Botox injections are a popular way to temporarily reduce the appearance of wrinkles and fine lines on the face. While generally safe when administered properly, Botox does have potential side effects. One of the most concerning potential side effects of Botox is eyelid drooping, also known as ptosis.
What is ptosis?
Ptosis refers to drooping or falling of the upper eyelid. It occurs when the muscle that lifts the eyelid (levator palpebrae superioris) becomes weak or paralyzed, preventing the eyelid from opening fully. Ptosis can affect one or both eyes.
Causes of ptosis
There are several possible causes of ptosis:
- Aging – Drooping eyelids can occur due to weakening of the levator muscle with age.
- Medical conditions – Such as stroke, tumor, nerve damage or injury.
- Side effect of medications – Some medications, including Botox, can cause muscle weakness that leads to ptosis.
How does Botox cause ptosis?
Botox contains botulinum toxin, which blocks signals from the nerves to the muscles. When injected in the forehead, crows feet area, and other parts of the upper face, Botox reduces muscle contractions to smooth wrinkles. However, it can also diffuse into nearby muscles like the levator palpebrae superioris.
Paralysis or weakness of this eyelid lifting muscle makes it difficult to keep the eyes fully open, causing an eyelid droop. Ptosis is a well-known adverse effect of Botox that patients must be informed about prior to treatment.
Timeline for Botox ptosis
If ptosis occurs after Botox injections, it usually begins within the first week after the procedure. Here is a general timeline:
- Within 2-3 days – Early onset ptosis may occur.
- Within 1 week – Most cases of ptosis will be apparent.
- Within 2 weeks – Maximum drooping effect is seen.
In a study published in the journal Clinical Ophthalmology, researchers analyzed cases of ptosis after Botox injections for facial wrinkles. Out of 403 patients, 19 (4.7%) developed ptosis. They found:
- Onset of ptosis ranged from 1 to 30 days after Botox treatment.
- The average onset time was 9.7 days.
Based on this and other studies, patients can expect ptosis within the first 1-2 weeks after Botox if it is going to occur. But some cases may begin sooner or later.
Factors affecting timing of ptosis from Botox
Certain factors can influence when someone may develop an eyelid droop after Botox:
- Botox dosage – Higher doses and injections near the eyes increase risk.
- Underlying weakness – People with pre-existing eyelid muscle weakness may react sooner.
- Repeat injections – Previous Botox increases susceptibility.
- Certain medications – Interactions with drugs like sleeping pills.
How long does Botox ptosis last?
The effects of Botox typically wear off within 3-6 months. As the Botox toxin gets metabolized, signal transmission to the muscles begins to recover. This leads to gradual strengthening of the eyelid muscle and lifting of the droop.
In cases of ptosis after Botox injections near the eyes, patients can expect resolution of eyelid drooping as the Botox effect fades. Here is a general timeline for duration:
- Mild ptosis: Usually resolves within 1-2 months
- Moderate ptosis: May last 2-3 months
- Severe ptosis: Can take 4-6 months to fully reverse
However, there are exceptions where ptosis lasts longer than expected or becomes permanent. Factors such as older age, high Botox dose, and underlying muscle disorders increase the risk of long-term or permanent eyelid drooping.
Options for treating prolonged Botox ptosis
If ptosis from Botox persists longer than desired, there are treatment options to consider:
- Additional doses of apraclonidine eye drops – Can provide temporary lifting
- Eyelid crutches – Can be worn to manually lift the eyelid
- Ptosis surgery – To tighten the levator muscle and lift the eyelid
Working closely with an experienced oculoplastic surgeon is important in cases of lasting Botox ptosis to discuss management approaches.
Risk factors for ptosis with Botox
While anyone receiving Botox around the eyes could develop ptosis, certain factors increase the risk:
- Advanced age – Muscle weakness more likely
- Very close injection to levator muscle
- High Botox dosage used
- Pre-existing eyelid or muscle issues
- Multiple previous Botox treatments
- Concurrent use of medications that enhance Botox effects
Being aware of these risk factors allows patients and providers to take steps to lower ptosis risk when considering Botox treatment.
Steps to reduce risk of ptosis with Botox
Some recommendations to lower the chances of ptosis with Botox include:
- Avoiding Botox above the eyes or close to the upper lid
- Using the lowest effective dose
- Not injecting into the levator muscle
- Allowing at least 3 months between Botox treatments
- Modifying dosage in elderly patients and those with pre-existing eyelid or muscle issues
Signs and symptoms of Botox ptosis
With ptosis after Botox injections, patients may experience:
- Drooping of one or both upper eyelids
- Inability to fully open the eyes
- Feeling that the eyelids are heavy or tired
- Reduced field of vision due to eyelid covering the pupil
- Difficulty lifting the eyebrows
The signs and symptoms of ptosis can range from barely noticeable to severely obstructing vision. Mild cases may only be apparent on close inspection, while severe ptosis can prevent the eye from opening at all.
Assessing severity of Botox ptosis
Doctors grade ptosis on a scale by measuring marginal reflex distance (MRD), which is the space between the upper eyelid and the pupil:
| Ptosis Grade | Marginal Reflex Distance (MRD) |
| Mild | 2 to 4 mm |
| Moderate | 1 to 2 mm |
| Severe | Less than 1 mm |
This helps guide treatment options, such as conservative measures for mild cases versus surgical correction for severe ptosis obstructing vision.
Preventing Botox ptosis
The most effective way to prevent ptosis from Botox injections around the eyes is to avoid injecting into the upper eyelid area altogether. However, some patients do request Botox to reduce crow’s feet and wrinkles in the forehead near the eyebrows.
In these cases, proper injection technique and dosage can lower (but not eliminate) the risk of ptosis:
- Carefully inject Botox at least 1 cm above the bony orbital rim of the eye socket to avoid diffusion downward.
- Use the minimal effective dose and volume needed.
- Inject slowly and evenly when treating multiple points in the upper face.
- Do not inject directly into the levator palpebrae superioris muscle.
- Avoid reinjection above the eyes within 3 months of previous treatment.
Proper injection technique minimizes, but does not remove, the risk of ptosis with upper facial Botox treatments.
Steps to take if Botox ptosis occurs
If eyelid drooping develops after Botox injections near the eyes, here are some steps to take:
- See an ophthalmologist promptly for evaluation of ptosis severity.
- Use eyedrops like apraclonidine to temporarily lift the eyelid while waiting for Botox to wear off.
- Consider eyelid crutches if vision is very obstructed.
- Wait for Botox effect to fade over several months and monitor for resolution.
- Discuss need for ptosis surgery if drooping persists long-term.
With proper monitoring and management, most cases of Botox ptosis will improve within a few months. But persisting, severe ptosis may require surgical correction.
Conclusion
Ptosis, or eyelid drooping, is a known possible side effect of Botox injections around the upper face and eyes. If it occurs, patients typically notice eyelid drooping within the first 1-2 weeks after Botox treatment. Mild cases usually resolve fully within a couple months, while severe ptosis can take 4-6 months to improve as the effects of Botox wear off. Proper injection technique, dosage, and avoiding reinjection too soon can reduce the risk of ptosis with Botox for forehead and eye wrinkles.