February 9, 2023

eyelid ptosis eye

Having recently posted a video tutorial on Instagram demonstrating performing a brow lift using botulinum toxin (Botox®), Dr Tim Pearce was inundated with questions asking how he was able to inject underneath the eyebrow and not cause an eyelid ptosis.

In this blog, Dr Tim will delve into his technique and reasoning behind injecting Botox under the eyebrow to achieve a brow lift.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

What happens when you inject the eyelid with Botox?

As aesthetic clinicians, we are all afraid of causing eyelid ptosis when we inject patients with botulinum toxin. The key, as always, comes with understanding the anatomy – the nuances of different muscles and how they are affected by the neurotoxin. This improved understanding may even be contrary to your initial thinking when you first learned how to inject botulinum toxin in this area.

When viewing Dr Tim’s brow lift tutorial video, many were concerned that his injection points were so close to the eyelid that they would cause an eyelid drop or ptosis.

Instagram BOTOX Brow Lift Tutorial

Interestingly, clinical studies have already been performed (mostly in the ophthalmology specialty) to assess the eyelid following injection with botulinum toxin and you may be surprised to discover that it lifts the eyelid.


What causes eyelid ptosis when injecting Botox?

The superficial muscles in the eyelid are the protractors of the eyelid, they are not the retractors. The retractor is the levator palpebrae muscle which runs in the orbit, and this is the muscle we are most concerned about avoiding when injecting near the eyelid.

Conversely, injecting the orbicularis oculi, which runs in the eyelid, allows your eyelid to open slightly. This is because when you close your eyes, it is contracting, and when you relax, it opens. This is the reverse of most aesthetic practitioners’ understanding and means you do not need to worry too much about eyelid ptosis when treating this muscle. In fact, it is used as a treatment for eyelid ptosis following accidental injection of the levator palpebrae muscle because superficially injecting the orbicularis oculi will cause the eyelid to lift.

However, we can get eyelid ptosis from injecting superior to the eye, warns Dr Tim, but knowing precisely where these muscles are located, and the layer of tissue that they are within, will give you confidence to inject in areas where mainstream understanding dictates that you will get an eyelid ptosis.

Understanding the anatomy of the eye and the impact on eyelid ptosis

Let’s first consider the multiple anatomical layers within the eye area. Starting with the top layer; we begin with the dermis, followed by a thin layer of fat in the hypodermis, beneath is the orbicularis oculi muscle, followed by the retro-orbicularis oculi fat pad, moving deeper is the orbital septum, with the preseptal fat pads underneath, and finally the levator palpebrae muscle.

By placing the botulinum toxin on top of the orbicularis occuli muscle, you can see that the levator palpebrae muscle is shielded from the effects of the toxin by multiple different layers of tissue. By injecting tiny amounts, just on top of the muscle, the other layers protect the important structures within the orbit, meaning that it is the depth of injection, rather than the position, relative to the eyelid, that keeps those internal structures safe.

How many units of Botox do you use under the eyebrow for a brow lift?

This was also a common question in response to the demonstration video, and Dr Tim explains that when injecting underneath the eyebrow, he uses a one-unit dose of Botox. This is enough to achieve a difference and affect the muscle fibres that are pulling the eyebrow downwards because the aim is not to paralyse the bulk of the muscle. One unit is also a safe amount of Botox – the dose-response curve notes that smaller doses are less likely to cause problems.

Dr Tim typically uses one to three units of Botox underneath the brow, in conjunction with the stronger doses recommended in the license at the lateral canthus. He also uses the standard dilution of 2.5mls of bacteriostatic saline with 100 units of Botox, but rarely may use a more concentrated form if treating in an area where he wants to ensure less spread, most likely when treating the lower face, injecting the depressor angularis oris (DAO) or the mentalis.

Does the brow lift occur from injecting below the eyebrow or from injecting above the eyebrow as well?

If you inject directly above the eyebrow, in the frontalis muscle – this is the elevator of the eyebrow – you are going to decrease the power of that muscle to lift. It is therefore more likely to achieve a drop – losing the eyebrow arch – which most aesthetic clinicians fear greatly.

A brow lift can only be realised when you affect the tug of war that is going on at the eyebrow between the two muscles – the elevator (frontalis) and the depressor (orbicularis oculi).

Note that if you shut your eyes very tightly, your eyebrow will lower; this is caused by the depressor action of orbicularis oculi.

If the orbicularis oculi muscle is weakened with botulinum toxin, it will reduce its strength and downward pull. To create the eyebrow lift, we also increase the resting tone of the lateral frontalis muscle, by treating the middle of the frontalis which makes the lateral more active. As a rule of thumb, we do not want to inject in this elevating part of the frontalis muscle that raises the eyebrow laterally because it will impact on the eyebrow arch and could risk a brow ptosis.

botox-spock-brow-largeHowever, on noting this, you may be concerned that this approach may cause a so-called Spock brow. Dr Tim explains that typically a Spock brow is a medial brow ptosis and a lateral brow lift. If you over treat the middle and under treat the side, it will result in this disequilibrium. There will be too much activity and too much heaviness in the middle, creating the unpleasant brow shape. He acknowledges that his approach to achieving a brow lift could put the result on the Spock brow spectrum but asserts that everything we do as aesthetic clinicians is about trying to make small adjustments to create a happy medium.

If required, perhaps due to a very strong frontalis that creates a lateral brow lift that is too significant, then one unit can be placed at the top of the lateral frontalis.

It is better to start by under treating, particularly with a new or older patient, and make that simple adjustment at a two-week follow-up appointment, ensuring you add it to their patient notes for next time!

For more on this topic from Dr Tim, read his blog on how to identify and fix eyelid ptosis caused by Botox injections and the best Botox brow lift injection patterns to avoid ptosis and Spock brow.

For more information on eye and eyelid anatomy, watch his video on eyelid ptosis from botulinum toxins, understanding the crucial anatomy.

If you have any questions or comments about eyelid ptosis or Botox brow lift treatments, you can find Dr Tim Pearce on Instagram.

Is your worst nightmare causing a VO?

If you want to be a great injector then you need to get over your fear of complications. Register here for the next webinar to help you overcome your complications anxiety >>

Subscribe to our YouTube channel for really useful regular tips and advice.  YouTube


Botox® is a registered trademark of Allergan Aesthetics plc.

Aesthetics Mastery Show

How To Inject Botox Under The Brow | Botox Brow Lift Advice

In this Aesthetics Mastery Show, Dr. Tim looks into the technique and reasoning behind injecting Botox under the eyebrow to achieve a brow lift. He also addresses frequently asked questions regarding this injection process, including how to avoid a “Spock brow” and the depth of injection in that area. Watch the full Aesthetics Mastery Show here.

The show has had over 18,000 views in under a week. It’s also had comments and feedback messages, including:

Roberto Salgado said:

“Excellent information, so well understood! I’ve been watching your videos a few months ago and have followed some of your advices. Thank you very much for sharing!!”

CC added:

“It is CRAZY how you can be taught one way and then learn to do it the exact OPPOSITE way. Shows that cosmetics is infantile in it’s development still.”

April Grosvenor asked:

“I love it. Been doing it for years. Loved that brow lift video BTW. Great upgrade. Can u show a great forehead pattern for those clients’ frontalis seems to go all the way over and past the temporal crest”

To which Dr Tim’s team replied:

“Those that go past the temporal crest are more likely to Spock so just make sure you treat frontalis where you see movement, it will hinder lift if that is what your are trying to achieve.
Kindest regards Mary. Clinical advisor for Dr Tim”

Read more comments or join in the debate on our YouTube channel.

Dr Tim Pearce eLearning

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

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.

Get In Touch

Please leave a message