- Allergic reaction is rare but possible and one reason why injections are best done in a medical office, rather than someone’s living room (with reference to Botox® parties) so that an acute allergic reaction may be treated.
- Headaches are sometimes reported after injection, but at the same rate as for placebo.
- Droopy eyelids or eyebrows are complications seen with some regularity (3%) in large series of patients. This problem is thought to be due to diffusion of the toxin down around the levator muscle, which pulls up on the upper eyelid. Of course, the operator does not inject Botox® directly into the upper eyelid. When injecting the corrugator muscle above the medial portion of the brow, some of the Botox® may diffuse down to this muscle. To avoid this phenomenon,
experienced operators stay above the eyebrow with their injections, avoiding the central portion of the brow. The other reason for avoiding injection over the mid-portion of the eyebrow is that this weakens the frontalis muscle that pulls up on the eyebrow. The eyebrow drops, the exact reverse of the desired outcome - eyebrow elevation. A flattened eyebrow not only is unattractive, but can cause the skin of the upper eyelid to drop too, particularly if the patient is in the habit of (unconsciously) using the frontalis to hoist the eyebrow up to help offset the sagging skin of the upper lid.
Sometimes patients wonder why they can still see wrinkles above the midportion and lateral eyebrow after their Botox® treatment. They are pleased with how smooth
the middle of the forehead looks and would like these latera creases smoothed out too. The problem is that treatment of these areas risks dropping the brow. Patients readily understand this concept when it is explained to them.
Eyebrow Wrinkles: What Can Be Done
I inject a small amount of additional Botox® in the lateral forehead or just above the eyebrow. This can achieve just the right degree of wrinkle improvement without dropping the brow. Patients need to know that there is some risk in trying to achieve perfection, but this approach of using a small touchup Botox® injection has worked well in my practice.
What is the frequency of eye brow complications?
I have had one case of a droopy upper eyelid in which diffusion of Botox® to the levator
muscle was likely the cause. It was subtle enough that the
patient herself was aware of it but few other people
noticed. I had a memorable male patient whose brows dropped
after a Botox® injection. In retrospect, this patient would
likely have benefitted from an endoscopic forehead lift. He
already had low-set ("ptotic") brows and the Botox® treatment was just enough to drop his brows.