What is droopy eyelid or eyebrow (ptosis) due to Botox?
A droopy eyelid or eyebrow is one of the most common side effects of botulinum toxin type A injection (Botox, Dysport, Azzalure, Xeomin, Bocouture, etc.). It occurs in up to 5% of patients when Botox treatment is performed by an inexperienced injector. When an experienced provider injects with the proper technique, eyebrow or eyelid ptosis occurrence can be reduced below 1% of cases.
Botox is a neuromodulator drug widely used in the treatment of dynamic (expression) wrinkles, with over 7.7 million treatments performed in 2019 in the USA alone. When properly injected, Botox relaxes the muscles in the treated area, reducing wrinkles and preventing their formation while also preserving some movement of the muscles.
When poorly injected, Botox can cause:
- facial asymmetries, when units of Botox are unevenly distributed on the two symmetrical halves of the face.
- total paralysis of the muscles, when too many units are injected in an area leading to an unnatural look and lack of facial expressiveness (frozen appearance and apparent lack of emotions).
- Failure to treat wrinkles, when too little is injected or when it is injected in the wrong spots.
- Increase in wrinkles, due to overcompensation when the muscle is treated unevenly in its upper and lower part
- Other bad cosmetic outcome such as the “Spock eyebrow” or “Joker eyebrow” look when Botox units are unevenly distributed in an area.
Droopy eyelid or eyebrow after Botox
Another potential bad Botox side effect is the droopy eyelid or eyebrow, known as ptosis of the eyelid or eyebrow. This side effect is seen between 5- and 14-days following Botox treatment. There are many reasons why this could happen, including when:
- too many units are injected or when Botox is improperly diluted with normal saline and/or adrenalin, or when a syringe that does not allow for precise dose visualization is used
- wrong site of injection
- when there is migration of the drug from one area to another
- when forehead is improperly evaluated during consultation. Some patients have excess eyelid skin and unconsciously tend to keep their eyebrows raised to have the eyes more open. Forcing the muscles to relax with Botox, doesn’t allow for this compensation, causing the tired look or heavy eyelid feeling. Other patients have stronger or weaker facial muscles than others, so using a standard dose would result in overtreating or undertreating a muscle.
- when patients did not follow the post-procedure advice from their treating physician, causing Botox to spread to other areas.
- when previous periorbital procedures where performed, altering the anatomy of the tissues around the eyes.
Botox may in rare cases cause eyelid edema. This usually resolves in about 2 weeks, and the causes for this are not fully understood.
It is not always the physician’s fault for Botox side effects; sometimes they may be due to the individual anatomy of the patient (we are not made exactly the same), the individual response to the drug or due to other circumstances. Choosing an experienced Botox provider will lower the chances to a minimum, but like any other medical or surgical procedure there is always the possibility of something going wrong.
How to fix droopy eyelid or eyebrow after Botox?
The good news with Botox is that it wears off and its effects are not permanent. Depending on the patient, many who experienced a side effect reported improvement within 6-8 weeks as the drug starts wearing off.
There are some ways to fix, at least partially, the issue. First thing you should do is refer to your doctor for an evaluation:
- If the droopy eyelid is the result of an uneven application of Botox, this can be easily corrected with further injections.
- The doctor may also perform a non-surgical brow lift using dermal fillers to correct the ptosis.
- The doctor may prescribe some Apraclonidine 0.5% eyedrops. These eyedrops may be used up to three times per day and stimulate the muscles to raise the upper eyelid, providing temporary relief.
- Massaging the muscles. You can try and use something like the back of an electric toothbrush for a couple of minutes 2-3 times a day to massage the affected area. Although there is not much evidence supporting this practice, some people have anecdotally found it helpful in speeding up the recovery.
- Using make-up or changing the hairstyle may also help in disguising the issue if you feel uncomfortable while in public.
How to prevent droopy eyelid or eyebrow after Botox injection?
The first and most important advice in preventing droopy eyelids or any other bad outcome from Botox, as well as from other medical treatments, is to refer to a properly trained and experienced practitioner. You may want to have a second opinion too, to compare the two consultations. If you want to avoid this hassle you can refer to a dermal clinic where they take care of vetting doctors and dermatologists, checking qualifications, knowledge and experience for your convenience.
After choosing the right provider, you should let the doctor know of any medication taken in the previous few weeks, as they can interact with Botox treatment. You should also tell if you had Botox treatment in the previous months or if you had facial surgeries in the past.
After treatment, you should follow your doctor’s advice including:
- Avoid rubbing or massaging your face for 24 hours and avoid facials, beauty treatments and professional face massages for a couple of days
- Avoid lying down for at least 4 hours
- Avoid make-up for 24 hours
- Avoid tight headwear for 24 hours
- Avoid sleeping on your face the first night
- Avoid alcohol consumption for at least 24 hours
- Avoid sun exposure or hot bath, saunas, steam rooms for a couple of days
- Avoid strenuous physical activity for 24 hours
- Avoid some medications, such as blood thinners (aspirin included) for a couple of days. Ask your treating physician before taking any.
How to fix a droopy eyelid with Botox?
Sometimes a droopy eyelid is not the result of a botched procedure, but it is caused physiologically by the aging process. Both males and females are affected by this issue, and they often complain to their doctor that they look tired when they look at themselves in the mirror as well as they receive comments from friends and acquaintances that they have a tired look. In some cases, the droopy eyelid affects their field of vision too. Many surgical and non-surgical options are available for these patients one of which is using neuromodulators: Botox may be used to create a brow lift effect, pulling the proper muscles and restoring a normal and rested appearance to these patients.
Resources: A Redaelli, R Forte – Journal of Cosmetic & Laser Therapy, M King – Journal of Clinical and Aesthetic Dermatology, M Crist – American Academy of Optometry, YS Chang, CC Chang – Medicine, MedTravel.asia, American Society of Plastic Surgery (ASPS)