Botox eyelids: why injections near the eyelid are avoided

The eyelids are one of the eleven areas of our guide to botulinum toxin treatment areas, but in a particular way: this is not an area that is treated, it is an area that is protected. This page explains why, and what you should know when neighbouring areas are treated. It does not replace a consultation.

Why talk about the eyelids?

The upper eyelid is lifted by a small muscle, the levator palpebrae superioris. If botulinum toxin reaches this muscle, it weakens and the eyelid droops: this is called eyelid ptosis³. Yet several commonly treated areas are very close: frown lines, the forehead, the tail of the eyebrow and crow’s feet.

This is why the label of the short-acting botulinum toxin (serotype E) asks to avoid injecting near the muscle that lifts the eyelid, particularly in people whose eyebrow-lowering muscles are very developed, and to place injections in the outer part of the corrugator at least 1 cm above the bony rim of the eye socket¹. Type A labels show the same caution: they point out a risk of ptosis, to be limited by respecting doses and the number of injection points², and ask, for crow’s feet, to inject just under the skin to limit spread⁶.

What the toxin does not do: it does not treat heavy eyelids caused by excess skin, or under-eye bags. These situations call for other approaches, to be discussed with your doctor.

When is the toxin used near the eyelids?

In the French labels, the toxin is used around the eyelids, never on the eyelid itself: for frown lines, crow’s feet and the forehead, depending on the product^2,5,6. An expert consensus published in 2010, written by an expert board convened around one manufacturer’s product, also describes treatment of fine lines on the lower eyelid⁴; this practice is off-label in France.

Some situations call for caution or contraindicate injection. The label of the short-acting toxin asks for caution when the eyelid is already drooping¹. The labels contraindicate injection in case of a generalised disorder of the muscles and of the junction between nerve and muscle (myasthenia gravis, Lambert-Eaton syndrome), allergy to the toxin or an infection at the injection site^1,2.

Which toxin for the eyelids?

Not a treatment area as such: the page explains why injections are avoided here.

No toxin, type A or serotype E, has an aesthetic indication for the eyelid in France^1,2. The short-acting toxin is approved for frown lines only, in the European Union and in Canada^1,7. The table above makes the point: any injection in this area would be off-label, and the priority is to spare it.

Is it a risk for me?

If you are considering treatment of frown lines, the forehead or crow’s feet, your doctor will assess the position of your eyelids and eyebrows before the injection. An eyelid that is already slightly low, asymmetry, or previous eyelid or eyebrow surgery are things to mention: the label of the short-acting toxin asks for the anatomy and any previous procedures to be taken into account¹.

Questions to ask your doctor: do my eyelids carry a particular risk? Where will you inject, and how far from the eye? What should I do if an eyelid droops? Whom should I contact in the following days?

Onset and duration

There is no onset to describe for an area that is not treated. The timeline of eyelid ptosis, on the other hand, is known. A review reports that it appears on average 3–14 days after the injection and resolves on its own as the effect of the toxin wears off³. For forehead treatment, one label gives a median onset of 9 days².

How long ptosis lasts therefore depends on how long the injected toxin works, as explained on the page about how long botulinum toxin takes to work and lasts.

What are the risks around the eyelids?

For neighbouring areas, the labels describe a drooping upper eyelid, eyelid swelling and dry eyes^1,2,5. For the short-acting toxin, a drooping eyelid was reported in 0.17% of people treated¹. The label also states that a drooping eyelid or a visual disturbance could affect driving¹.

If the eyelid droops, eye drops prescribed by a doctor can partly lift it while the effect of the toxin wears off³. The neighbouring areas are covered on the pages about crow’s feet lines, the eyebrow lift and frown lines between the eyebrows.

Difficulty swallowing, speaking or breathing requires immediate medical attention¹. A visual disturbance should also be checked by a doctor promptly. To recognise a drooping or swollen eyelid and know what to do, see the page on the eyelids after an injection.