How to avoid causing eyelid ptosis with botulinum toxin treatment

As aesthetic clinicians, we help patients look younger, empower them to have longer, healthier lives, and be psycho-socially confident. Treatments like botulinum toxin or Botox® are often part of the aesthetic treatment journey. However, we must ensure that patients are protected from potential negative side effects when delivering these treatments, including eyelid ptosis.

In this blog, Dr Tim Pearce explains the causes of eye-related complications, like eyelid ptosis, from botulinum toxin injections and how to avoid them by altering your injection technique. He will discuss the importance of 3D Anatomy, which improves visualisation of ‘danger areas’ that can lead to negative outcomes.

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Eyelid ptosis, the most feared complication with Botox

The side effect that is most feared by any clinician delivering botulinum toxin treatments in the face, and the one most likely to keep practitioners awake at night with worry, is an eyelid droop or eyelid ptosis.

This complication is very upsetting for patients, they cannot cover it or camouflage it with makeup, and it can disrupt their daily life, both cosmetically and functionally. Some may even get visual disturbance because the eyelid can be so low that they cannot see directly in front of themselves.

Learning to avoid eyelid ptosis starts with understanding the anatomy, ideally in three dimensions, using 3D anatomy diagrams and software tools like we have developed for Pro Tox. This allows you to see the structures in and around the eye, many of which are not often highlighted in mainstream aesthetic training, and gain detailed, visual insight into where the botulinum toxin would need to go to cause the side effect; then, you can make sure you do not place it in an area that could lead to drooping of the eyelid.

Considering the 3D anatomy of the eye

Looking at this 3D diagram of the anatomy of the eye, we see a semi-translucent area, the orbital membrane. This membrane represents the boundary between the orbit and the rest of the face. Most of the structures involved in causing the most concerning side effects related to the eye are behind this membrane, which gives us a big clue that we should avoid getting botulinum toxin into this area. However, we need to break down the anatomy still further to see the superior muscles of the eye.

The deepest muscle, attached to the sclera is the superior rectus muscle. It pulls the eye back, lifting it, and allowing an upward gaze towards the sky. On top is a smooth muscle sitting between the levator palpebrae muscle, and the superior rectus, called the tarsal or Muller’s muscle.

Being a smooth muscle means the tarsal is an involuntary muscle that does not respond to conscious control – you cannot actively say to yourself, “I’m going to contract Muller’s muscle”, but if you are stressed or anxious, had a recent fright or have taken stimulants, the muscle will become more active, and is why people’s eyes widen in certain circumstances.

Above the tarsal muscle, we find the muscle that is most adversely affected by botulinum toxin treatments, the levator palpebrae muscle, because it is the first muscle that Botox would encounter once it has passed through the fat around the upper eye.

The levator palpebrae muscle is a deep structure that resides on top of the superior rectus muscle as it passes back into the globe, approximately 4 to 5cm, before touching the back of the orbit.

Many aesthetic clinicians, understandably, assume that injecting the eyelid will cause eyelid ptosis, but injecting the eyelid causes the eyelid to open. To directly and adversely affect the muscle that pulls the eyelid open – the levator palpebrae muscle – you would need to get the botulinum toxin behind the eyelid.

How to inject Botox to avoid affecting the levator palpebrae muscle

To reiterate, avoiding the eyelid is not going to help you avoid eyelid ptosis. The key parameter is injection depth, particularly in relationship to the orbital membrane.

Spinning the concept on its head – if you wanted to cause an eyelid ptosis, what would you do? The simplest way would be to place a needle (with your dose of botulinum toxin) straight through orbicularis oculi, through the orbital membrane, and into the superior surface above the globe. Therefore, any remotely similar injection will increase the chance of causing this side effect and should be avoided.

Most botulinum toxin treatments close to this area of the eye involve treating the corrugator supercilii muscle, (or the orbicularis oculi muscle, in some cases), and your technique should be designed to reduce risk.

The origin of the corrugator supercilii is on the bone, just above the nasal bone, and its insertion is in the skin, near the mid-pupillary line, running in a relatively straight line. You can test it through contraction and should be injecting along its path. However, it is not as simple as injecting in the same way all along its path because you must follow the depth of the muscle.

When injecting botulinum toxin into the head of the corrugator supercilii muscle, start with a deep injection, aiming the needle towards the muscle’s origin. As you move laterally toward the medial part of the muscle, adjust to a medium depth. Finally, when injecting near the outer ends (or “tails”) of the corrugator, the depth should become more superficial.

If the injection is too deep and goes beyond the muscle, the toxin may spread beneath the corrugator and migrate toward the eye, increasing the risk of complications like eyelid drooping (ptosis). Even a depth difference of just half a millimetre can lead to this issue.

For an extra safety step, place some pressure on the inside of the orbital rim while you inject, and when you finish injecting, roll your finger away from the eye.

By carefully following the muscle’s path—starting deep and progressively reducing the depth—you minimise the risk of toxin spread and avoid complications like ptosis.

Get more helpful tips from Dr Tim on eye anatomy to prevent eyelid ptosis from Botox® and how to identify and fix eyelid ptosis caused by Botox injections.

Remember, if you have any questions or topics for discussion, you can find Dr Tim Pearce on Instagram.

Introducing Pro Tox

If you have been waiting to stop second-guessing yourself during botulinum toxin treatments, deliver flawless results that keep patients coming back, unlock advanced techniques, minimise complications, and finally feel like the expert injector you know you can be; find out more about the Pro Tox system from Dr Tim Pearce.

With Pro Tox, you will have the tools and comprehensive training to deliver consistently flawless results that keep your patients loyal, happy, and referring their friends – without needing review appointments or competing on price.

Botox® is a registered trademark of Allergan Aesthetics plc.

Aesthetics Mastery Show

Avoid Eyelid Ptosis From Botox Treatments

Dr Tim says:

“In this episode I explain how to avoid eye ptosis from Botox injections, the anatomy you need to master to avoid causing this complication and my top tips to grow your confidence when it comes to treating the eyes with Botox.”

Watch the full Aesthetics Mastery Show here.

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BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• BOTOX® Foundation Course
• Botulinum Toxin Complications Mastery

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.