The issue

The upper eyelid becomes droopy and more difficult to open after treatment with botulinum toxin. This can occur with one or both upper eyelids. It may first be discovered several days (2-7) after treatment with Botox, Dysport, or Xeomin.

The eyelid can remain droopy for for several weeks (3-6) or more rarely, for several months.

What causes the droopy eyelid?

Botulinum toxin, also known as Botox, Dysport, or Xeomin is a protein that relaxes muscles.

When a droopy upper eyelid is seen after treatment, the injected botulinum toxin, meant to reduce frown lines and/or lift the eyebrows has affected one or both of the eyelid-lifting muscles, the levator palpabrae superioris and muellers muscle.

Botox and other botulinum toxins are injected in small amounts of liquid under the skin, into muscles. The liquid consists of a vacuum-dried powder with purified botulinum protein and albumin. Your doctor reconstitutes the powder with saline. The amount of saline used can differ among physicians and the more saline used, the more the botulinum will diffuse or spread after injection. Droopy eyelids after injection can be a result of the injected liquid spreading too far or the injection site being positioned too close to the eyelid.

In certain cases, a droopy eyelid may have been present before botulinum treatment, but was previously masked by the person using their eyebrow lifting muscles to lift the eyebrows and eyelids. If the forehead is treated with botulinum, the forehead muscles are relaxed and the eyebrows and/or eyelids may appear heavy or droopy.

There are other rare and more serious causes of droopy upper eyelids that are not caused by botulinum toxin. Botulinum-associated eyelid droop is usually not accompanied by other neurologic problems (headaches, dizziness, numbness, weakness, etc.) which could suggest other causes.

Often seen with

Reduced wrinkles and brows furrows (due to botulinum treatment), reduced eyelid lifting ability, normal pupil examination.

Not to be confused with

Droopy upper eyelid due to other causes (including aging changes, disinsertion of the eyelid-lifting muscle tendon, nerve palsies, migraine, stroke, etc.).

What you see in the mirror

The affected eyelid sits lower in position and this may interfere with vision. It is more difficult to open the eyelids on the affected side.