botox injections and the lid position has not actually changed, but rather your upper lid skin is bunching due to excess; it may be time for surgical cosmetic blepharoplasty.

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