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Dr Tim Pearce
Patients often ask their aesthetic practitioner for botulinum toxin or Botox® treatment under the eye area to rid themselves of fine lines and wrinkles, or a ‘jelly roll’. This is distinct from the common areas for Botox treatment for the upper face and is a tricky area to treat. Now, many aesthetic clinicians are asking if they should be injecting Botox under the eye, as an off-label indication, or not.
In this blog, Dr Tim Pearce explains when you might inject botulinum toxin under the eye, and when you would not. He notes that you can achieve a great result with this technique, although it is not straightforward, and patient selection is critical. He discusses the potential risks, side effects, and ways to address patient concerns in this area.
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Why would you consider injecting Botox under the eye?
Several indications could lead to the decision to inject botulinum toxin under the eye, but the most common one is probably to address fine lines and wrinkles. However, this technique can also be used to treat the so-called ‘jelly roll’ which is created from compression of the lower eyelid by the contraction of the orbicularis oculi muscle. You can also widen the eyes, of certain people, using this treatment technique.
Treating the under eye with Botox for fine lines and wrinkles
This is a very common request from patients but does not usually achieve a great result, although there are some exceptions.
Firstly, we must consider the type of wrinkle presented because some people have a line under their eye that annoys them, but you will find that it is part of their normal eye structure and is meant to be there. It is not a crease and you do not want to treat those lines. Some people develop fine lines and creases only when the zygomaticus muscle is contracting, meaning that they are predominantly caused by the skin underneath the eye being compressed by the larger muscle in the cheek as the cheek is raised. This also cannot be treated using botulinum toxin under the eye (in the inferior part of the orbicularis oculi muscle).
The criteria for successfully treating fine lines and wrinkles under the eye would include clear contractility or hyperactivity of the muscle that is separate from the zygomaticus muscles, notes Dr Tim. You will sometimes see patients with activity in the muscle that causes lots of fine lines and wrinkles and it tends to be accompanied by a little bit of volume loss. These patients may see a benefit from botulinum toxin treatment if the muscle is constantly active.
You can place a tiny dose of Botox and it might make it more relaxed at rest, creating fewer creases that persist when they are not smiling. However, these patients can sometimes get a very good result with other treatment modalities which should be considered. Volume depletion can be directly underneath the skin, but it can also be lateral in the cheek and the muscle pulls against the emptier space caused by ageing. Hence, replacing volume around the cheek can sometimes improve the orbital lines and wrinkles, tightening the crinkled surface underneath her eyes.
Treating the under eye with Botox for eye-widening
To widen the eye, the botulinum toxin injection must be placed differently. When treating lines and wrinkles, placement is in the palpable part of the lower eyelid, however, in this instance, we are still underneath the eye but in the orbital part of orbicularis oculi.
Relaxing the muscle in the midline, just underneath the pupil, can create a rounder appearance to the eye which is particularly popular in Korea and the Far East where people believe it is more beautiful. In the West, we tend to favour almond-shaped eyes.
Treating the under eye with Botox to soften the jelly roll
The ‘jelly roll’ is a manifestation of skin bunching up underneath the eye when the orbicularis oculi muscle is contracting during a smile. Coincidentally, this is also considered beautiful in the Far East where they purposely cause the look with make-up, tape, or dermal filler treatment creating ‘aegyo sal’ – Korean for cute or baby eye skin. In the West, we are aiming for the opposite and seek to soften the aegyo sal or jelly roll using botulinum toxin.
This treatment requires a slightly higher dose of Botox covering more of the area because the aim is to stop all the upward pull of orbicularis oculi to reduce the skin bunching that forms the bulge.
Dr Tim warns that this could have a negative effect on the person’s smile, making it look less real, less like a true Duchenne smile if you decrease cheek elevation too much. Similarly, you can affect the appearance of the eyes when smiling. Normally your eyes should narrow when you smile, but if you relax the muscle too much, it can result in too much sclera (whites of the eye) showing upon smiling which can cause a psychotic look.
The importance of patient selection for injecting Botox under the eye?
Age is a key consideration for patient selection, these techniques do work but only in certain patient groups and it does get harder to achieve a good result the older the patients get.
Treating older patients with any Botox indication is trickier because the balancing point between too little and too much is narrower than in younger cohorts. Aesthetic clinicians must learn and understand the types of patients that can benefit from each of these treatment approaches to the undereye area and prepare their patients for a time when it will no longer work, and they become unsuitable candidates.
Read up on how to get a great result with Botox in older patients.
Potential complications from injecting Botox under the eye
When considering potential complications, it is also worth noting aesthetic complications, i.e., creating a result that makes the patient look worse than if they had no treatment at all, and not just those related to adverse clinical effects or medical risk.
At the extreme end of potential complications, we have ectropion. This would be very rare and would likely only occur in a very old patient who would probably be contraindicated for treatment. If you were to overtreat the muscle, and skin laxity was insufficient enough, you could cause an ectropion where the eyelid skin hangs outwards, with the eyelashes emerging, and the pink part of the eye becoming visible. This would only happen in a patient where the only thing holding the eyelid against the lower part of the globe is the muscle activity itself.
In those a little younger – 40s, 50s and above – there is the possibility of creating sagging in the undereye area with over treatment, resulting in more of the sclera showing underneath their eye, giving a sallow, stressed out, unhealthy, or psychotic look which is aesthetically displeasing.
Another potential complication is a dynamic difference when the patient smiles. In this instance, you have relaxed the orbicularis oculi muscle all the way around except for the medial part, and this is where it is now pulling every time the patient smiles. This results in a pinched appearance. The botulinum toxin has neutralised a lot of the muscles that are pulling outwards and balancing the skin underneath the eyes, but we are left with only the muscle that pulls inwards untreated, hence, it pinches, and the nose also pinches inwards creating lines on the nose and lines underneath the eye. The eyes similarly narrow medially but not laterally, creating a result that simply does not appear natural when the individual smiles during normal human interactions.
In conclusion, Dr Tim states that there are benefits to treating underneath the eye with botulinum toxin, but it is only indicated in a very narrow patient group due to the risk of creating an unnatural or ‘weird look’.
For additional guidance on botulinum toxin treatments, download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin
Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.
Aesthetics Mastery Show
Under eye Botox Lesson
Dr Tim says:
“Injecting the under eyes with Botox can be tricky. A great result for patients can be achieved with this technique but patient selection is so important here! I explain more in this video. “
Watch the full Aesthetics Mastery Show here.
The show has had thousands of views already and has also generated some interesting feedback, queries and debate.
@swierplife
“Thanks for this video! I’m 40 and I love my undereye tox, but I have no skin laxity. I’m sure there will be a point I can’t do it anymore”
@GO-xt4pp
“This is what happened to me, I did Botox 1st time between eyebrows and around the eye wrinkles. Left eye is perfect and right one was swollen for 1.5 month, then upper lid opened up and the eye hurts and dry and looks like crazy eye. And when smiled yes around the nose it was pulling all the tension and would wrinkle unusually a lot.”
Read more comments and join in the debate on our YouTube channel.
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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:
Both give CPD and certificates on completion.
In addition, browse our FREE downloadable resources on complications.
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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.
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