March 16, 2023

eyelid ptosis eye

Dr Tim Pearce recently shared a video showing him injecting Botox® (botulinum toxin) around the eye with the needle pointed towards the eye. This generated a lot of interest and comments, with many aesthetic sector colleagues unhappy with this direction.

Therefore, in this blog, Dr Tim Pearce will explain why you can inject botulinum toxin pointing towards the eye in certain circumstances (and with certain levels of skill), but also why you should not do that in many other situations.

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 >>

Why should you not point the needle towards the eye when injecting botulinum toxin?

Dr Tim has been an aesthetic medical trainer for many years; he teaches new students to inject pointing AWAY from the eye and explains that there is a very important reason for this methodology.

When a practitioner first starts injecting cosmetic injectables, their control over the needle, the dexterity required, and their 3D facial anatomy awareness is relatively poor. Therefore, the teaching layers on top different things that can be done which decrease the chance of one error being a critical error for the patient. For example, the singular error of injecting too deeply, if pointing towards the eye, has very different consequences than if you are pointing away from the eye and injecting too deeply. Hence, newer injectors should always inject away from the eye because it is less likely that one error will lead to an undesirable consequence.

His experience, training many thousands of clinicians, has revealed that people have differing levels of dexterity and ability to control their spine movements, making them unstable in their upper body; hence, controlling needle depth and ultimately injection safety is compromised. Therefore, when undertaking foundation training courses in botulinum toxin and dermal fillers, he trains healthcare practitioners to inject away from the eye due to the variations in the control of their fine motor movements. For more advice on good injection techniques, including needle depth and body positioning, read Dr Tim’s blog on injection techniques 101.

Dr Tim goes on to share that when he is injecting botulinum toxin, he is very aware of exactly where the needle tip is positioned, especially with superficial injections. He has also spent many years thinking about the anatomy around the eye and feels very confident that he is not going to be placing botulinum toxin into the orbit or into a different layer of tissue, for example. He notes that if he were to go too deeply, he would know not to inject and would notice the incorrect needle placement, going on to state that this does not happen to him anymore because he has performed a considerable amount of treatments and has good control over the needle tip, thanks to thousands of repetitions.

Reiterating his warning, Dr Tim states that if you are a newer injector or you are using a blunted needle, it is quite easy to be trying to inject into a certain tissue plane and for the skin not to give away, suddenly popping, and resulting in the needle going in deeper than you meant it to. This can create a tract and botulinum toxin could flow into an area that you did not mean to treat and might increase your risk. If you have very good control, can place the needle so the depth and angle is correct, then the direction the needle is pointing may matter less, but is one of many factors to consider when injecting.

What is happening when you are injecting botulinum toxin?

There are several considerations that you must pay attention to when injecting botulinum toxin, notes Dr Tim.

  • What is the depth of your needle?
  • Where is the needle positioned?
  • Where is the bolus going to fill? – When you place a 0.5 ml bolus of combined saline and botulinum toxin, it will fill around the exit point of the needle. It is not like a hose, it does not spray the solution underneath the tissue, it forms a bubble above the bevel of the needle. If your needle tip is accurately placed, you should be able to deliver a bolus safely no matter which direction you point the needle. Problems arise from tracks caused by the needle.
  • Choose a safe entry point so you know exactly where the needle bevel is positioned.
  • Develop your 3D understanding of the face so you know the safe areas to inject and the unsafe areas; the direction of the needle is one safer way to do this in the beginning.

Does injecting towards the eye leave the eye unprotected?

The short answer to this is no, says Dr Tim, because there are multiple other ways you are protecting the eye, the most important of which is having control over the needle depth.

If you are confident that you are only injecting two to three millimetres underneath the skin, then the direction of the needle does not make much difference because of the way the botulinum toxin flows out from the bevel of the needle as a bubble and not in a line in the direction the needle is pointing. You can tell, because every time you inject you see the skin raise up in a bleb. The eye in therefore protected by the position and depth of your needle.

Inject in a way that you feel safe

dr tim rhinoplasty treatmentDr Tim concludes that it is worth thinking about the direction of your needle in many of the places where we are injecting. He feels safe when it is a superficial injection with botulinum toxin but highlights that if you are performing a dermal filler treatment in the tear trough and you cannot see the end of your instrument very well, it is much more important that you are pointing in a safe direction.

He warns that although he feels comfortable doing it, it does not mean you should do it. Dr Tim recommends that if you are within your first few hundred patients, do continue to inject away from the eye for safety.

Despite this, he is pleased that this has encouraged discussion and a feeling of discomfort amongst other aesthetic clinicians because it makes them think through what they are doing in their practice, the certainty of their methods, and the safeguards they have in place.

You can download Dr Tim Pearce’s free guide to 26 essential patterns for Botox® for more specific information on product placement when treating with botulinum toxin.

Dr Tim always loves to hear from his followers, so why not drop him a comment on social media if you have more to say on needle depth and direction when injecting Botox you can find Dr Tim Pearce on Instagram.


Botox® is a registered trademark of Allergan Aesthetics plc.

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Aesthetics Mastery Show

Can you inject Botox towards the eye? Botox Needle Placement & Injection Techniques.

In this episode, Dr Tim thoroughly explains his technique, provides safety advice, discusses needle placement, and shares his injection techniques. This video will help you gain a better understanding of how to safely perform Botox injections around the eye. Watch the full Aesthetics Mastery Show here.

The show has had great interaction from practitioners and patients with over 7k views since it was released on 2nd March.

Br@dley reported on his own experiences, saying:

“I had just a smidge of post prick bruising exactly where you show here (not his fault I have practically transparent fair skin) but I noticed how much MORE of a difference it makes with my under-eye texture. Like many people, I really thought I needed filler here but when I started getting my eye/occular/crows whatever done the way shown above I look my age and even on the most stressful of days the lines that bothered me so much before just barely start to form and even then are not nearly as strong. While I do use tretinoin i keep it far away from this area for fear of getting a case of the “grannies” (false overnight hyperagingaffect of drying) and I have no idea what the actual concentration of retinol is in my eye serum but i’m pretty sure the botox holding things in proper place is whats doing the job and would never tell my friends “oh yes just try this retinol cream” id recommend tretinoin to anyone, but not anything else over a proper dr pearce method/inspired treatment.”

Dr Owen Thomas of Infinity Aesthetics said:

“I think the main thing is many people don’t like the idea of injecting towards an eye rather than there being a logical reason. I guess many injectors are quite new to injecting generally and after years in hospital and GP it’s so interesting to hear how little control people have over a needle!”

Read more questions and answers or join in the debate on our YouTube channel.

Filler Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

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.

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