Is it safe to inject Botox (Botulinum toxin) under the eye for cosmetic purposes?

Botox Injections Under the Eye for Cosmetic Purposes

Botox can be safely injected under the eye for cosmetic improvement of infraorbital wrinkles and eye widening, but requires precise technique with low doses (2-4 units) to minimize complications, particularly lower eyelid edema and incomplete eyelid closure. 1

Evidence-Based Dosing and Technique

Recommended Dosing Protocol

• Use 2-4 units of botulinum toxin in the lower eyelid for optimal balance between efficacy and safety 1
• Inject 3 mm below the ciliary margin into the orbicularis oculi muscle 1
• Higher doses (8 units) significantly increase bothersome side effects including lower eyelid edema and incomplete sphincter function 1
• A dose-response curve exists, but a plateau effect occurs at higher doses with diminishing returns and increased complications 1

Synergistic Treatment Approach

• Combining lower eyelid treatment (4 units) with lateral orbital area treatment (12 units for crow's feet) produces superior results compared to treating the lower eyelid alone 1
• This combination approach achieves greater palpebral aperture increase (4.5 mm at full smile versus 2.6 mm with lower lid alone) while maintaining safety 1
• The synergistic effect allows for lower doses in each area, reducing complication risk 1

Expected Outcomes

Cosmetic Improvements

• Moderate to dramatic improvement in infraorbital wrinkles, with patient-reported grades of 1.18-1.63 for lower lid alone and 1.73-2.25 when combined with lateral orbital treatment 1
• Measurable increase in palpebral aperture (eye widening effect) of 1.8-2.2 mm at rest and 2.6-4.5 mm at full smile depending on dosing and combination treatment 1
• Physician evaluations consistently show grades of 1.85-2.35 for improvement 1

Complications and Risk Mitigation

Common Adverse Events

• Eyelid ptosis (drooping) is the most significant complication with elevated proportional reporting ratios across all botulinum toxin brands 2, 3
• Lower eyelid edema occurs frequently, particularly at doses of 8 units or higher 1
• Incomplete eyelid closure (lagophthalmos) can occur, potentially leading to corneal exposure 3
• Palpebral ectropion and prominence of palpebral bags are possible 3
• Most adverse events are mild and temporary, resolving spontaneously 4

Critical Safety Considerations

• Avoid injection too close to the eyelid margin to prevent direct muscle paralysis affecting eyelid closure 1
• Patients with pre-existing incomplete eyelid closure or dry eye should be approached with extreme caution, as botulinum toxin injection has been associated with worsening dry eye 5
• Use small gauge needles (30G) for enhanced safety in the delicate periorbital area 6
• Ensure adequate blinking and complete lid closure capability before treatment, as these are critical for ocular surface health 5

Contraindications

• Active ocular surface infection or inflammation 7
• History of neuromuscular disorders 7
• Pregnancy (individualized assessment required) 5
• Pre-existing lagophthalmos or severe dry eye 5

Clinical Pitfalls to Avoid

Dosing Errors

• Do not exceed 4 units in the lower eyelid as eight of eight subjects receiving 8 units reported bothersome side effects 1
• Recognize that higher doses produce unattractive results despite greater eye widening 1

Anatomical Considerations

• Respect safety zones and understand frontalis muscle patterns to avoid eyebrow asymmetry 3
• Maintain 3 mm distance from ciliary margin to avoid direct eyelid muscle paralysis 1
• Consider individual anatomy variations before injection 3

Patient Selection

• Screen for underlying conditions that may increase complication risk, including diabetes, morbid obesity, and autoimmune conditions 5
• Assess for concurrent use of antihistamines, antidepressants, or other medications that may exacerbate dry eye 5

Alternative and Complementary Approaches

Non-Botulinum Options

• Platelet-Rich Fibrin (PRF) is a safe alternative for periorbital rejuvenation with favorable safety profile and improvements in wrinkles and skin quality 6
• Chemical peels (TCA 3.75% and lactic acid 15%) are more effective than PRP for periorbital hyperpigmentation 8
• These alternatives avoid the neuromuscular complications associated with botulinum toxin 6

Therapeutic Uses

• Botulinum toxin has established therapeutic benefit for improving eyelid closure in Bell's palsy patients with lagophthalmos 5
• Temporary tarsorrhaphy with botulinum toxin can protect the cornea when blinking or lid closure is inadequate 5
• Chemodenervation of extraocular muscles is an established treatment for strabismus, though complications include ptosis and globe perforation 5

Patient Counseling Requirements

Pre-Treatment Discussion

• Inform patients that results are temporary, lasting months rather than permanent 5
• Discuss realistic expectations regarding degree of improvement 1
• Warn about potential bruising, swelling, eyelid edema, and temporary incomplete eyelid closure 6, 1
• Explain that side effects are typically self-limited but may be bothersome 4

Post-Treatment Monitoring

• Monitor for signs of corneal exposure including burning, itching, eye irritation, vision changes, and pain 5
• Advise patients to report any difficulty with complete eyelid closure immediately 3
• Consider ophthalmology referral if complications develop, particularly lagophthalmos or corneal symptoms 5