Understanding Eyelid Ptosis After Botox Injections

Have you ever had a patient mention a droopy eyelid after Botox treatment and felt a little unsure about what’s going on? Or maybe you’re just curious about this side effect that doesn’t get talked about enough? You’re definitely not alone! I think it’s really helpful, maybe even reassuring to understand a bit more about eyelid ptosis after Botox, especially since it can be quite worrying for both you and your patients.

So, what exactly is eyelid ptosis? Well, it’s when the upper eyelid droops lower than usual, sometimes even partly covering the pupil. It can feel quite unsettling when it happens after Botox injections, but here’s the tricky bit, it’s often confused with other things, like brow ptosis or natural asymmetry that maybe your patient just hadn’t noticed before. It happens more than you might think!

In this little guide, I want to gently walk you through what true eyelid ptosis is, how to spot it properly (without mixing it up with other conditions), and what you might be able to do to help fix it.

And don’t worry, I’ll also share some practical tips on how to avoid causing ptosis in the first place, so your treatments can be as safe and effective as possible. Let's dive in and take the mystery out of Botox-induced ptosis together.

What Exactly Is Eyelid Ptosis and Why Does It Happen After Botox?

So, let’s get comfy with this term first, eyelid ptosis. It basically means the upper eyelid droops down more than usual, sometimes partially covering the eye. Now, I know that sounds a little alarming, but it’s really important to remember that it’s quite a rare side effect of Botox injections, especially when treatments are done carefully.

You see, the eyelid is lifted by a muscle called the levator palpebrae superioris, which works in a kind of elegant pulley system to keep your eyes open and bright. When Botox sneaks a little too close to this muscle often by accident, it can cause that muscle to relax too much, and then the eyelid can droop. It’s sort of like a gentle “oops” from the toxin, and we definitely want to avoid that as much as possible!

But here’s a tiny nugget that often trips people up: a lot of the time, what looks like a droopy eyelid is actually a case of brow ptosis where the eyebrow itself sinks a bit or even natural facial asymmetry that might have always been there but went unnoticed until after the treatment. So, the first step is always to check carefully which one you’re dealing with.

Does that make sense so far? I promise it’s easier to spot once you know what to look for, and that’s exactly what we’ll explore next!

How to Tell If It’s Eyelid Ptosis or Something Else

Okay, so now that we know what eyelid ptosis actually means, the next little puzzle is figuring out whether that droopy look is really ptosis or if it’s one of its sneaky lookalikes. This bit can be tricky, but don’t worry, with a little practice, you’ll be spotting the difference in no time!

First off, remember: eyelid ptosis is about the upper eyelid drooping below its usual position relative to the pupil. The key is to look closely at the eyelid margin compared to the center of the eye, that pupil is your best friend here! If the eyelid is shading or covering the pupil, you might be dealing with true ptosis.

Now, in contrast, brow ptosis is when the eyebrow itself starts to sag and droop down towards the eyelid. This can create the illusion of a droopy eyelid because the skin and soft tissue above the eye seem to weigh down the whole area. This is more common than you might think, especially in patients with naturally heavier brows or those experiencing age-related skin laxity.

Also, don’t forget about congenital asymmetry, that’s a fancy way of saying some people just have a slight natural difference between their eyes or eyelids. Sometimes patients only really notice it after treatments because they’re looking so closely at their face, and it can be mistaken for a treatment side effect.

So, the best tip I can give you is: always check your patient’s before photos carefully! It’s like detective work, spotting what’s new versus what’s always been there can save a lot of stress later on.

Treating Eyelid Ptosis Caused by Botox

I know this sounds a little surprising, but sometimes the best way to fix a droopy eyelid caused by Botox is with a tiny bit more Botox. The eyelid muscles work in pairs, the levator palpebrae lifts the lid, and the orbicularis oculi muscle gently closes it. By carefully injecting a small amount (usually 1 to 3 units) of Botox into the orbicularis oculi muscle, you can reduce its pull and help lift the eyelid slightly.

“You know, I found it really reassuring to read a 2023 case report by Musharbash and Chakra in the Aesthetic Surgery Journal, where they shared how a full eyelid ptosis after Botox was actually reversed with a second, carefully placed dose of botulinum toxin. Isn’t that fascinating? It just goes to show how much of this comes down to understanding facial anatomy, timing, and using a really gentle, bespoke approach when we’re correcting something that’s gone a little off-track.

Nurse Marina’s Clinical Tips for Managing Eyelid Ptosis After Botulinum Toxin Injections

Tip	Clinical Insight	Extra Notes
Take clear before-and-after photos	Document pre-existing asymmetry or subtle ptosis that might have gone unnoticed.	Use consistent lighting and head position for accuracy.
Differentiate eyelid vs. brow ptosis	Measure MRD1 (marginal reflex distance 1). True ptosis affects eyelid margin, while brow ptosis affects frontalis function.	Gently lift the brow to see if the lid lifts too, a little trick I love using!
Rule out systemic or neurological causes	Consider conditions like myasthenia gravis, Horner’s syndrome, or age-related ptosis before attributing it to Botox.	If in doubt, refer, always safer!
Micro-dose additional Botox (if appropriate)	Inject 1–2 units in the orbicularis oculi to reduce downward pull, supporting muscular balance.	Always tread lightly.
Reassure and educate the patient	Most cases of Botox-induced eyelid ptosis resolve in 2–6 weeks. Encourage patience and gentle support.	Encourage patience and gentle support.
Document thoroughly	Note units, injection points, dilution, and client response.	Always write down everything.

Managing Eyelid Ptosis

I know, eyelid ptosis after Botox injections might sound a bit scary at first, but honestly, with the right knowledge and a calm approach, it’s something you can manage really well. Whether it’s spotting the difference between true eyelid ptosis and brow drooping, knowing which treatment options to try, or simply preventing it from happening in the first place, you’ve got the tools to keep your patients smiling and feeling great.

Thank you so much for spending this time with me, I really hope you feel a little more confident about handling eyelid ptosis now. If you have any questions or want to share your experiences, I’d love to hear from you. You can always drop me a message or find me on social media.

About Me

Hi, I’m Nurse Marina, and I’m so glad you’re here! Before transitioning into aesthetics, I spent 6 years as a Cardiac Nurse at KIMS Hospital in Maidstone, where I developed a deep understanding of anatomy. I then honed my skills as a Specialist Aesthetics Nurse at Spencer Private Hospital in Kent.

I’m a proud member of professional organizations like JCCP, BAMAN, NMC, ACE Group, and the Royal College of Nursing. I want to make sure that every treatment I deliver is backed by the latest knowledge and techniques in medical aesthetics.

To contact me directly, call me on 07413138825 or send me a DM on Facebook or Instagram.

References

1. Musharbash, I., & Chakra, R. (2023). Treatment of full eyelid ptosis following Botox injection: A case report. Aesthetic Surgery Journal, 43(9), 955-961.

   • This case report demonstrates the successful reversal of eyelid ptosis caused by Botox injections using a second dose of botulinum toxin. JAAD Case Reports+2ResearchGate+2PMC+2

2. Kushner, B. J. (1999). Botulinum toxin treatment of mechanical eyelid ptosis. Ophthalmology, 106(1), 144-147.

   • This study examines the use of botulinum toxin to treat mechanical eyelid ptosis, highlighting its potential benefits and limitations.