Botox Injection to the Central Eyelid and Brow Areas Is a Low-Risk Procedure

Study finds complications of blepharoptosis or diplopia unlikely


Fear of the characteristic drooping eyelids of blepharoptosis has prevented many ophthalmologists from injecting Botox® into the central upper eyelid and brow regions. However, Cleveland Clinic researchers hope their retrospective study on the subject will relieve their concerns.


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The study’s findings show that the risk of blepharoptosis is low and the injection practice is safe to use when indicated as a means to achieve clinical objectives in cosmetic procedures and the treatment of facial spasm conditions.

“Our outcomes are important,” says Julian Perry, MD, oculoplastic surgeon at Cleveland Clinic Cole Eye Institute and one of the study’s authors. “They change the current paradigm and philosophy on the safety of neurotoxin injection into the central areas of the eyelid and brows.”

Researchers evaluate methods, outcomes in 300 procedures

Published last year in Ophthalmic Plastic and Reconstructive Surgery, the research involved a retrospective review of the charts of all patients who underwent onabotulinum toxin A injection to the central upper eyelid and eyebrow at Cole Eye Institute over a 10-month period.


“We evaluated almost 88 patients with a total of 300 procedures, so we had a good database to determine the side effects of the Botox injections, such as droopy eyelids or double vision,” Dr. Perry says.

The surgeons also reviewed the amount of neurotoxin injected, the dilution method and all complications recorded.


The study included 300 procedures performed on 88 patients. Some had Botox brow lifts; treatments were for blepharospasm (34 patients/176 procedures), facial nerve disorders (2 patients/9 procedures), hemifacial spasm (21 patients/40 procedures), and facial rhytides/eyebrow ptosis (31 patients/75 procedures).

Study reports few complications

Surgeons who took part in the research injected a relatively high average amount of neurotoxin into the central upper eyelid and eyebrow regions, in amounts ranging from 2 to 12.5 units per encounter.


Blepharoptosis occurred in 1 percent of total encounters. Rates after traditional periocular botulinum neurotoxin injections that avoid the central upper eyelid can average around 13 percent, the study notes.

Other complications included diplopia (4 percent of total encounters), lagophthalmos (1 percent of total encounters) and blurry vision (1 percent of total encounters). Minor local effects, including bruising, bleeding, pain and mild swelling were recorded in 3.3 percent of total encounters.

Nearly all patients with complications were treated for hemifacial spasm or blepharospasm rather than cosmetic reasons. In 50 brow lifts, there were no cases of blepharoptosis.

Neurotoxin injections safe when indicated for chemodenervation

“These outcomes are novel,” Dr. Perry says. “They show the safety of injecting Botox into regions many practitioners have avoided.”



Lack of detailed understanding of the underlying anatomy might account for the unwillingness to make injections into the central eyelid/eyebrow area, he says, noting that there is a significant amount of orbicularis muscle above the central brow.

“Our research, in combination with the anatomic studies we’ve published, could ease their fears and change the status quo,” he says.


Surgeons at Cole Eye Institute have routinely injected neurotoxins into the pretarsal, preseptal and orbital orbicularis muscle of the central upper eyelid for 10 years without noticing significantly increased rates of iatrogenic blepharoptosis, the study notes.

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