How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (2022)

By Andrea Callaway

April 21, 2022

How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (1)Eyelid ptosis or a droopy upper eyelid can be an upsetting complication for your patients after cosmetic botulinum toxin or Botox® injections, but are you identifying it correctly, and is there more to the story, as well as your options for correction?

In this blog, Dr Tim Pearce talks about how to make sure you are not confusing eyelid ptosis with eyebrow ptosis or existing, congenital asymmetry, alongside three treatment options to help you to deal with this condition, ensuring you are in control and stress free for your patient as well as yourself.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certifiedlearning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

What is eyelid ptosis?

Eyelid ptosis is the medical term for a droopy eyelid; it is especially important if it is a new symptom, is asymmetrical, or affects vision.

It is vital to note that we are looking at the eyelid with reference to the pupil, and not the eyebrow, or the skin above the eyebrow, something which often confuses new aesthetic injectors.

Most of the cases of eyelid ptosis that Dr Tim sees reported on online forums are in fact eyebrow ptosis. A drooping frontalis muscle can rest on the eyelid and create a sense of heaviness in the area that to the inexperienced or less well-trained eye looks as if the botulinum toxin has affected the eyelid. With misdiagnosis, the patient gets the wrong treatment, and the aesthetic clinician is prone to repeating the same mistakes in diagnosing between eyelid and eyebrow ptosis.

(Video) 3 Ways to Fix Eyelid Ptosis After Botox

What causes eyelid ptosis?

There are multiple causes of a true eyelid ptosis, and it is wise to consider all of them if a patient presents to you at any stage with a ptosis.

The first scenario, the one that we are expecting in 1% of botulinum toxin treatments is when the neurotoxin makes its way into the orbit of the eye affecting the levator palpebrae muscle.

Dr Tim notes that a risk of occurrence of 1/100 is not his personal understanding, as it is far less frequent than that in his experience in clinic; however, if the incidence is that high in wider practice, he surmises that it is probably because injectors do not understand the anatomy and are injecting too deeply and to near to the orbit.

Why not download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin treatments.

The primary muscle of elevation is the levator palpebrae muscle. It runs all the way from its origin on the lesser wing of the sphenoid bone, over the top of the globe, and over the superior rectus muscle until if fans out and becomes a tendon sheath called the levator aponeurosis.It passes over a transverse suspensory ligament, the Whitnall’s ligament which is part of a pulley system allowing the horizontal levator muscle to exert more of a vertical force on the levator aponeurosis, that pulls the eyelid upwards.

How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (2)

Posterior to the levator aponeurosis is the superior tarsal muscle, also called Müller’s muscle. This is a smooth muscle that also elevates the eyelid, but it is not under conscious control, it responds to the sympathetic nervous system when you are acutely stressed or excited.

Did Botox cause the eyelid ptosis?

A lot of aesthetic practitioners immediately blame themselves for any side effects, symptoms, or complaints that occur after a procedure, and patients also reasonably connect what they see to procedures they have had done, but there are many causes of asymmetry in this area that are not related to botulinum toxin treatments, which you should rule out before blaming yourself.

Did Botox cause the eyelid ptosis?

A lot of aesthetic practitioners immediately blame themselves for any side effects, symptoms, or complaints that occur after a procedure, and patients also reasonably connect what they see to procedures they have had done, but there are many causes of asymmetry in this area that are not related to botulinum toxin treatments, which you should rule out before blaming yourself.

Congenital eyelid ptosis

There are people with congenital eyelid ptosis, usually mild and asymmetrical. It is present life long, but often gets worse as you age. In fact, Dr Tim himself has a slight asymmetry in his eyelids, check out the photo below to see if you can spot it.

(Video) How to reduce the risk of eyelid ptosis

His advice is to ALWAYS check your before photographs of the patient. It is very common for patients to spot old or existing facial anomalies for the first time after having a new cosmetic procedure because they analyse themselves in much more detail afterwards and this is most often the case with mild ptosis.

Brow ptosis not eyelid ptosis

How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (3)Aesthetic injectors are commonly confused when encountering a brow ptosis, especially on patients whose skin runs uninterrupted to the eyelid.

A slump in the forehead tissue can transmit some energy into the upper eyelid area, usually this narrows the space between the eyebrow and the lid line, much more so than it drops the eyelid itself. This is what you must look for on examination, as the way you may treat a drooping eyelid is very different to treating a drooping eyebrow.

Myasthenia Gravis

There are several notable medical conditions which could look very similar to a side effect from botulinum toxin treatment, presenting with a droopy eyelid; one of which is myasthenia gravis.

How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (4)

This disease affects the neuromuscular junction and is caused by autoimmune destruction of the acetylcholine receptor. The more active the area, the more likely it is that symptoms will occur, so it is common for the eyelid to droop early in the disease, and this can also be asymmetrical.

Horner syndrome

Horner syndrome is another condition which can cause an eyelid ptosis, it results from disruption of the sympathetic nerve innervation to the face which can be for various reasons, the most serious of which is an apical lung cancer affecting the sympathetic nerve plexus in the chest. This causes a drooping eyelid, a loss of sweating on the affected side of the face, and constriction of the pupil.

Ways to treat eyelid ptosis caused by Botox injections

Having ruled out existing medical causes of eyelid ptosis, there are several options to be aware of for treating eyelid drooping caused by botulinum toxin treatment, even if you refer the patient onwards and seek help outside your own clinical practice and skillset.

Iopidine (apraclonidine) or oxymetazoline hydrochloride

If your patient has a botulinum toxin side effect, or a mild congenital ptosis, you can use medication (in the form of drops) that stimulates the smooth muscle in the eye – the tarsal muscle or Müller’s muscle – which responds to sympathetic stimulation. The fight or flight response causes widening of the eye, and drugs like Iopidine® (apraclonidine) or oxymetazoline hydrochloride mimic the sympathetic response and can be used to temporarily lift the eye for between 4-6 hours. These prescription medicines would be used off label in the UK, and may not be suitable for all patients, but a licensed product called Upneeq® is available in the USA.

Further botulinum toxin treatment

The next option for correction, which surprises many patients, is that you can treat an eyelid ptosis, even one caused by botulinum toxin injections, with MORE botulinum toxin!

(Video) Eyelid Ptosis From Botulinum Toxins - Understanding The Crucial Anatomy.

The eyelid, like most moving structures in the body has muscles which oppose each other. Eyelid retractors – the tarsal muscle and levator palpebrae muscles – are opposed by the palpebral part of orbicularis oculi – the protractors. This means that if you inject the upper eyelid, the orbicularis oculi muscle, anterior to the tarsal muscle, with 1-3 units of Botox®, it can lift a drooping eyelid by a millimetre or so.

Many aesthetic clinicians managing an eyelid ptosis complication as a side effect of botulinum toxin treatment will use both options, as the drops work in minutes, but need constant reapplication, and the botulinum toxin takes a couple of weeks to work, but once activated, the result is consistent.

Ptosis surgery

Dr Tim highlights that it is worth understanding and being aware of the surgical options available for congenital asymmetries and eyelid ptosis, even as an educational point for non-surgical aesthetic practitioners. These are obviously not used for correction in the case of a botulinum toxin side effect; however, pre-existing, or age-related ptosis often require surgery.

Ptosis surgery is not the same as a blepharoplasty and requires the skills of an oculoplastic surgeon who operates on the eyelid itself. There are two main options for this kind of surgery.

The first is to target the levator aponeurosis tendon – the levator palpebrae muscle inserts into this tendon – and shorten it by the required amount to create a lift. This type of surgery is often reserved for older patients with functional problems due to severe drooping of the eyelid obstructing their vision, and it is less likely to give a perfect aesthetic result. The second is a less powerful, but more aesthetically predictable type of surgery to create a more controlled aesthetic result whereby a section of the tarsal muscle is removed through the posterior side of the eyelid.

If you are interested in learning more about the dynamics of such surgical interventions for eyelid ptosis, to help when you consult with your patients, Dr Tim recommends following Dr Guy Massry who has several videos on his Instagram feed.

What are your thoughts on and experiences with managing eyelid ptosis? Why not drop Dr Tim a comment or question on social media, you can find you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

3 Ways to Fix Eyelid Ptosis After Botox

Dr Tim Pearce talks about how to identify eyelid ptosis, which is often confused with eyebrow ptosis or existing asymmetry that the patient didn’t notice prior to treatment. He also covers 3 treatment options so that you can feel in control and stress free when dealing with this condition.

The show has over 10k views and some great feedback from aesthetics professionals. Some of the latest comments include:

(Video) Lecture on eyelid and brow ptosis

“Dr Tim, you are IMO the best educator an speaker in the field. I always enjoy so much your videos and the way you present the information. Thank you for the amazing work you upload “

Catalina G

“You are incredible you teach us how to prevent then you teach us even more ways in different techniques to prevent even more and now you teach us when we do mess up exactly how to fix it you’ve got to be the most well-rounded and well-schooled doctor in this beautiful art thank you so much and may God bless you and your beautiful wife all of us really appreciate this so much you could have just spent all of your time indulging in your practice in making actual money instead of making these fantastic videos that’s what I call a true humanitarian and a true professional in anesthetics”

Jennifer Craig

Read more and add your own comments on our YouTube channel.

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Subscribe to our YouTube channel for really useful regular tips and advice. How to fix eyelid droop or ptosis from Botox | Dr Tim Pearce (5)

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In addition, browse our FREE downloadable resources on complications.

(Video) Best Botox Eyebrow Lift Injection Patterns, Avoiding Spock Brow & Ptosis

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessibleBOTOX® and dermal filler online coursesfor fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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FAQs

How do you fix brow ptosis? ›

Nonsurgical treatment may be pursued in particular cases. Botulinum toxin injections effectively treat spastic brow ptosis or even slightly elevate the brow by weakening the depressor supercilii muscle; more systemic etiologies like myasthenia gravis will require specialized medical therapy.

Can eyedrops fix ptosis? ›

While it may sound like science fiction, the FDA-approved eye lifting drop is real: UPNEEQ® is a prescription eye drop that temporarily improves droopy eyelids, or ptosis, with a single daily dose.

How do you treat eyelid ptosis from Botox? ›

There is currently no treatment for botulinum toxin-induced ptosis. Patients who suffer such a complication have to wait for several weeks until the effects of the toxin wear off. This case report suggests that apraclonidine can provide a reversal option for physicians and their patients.

How long does brow ptosis last after Botox? ›

Lid and brow ptosis from Botox usually appears a few days to a week after being injected. Usually, it gets better after three to four weeks.

How common is ptosis after Botox? ›

The most common negative reaction to injections to your face is a droopy eyelid, also called ptosis or blepharoptosis. Most people don't have this problem. Around 5% of people who get Botox will have problems with eyelid droop. This number falls to less than 1% if a skilled doctor does the injection.

What drops help ptosis? ›

A therapy recommended to treat ptosis resulting from administration of botulinum toxins A and B is Iopidine (apraclonidine 0.5 %) eye drops. Apraclonidine is an alpha2-adrenergic agonist, which causes Muller muscles to contract quickly elevating the upper eyelid 1-3 mm.

Will Botox ptosis go away? ›

Although ptosis may persist for the whole duration of effect of treatment with botulinum toxin type A, it will usually settle more quickly and eyelid ptosis will often settle within 3 to 4 weeks and brow ptosis within six weeks.

How can I reverse Botox fast? ›

In those cases, a drug called pyridostigmine can reverse the paralysis by encouraging muscles to contract. The official antidote to botulinum toxin is difficult to procure quickly and takes several days to work, while pyridostigmine begins to relieve symptoms within hours.

How can I make Botox wear off faster? ›

Answer: Unfortunately, there is no way to make Botox wear off faster. Unfortunately, there is no way to make Botox wear off faster. Generally, results will last from 3-4 months.

Can Botox eyebrow droop be fixed? ›

Eyebrow unevenness can be corrected by injecting a little more neurotoxin into the side that is lower. This will eventually correct the asymmetry. The best outcome one can have from getting Botox injections is a relaxed, refreshed and more youthful appearance, without seeming as though one has done anything.

Can Botox give you hooded eyes? ›

Yes, Botox can cause droopy eyelids if it is injected in the wrong place or if too much is used. Because Botox is a muscle relaxing toxin, if it is injected into the muscles that hold the eyelids or eyebrows up, then this can cause the muscles that pull the eyelids down to be more emphasised.

Can you reverse Botox? ›

The simple answer to this question is no Botox cannot be reversed. There is no known 'antidote' to Botox although this does not necessarily mean there is nothing that can be done if you experience certain unwanted results.

Does eyelid tape work for ptosis? ›

Double eyelid tapes may serve as an effective, safe, and reliable therapeutic option for severe ptosis in patients with myotonic dystrophy.

What vitamins help ptosis? ›

Ultimately, even though the administration of Vitamins B1 and B6 seems to promote complete recovery of bilateral ptosis, further research is required to valorize this finding and determine the neurological monitoring of vincristine administration.

Does retinol help ptosis? ›

Yes, you can, retinol is able to work on the upper and lower eyelids and areas of skin. This is because it can penetrate the lower layers of the skin and boost collagen production. This will result in the skin around the eye will become tightened with signs of sagginess, fine lines, and wrinkles visibly reduced.

Why do my eyes look weird after Botox? ›

This happens because the muscles that raise the eyebrows have been relaxed by the botox. Unfortunately this can occur when botox is injected into the forehead muscles. Sometimes injecting into the lateral edge of the brow may help to lift the eyes and sometimes eye drops will counteract the effects of the botox.

When do Botox side effects go away? ›

However, it is possible that as the amount of the Botox drug in your body decreases, the symptoms you were using Botox to treat may make a comeback. The effects of Botox treatments generally wear off after about 12 weeks, and occasionally this can result in the return of your initial condition.

How do you treat ptosis without surgery? ›

Certain prescription eye drops are available, which can serve as a temporary solution to address the condition of ptosis. The effect of the treatment can last for about eight hours, and can be repeated for maintain the look. Botox may be used in some cases to treat the muscle that is causing the eyelids to close.

Can you buy apraclonidine over the counter? ›

No, apraclonidine (Iopidine) is not available OTC. It requires a prescription from a healthcare provider.

Do eyelid lifting creams work? ›

A good lifting eye cream can restore the skin's firmness and elasticity and reduce the appearance of droopy eyelids. The best eye cream formulae come with powerful ingredients like hyaluronic acid, pro-retinol, or vitamin E to combat the aging signs and minimize the droop.

Is there medication for droopy eyelids? ›

Recently a once a day prescription eye drop, called Upneeq, became available to help with droopy eyelids. The prescription eye drop provides an alternative to surgery and off-label drugs, the only options for fixing droopy eyelid until now. Upneeq works on a muscle that elevates the eyelid.

Does brow ptosis go away? ›

Brow ptosis creates an extremely negative appearance and can persist for up to 3 months.

How does brow ptosis happen? ›

Brow ptosis is caused by a relative over relaxation of the brow elevators. Remember the brows are held in position by a number of opposing muscles and the force of gravity. The frontalis muscle both supports at rest and moves the eyebrows up, while the glabella complex and the orbicularis oculi pull the brow down.

How do you know if you have brow ptosis? ›

The signs of brow ptosis consist of brows at or below the superior orbital rim. As discussed, patients typically have more temporal brow droop than medial brow droop. Prominent brow ptosis may give the appearance of significant dermatochalasis.

Where do you inject for brow ptosis? ›

Brow ptosis.

When treating the frontalis muscle, always inject at mid-forehead or above (at least 2cm above the brow in all patients and for older patients, ensure injections are at least 4cm above the brow).

How common is ptosis after Botox? ›

The most common negative reaction to injections to your face is a droopy eyelid, also called ptosis or blepharoptosis. Most people don't have this problem. Around 5% of people who get Botox will have problems with eyelid droop. This number falls to less than 1% if a skilled doctor does the injection.

Can Botox cause permanent ptosis? ›

Answer: Botox Results Are NOT Permanent.

Can you fix a heavy brow after Botox? ›

The Frontalis is the muscle in your forehead which controls the raising of your eyebrows. After 2 weeks, if you still feel heaviness, try gentle eyebrow raising exercises and blinking your eyelids rapidly for 30 seconds. Do this 4 times daily for 2-4 days as it may help resolve the heaviness.

Will droopy eyelid from Botox go away? ›

In most cases, droopy eyelid occurs between one and three weeks after treatment, and patients typically experience this adverse effect for just a few weeks. According to Dr. Holman, “It's important to remember that, like Botox treatments, a drooping eyelid is usually temporary. The effect will wear off after a while.

How can I reverse Botox fast? ›

In those cases, a drug called pyridostigmine can reverse the paralysis by encouraging muscles to contract. The official antidote to botulinum toxin is difficult to procure quickly and takes several days to work, while pyridostigmine begins to relieve symptoms within hours.

How can I make Botox wear off faster? ›

Massaging it after 2 weeks, and repetitive trials to use it, have shown to help in some cases. Heating pads: DON'T apply heating pads until 2 weeks after treatment. After 2 weeks, apply heating pads can help increase the blood supply to the affected areas, allowing Botox to wear off faster!

Why do my eyebrows droop after Botox? ›

The levator is the muscle that is responsible for maintaining the eyelids in their normal position. However, in some instances, Botox migrates from the injected treatment area and ends up in the levator muscle. When this occurs, it causes drooping eyelids or droopy eyebrow.

What kind of doctor treats droopy eyelid? ›

Your ophthalmologist determines the type of ptosis based on your medical history and the results of the comprehensive eye exam the doctor may have performed. You may then be referred to an oculoplastic specialist—an ophthalmologist with advanced training in plastic surgery of the eyes and surrounding areas.

Can Botox give you hooded eyes? ›

Yes, Botox can cause droopy eyelids if it is injected in the wrong place or if too much is used. Because Botox is a muscle relaxing toxin, if it is injected into the muscles that hold the eyelids or eyebrows up, then this can cause the muscles that pull the eyelids down to be more emphasised.

Where should you not inject Botox to avoid ptosis? ›

Eyelid ptosis is most commonly seen from inappropriate placement of botulinum toxin. This specific complication can be avoided by staying at least 2‐3 cm above the supraorbital margin or 1.5‐2 cm above the eyebrow while injecting into the frontalis.

What causes heavy eyelids after Botox? ›

Most issues of upper eyelid heaviness after Botox injections in the forehead area are due to over paralysis of the forehead muscle, causing drooping of the eyebrow. This, in turn, pushes the upper eyelid down.

Are those lines between and above your eyebrows starting to become more pronounced? Do your eyebrows seem lower than usual? It’s only natural to be bothered by these details on your face because a...

Also referred to as Botox brow lift, it’s a non-invasive procedure that treats frown lines between your brows and elevates your eyebrows as well.. Because the brow muscles are relaxed, your forehead muscles can easily pull them up and therefore elevate your brows and open up your eyes.. Getting Botox for brow lift or brow elevation certainly comes with lots of benefits.. Your doctor will typically inject Botox into the frown lines between your brows but he can also inject into other problem areas, such as your forehead and around your mouth or eyes.. Men’s brows should be just on the ridge while women’s brows should be above the edge of the brow ridge or in the superciliary arch.. Eyebrow surgery can ruin the ideal balance of the brows, which is why Botox may be the better alternative as brow depressors.. Also, if your lines and droopy brow are already way advanced, Botox treatment may not give you the results you desire in which case your doctor will recommend getting a surgical brow lift or eyelid lift instead from an experienced plastic surgeon.. Brow lifts come in three types – the endoscopic brow lift, the open brow lift, and the limited incision lateral brow lift.. The surgical brow lift will bring the brows up while the Botox injections will smooth the frown lines on your forehead.. The toxin works by keeping your facial nerves from sending signals to your treated muscles which makes the muscles that lift your brows do their function easily without resistance from the muscles that pull your brows down.. Over-plucking or over-tweezing your brows – there was a time when thinner brows were considered fashionable, so you may have plucked and tweezed your brows to death for many years.. Not filling in your eyebrows’ tails – brows do recede, so the outer brow or the tails of your eyebrows may need extra attention.

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Patient identification, efficacy, safety, dosing and administration, and resources for BOTOX<sup>®</sup> for Chronic Migraine. Click here for full Safety and Prescribing Information, including Boxed Warning

WARNING: DISTANT SPREAD OF TOXIN EFFECT Postmarketing reports indicate that the effects of BOTOX and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects.. Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse reactions associated with fatal outcomes, have been reported in patients who received BOTOX injections for unapproved uses.. In clinical trials, 30.6% of adult patients (33/108) who were not using CIC prior to injection required catheterization for urinary retention following treatment with BOTOX 200 Units, as compared to 6.7% of patients (7/104) treated with placebo.. The most frequently reported adverse reactions within 12 weeks of BOTOX injection for detrusor overactivity associated with a neurologic condition include UTI (BOTOX 24%, placebo 17%); urinary retention (BOTOX 17%, placebo 3%); and hematuria (BOTOX 4%, placebo 3%).. The most frequently reported adverse reactions during the 12 weeks following BOTOX injection of 200 Units for pediatric detrusor overactivity associated with a neurologic condition include bacteriuria (20%), UTI (7%), leukocyturia (7%), and hematuria (3%).. The most frequently reported adverse reactions following injection of BOTOX for cervical dystonia include dysphagia (19%), upper respiratory infection (12%), neck pain (11%), and headache (11%).. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.

Videos

1. How To Reduce The Chances Of An Eyelid Ptosis From Anti-Aging Injections
(Dr Tim Pearce)
2. How would I treat eyelid ptosis and brow ptosis?
(Cosmetic Courses)
3. Botox Eyebrow Lift Strategy - avoiding brow drops and spock brows.
(SkinViva Training)
4. How To Avoid This Frontalis Mistake
(Dr Tim Pearce)
5. NEW BOTOX PATTERN: Dr Tim analyses much-talked-about new glabella pattern [Aesthetics Mastery Show]
(Dr Tim Pearce)
6. What Is The Difference Between Heavy Brow & Ptosis? | Aesthetics Mastery
(SkinViva Training)

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