When Neuromodulator Injections Lead to Complications

By Julie Bain

You likely think of Botox or Dysport as a quick, safe, predictable way to tone down your frown lines and give your eyes a lift. It is, but there is also a small risk that it could have the opposite effect, even with an experienced physician. Here’s what Dr. Hooman Khorasani wants you to know. In this article he hopes to answer the following questions:

Why did my eyelids/eyebrows droop after neuromodulators (Botox/Dysport)?
What are the main reasons for eyelid/eyebrow drooping after neuromodulators (Botox/Dysport)? 
Is it possible to get eyelid/eyebrow drooping after seeing a board-certified doctor for neuromodulators (Botox/Dysport)?
How common is eyelid/eyebrow drooping after neuromodulators (Botox/Dysport)? 
Can eyelid/eyebrow drooping after neuromodulators (Botox/Dysport) be permanent?
How many days will my eyelids/eyebrows be droopy after neuromodulators (Botox/Dysport) injection? 
How can I speed up the recovery from eyelid/eyebrow drooping caused by neuromodulators (Botox/Dysport) injection?
What is Upneeq? And how does it work? 
Is eyelid/eyebrow drooping more common with Botox versus Dysport?

Background on Neuromodulators

It was just 20 years ago that the FDA first approved botulinum toxin injections to temporarily smooth frown lines. This treatment raised eyebrows, literally and figuratively, and seemed to change the Hollywood standard of beauty almost overnight. Soon the first approved brand became a verb, as millions of people “got Botoxed” on a regular basis, two or three times a year, in pursuit of a more youthful appearance without surgery.

As other brands of neuromodulators (meaning that they relax the contracting of muscles), entered the market, including Dysport in 2009, their popularity skyrocketed. It also became clear that there is both an art and a science to performing the procedure. While most patients look realistically refreshed or less “crabby” as their wrinkles relax, occasionally others may look “surprised” or even a little “blank” because their facial muscles can’t move to express emotions as before the treatment. You’ve probably heard a few jokes about actors or reality TV celebs looking like they got “too much Botox.” But if something looks awry, it’s not always as simple as that.

Complications Can Happen

Many patients have become so comfortable with their regular appointment for Botox or Dysport, it’s like getting their teeth cleaned or replacing the battery in the smoke detector. However, it’s important to know that sometimes complications may arise. The most common complication is the opposite of what is intended. Instead of opening up the eye or raising the brow, the brow may appear to drop and/or the skin of the eyelid to droop and cause the eye to look more closed or hooded. This is called ptosis (pronounced “TOE-sis”).

Ptosis is rare, but research estimates that anywhere from 1 to 5 percent of cases may experience it. Research also shows that these adverse effects are more common with less experienced practitioners. Dr. Khorasani reminds patients to seek an experienced, board-certified dermatologist or cosmetic surgeon for these injections. (He is a rare breed, being quadruple board-certified in dermatology, cosmetic surgery, facial cosmetic surgery and Mohs surgery.)

Nevertheless, even superstar physicians with many years of experience and mostly successful results occasionally see rare complications from neuromodulators in their patients. This happened with one of Dr. Khorasani’s patients in the summer of 2022.

One Patient’s Experience

This patient, a woman in her early 60s with a history of nonmelanoma skin cancers, had previously seen Dr. Khorasani for Mohs surgery — twice for basal cell carcinoma (BCC) and once for squamous cell carcinoma (SCC), the two most common types of skin cancer. She had been thrilled with the results and how well the scars healed. On a follow-up visit, she asked him about Botox. It had been about six months since she had received Botox from the dermatologist she sees regularly. While she had been satisfied with her results, she said she had sometimes thought she looked a little too “surprised” after the treatment, and that her eye shape became rounder, deviating from the natural almond shape she had when she was younger. She also noticed that her horizontal forehead lines had become more pronounced, and she had never had the horizontal lines injected in the past.

“Dr. Khorasani’s team took many photos before the procedure,” the patient says. “He asked me about my expectations, reviewed my medical history and took his time assessing my face before determining the dose and treatment plan, using Dysport. I had been treated with both Botox and Dysport in the past. He was very methodical as every injection site was measured, marked and documented with a photograph. Aside from the fact that I was treating my forehead lines for the first time, my treatment to the frown lines didn’t seem to differ from what I had done before. But within a few days, I felt that something was wrong.”

“It felt weird,” she says. “Hard to explain, but my forehead felt very tight and looked smoother than it had in years. That was a plus.” The ‘11s’ between the brows (doctors call them glabellar lines) had relaxed appropriately, “and I felt like my eyes broadened a bit, more to the shape I had when young.” Unfortunately, though, her eyebrows looked more straight than arched, and she experienced eyelid droop, in which the eyelid skin fell and folded over almost to her lash line, creating a hooded effect that made her eyes feel dry and irritated.

“I certainly didn’t look hideous,” she says, laughing, while looking at photos from six days after receiving the injections. “But I did look different, probably a little tired or sad. Because of the hooded eyelid, there was nowhere for my eyelash curler or my mascara to go. Eye shadow was difficult to apply. Also, I couldn’t raise my eyebrows or widen my eyes using my facial muscles.”

And people noticed. “I went to the office, where a close colleague blurted out, ‘What did you do to your eyes?’ Yikes. I didn’t know what to say yet, as I hadn’t contacted Dr. Khorasani about it. At my dance studio, a regional director was there who hadn’t seen me in a while. I was just sitting quietly, changing my shoes, when she looked over and said, ‘What’s wrong?’ She thought maybe I was upset or had been crying. I assured her I was fine.”

The Doctor’s Reassurance

That spurred the patient to contact Dr. Khorasani’s office, and she came in the next day. He immediately recognized the side effect as ptosis and reassured her that it does happen in a small subset of patients. He informed her that there is a solution to this temporary side effect that can aid in speeding up recovery. “I had read about it in the medical literature,” Dr. Khorasani says, “but I have only seen this adverse effect in a dozen patients throughout my 17 years of experience. And I've never had any patients experience permanent drooping from Dysport or Botox.” He informed his patient that the worst of this effect is typically experienced in the first two and a half weeks, and it would likely resolve within six weeks.

Before and After results of Neuromodulator Botox/Dysport by Dr. Khorasani

A Lesson on Human Anatomy

He explained that neuromodulators work by changing the way the nerves around the eyes interact with the muscles. “Two muscle groups compete with each other to control eyelid function: When you contract your orbicularis oculi, the sphincter muscle around the eye, it lowers the brow. When you contract your frontalis muscle (forehead muscle), it elevates your brow. Therefore, the forehead muscles are the brow elevators and the brow muscles are considered the brow depressors. The interplay between these two muscles is very important.

Changes in Anatomy of the Forehead Muscle as We Age 

Eyelid skin naturally becomes droopier over the age of 50. (Dr. Khorasani refers to this as “a sign of wisdom.”) Some patients may be compensating to hold their eyelid skin up by elevating their brow, so they have high tone in the frontalis muscle. But if that frontalis muscle is weakened by the neuromodulator, then it can potentially bring down the brow.

In order to avoid this, a properly trained physician ensures that the injections are placed in the upper half of the forehead muscle, as these are the fibers that typically are not as involved with keeping the brow up. The majority of that work is accomplished by the lower fibers of the forehead muscle (frontalis).

“Besides ensuring injection sites are placed high on the forehead,” Dr. Khorasani explains, “we take a second precaution of lowering the dose by 25 percent to avoid any diffusion (spreading) of this medication from the upper fibers of the frontalis to the lower fibers.”

Is eyelid/eyebrow dropping more common with Dysport versus Botox? 

No, multiple studies have shown that the incidence of eyelid or eyebrow dropping is the same for Botox or Dysport. In his own practice, Dr. Khorasani says, “I have seen dropping with both agents. The only exception to this is when we use neuromodulators in a surgical setting to relax muscles and improve scar outcome. In these instances where surgical swelling and diffusion of fluids is present, we have seen a bit more migration with Dysport and more likelihood of ptosis.”

So, if the injection technique and dose were appropriate, why did this patient develop ptosis?

The muscles of this patient’s forehead had weakened significantly after several surgeries for removal of skin cancers. Even though the injections were placed at the appropriate level and the dosage was reduced, these precautions were not enough to accommodate the weakened muscle fibers after multiple surgeries.

Are there any other serious conditions that may contribute to eyelid/eyebrow dropping after neuromodulators (Botox/Dysport)? 

“The answer is yes. If you have any preexisting neurologic or muscular dysfunction, then that weakening connection between the nerve and muscle can be exaggerated. The specifics of these conditions are beyond the scope of this article.

Any Fast Fixes?

“Even though these effects are temporary, no one wants to wait weeks for a problem to resolve — especially New Yorkers,” Dr. Khorasani says with a laugh. “The good news is that there are options. The first step is to try relaxing the opposite muscles.” So, if the orbicularis is fighting against the frontalis, the provider may inject a tiny amount of neuromodulator into the brow depressor muscle group to see if it gives the patient a little bit of elevation. “That helps for about 50 percent of patients with this problem,” he explains.

For those who don’t see any improvement, the next step is to try specially developed eyedrops called Upneeq.

What is Upneeq? And how does it work?

Upneeq is a prescription drop containing oxymetazoline hydrochloride ophthalmic solution 0.1 percent. It works by stimulating the superior tarsal muscle in the lower eyelid known as Muller’s muscle, which helps to elevate the upper eyelid.

Relaxing the opposite muscles didn’t help Dr. Khorasani’s patient, so she agreed to try the eyedrops and quickly became a fan. “I got a month’s worth of Upneeq two weeks after my injections,” she says. “Each dose comes in its own sterile vial. The drops are easy to use by placing one drop into each eye once a day. I had been feeling a ‘heaviness’ from my droopy eyelids resting on my eyeballs.” The drops had an almost instant soothing effect. She notes that “it immediately felt like they lightened the load.”  

She said she started seeing improvement after about a week of use. She kept using the drops each day, and when she reached her six-week follow-up with Dr. Khorasani, she was pleased to say she felt like her eyes were open but more natural, and her brows had an appropriate bit of arch to them but were still close to the shape she had when younger. Her forehead was still smooth and wrinkle-free. “Dr. Khorasani was right,” she says. “Six weeks went quickly, and I suddenly looked like myself again — slightly refreshed. Best of all, I could easily apply my eyeshadow and mega mascara!”

The Bottom Line

It is important to know that all neuromodulator injections come with risk. Also, Dr. Khorasani says, one brand is not better or worse than another: “Multiple studies have now shown that the risk of ptosis is the same with all the neuromodulators” (although it can vary with the experience and expertise of the medical practitioner, of course).

Physician error while injecting can lead to the rare complication of ptosis, but even the best and most experienced physicians occasionally see it.

Without going into too much anatomical detail, well-trained specialists know exactly where it is safe to inject and where the danger zones lie. But even so, despite all the training and experience, Dr. Khorasani says, “some rare patients develop ptosis just because there is a variability in the anatomy and the way that frontalis muscle attaches itself to the skin and the underlying musculature.”

Finding a doctor with expertise who knows your medical history, expectations and previous experience with injections is important. Then stick with that doctor for the best outcome. “Knowing your patient is so important; everyone’s anatomy is different,” Dr. Khorasani emphasizes. “So even when a rare side effect like ptosis happens, the doctor can document the anatomy and modify the approach to avoid this problem in the future.”

Why choose Botox/Dysport Injections with Dr. Khorasani?

With four board certifications in Dermatology, Cosmetic Surgery, Facial Cosmetic Surgery and Mohs micrographic surgery, Dr. Hooman Khorasani provides patients with cutting-edge treatments to achieve their aesthetic goals. His decades of work in research, and his 10-year run as head of the Division of Dermatologic and Cosmetic Surgery at Mount Sinai demonstrates his investment of time and energy to acquire and master the latest wrinkle and line reduction technologies.

Dr. Khorasani and his highly-specialized team look forward to working with you to transform your medical or aesthetic goals into reality. To expedite a request for a consultation, text message us securely or call our Manhattan office at: 212-230-3378 for more information.

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When Neuromodulator Injections Lead to Complications

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