Why Would You Ever Inject Botox Under the Eye?
It is a question that comes up again and again in clinics: why would you inject under the eye, and why would you not? The answer is not simple, and it is exactly why this area demands such careful thought. Patients often come asking for treatment to erase fine lines and wrinkles, but there is far more to it than that. The most important thing to realize is that the under-eye area is not a straightforward place to treat. You need to know which patients to select, which to deselect, and what the side effects and risks are before you even consider picking up a syringe.
So why on earth would you ever inject under the eye? There are several indications. The most common is fine lines and wrinkles, but you can also treat something called a jelly roll—a compression of the lower eyelid caused by the contracting orbicularis oculi muscle. And in some people, you can widen the eye itself. Let us explore each of these in turn.
Treating Fine Lines and Wrinkles Under the Eye
This is a very common request, but it is usually not a great result with botulinum toxin. There are exceptions, however. First, you must break down the type of line a patient has. Some lines under the eye are normal anatomical structures—like the lines on your hands. They are meant to be there. You will see these lines even on children. Botulinum toxin cannot solve them.
Next, there are fine lines and creases that appear only when the zygomaticus muscle contracts—the big cheek muscle that lifts the cheek. These lines are caused by the skin being compressed as the cheek raises. Again, injecting Botox into the inferior part of the orbicularis oculi will not fix this.
So when would you actually treat this problem? The criteria for me is clear: there must be contractility or hyperactivity of the orbicularis oculi muscle that is separate from the zygomaticus. You will sometimes see patients with muscle activity that causes many fine lines, often accompanied by a little volume loss. These patients can sometimes get a very good result—not just from the toxin, but from other factors too.
I will never forget one patient who complained of lines under her eyes. We did a full face treatment, and as I treated her cheek, we saw a dramatic improvement in the crinkled surface under her eyes. That happened because pulling the skin there caused a little tightening underneath. This will not work on all patients, but it is useful to think about what is causing the lines. Volume depletion can be directly under the skin, but it can also be lateral in the cheek. When the muscle pulls against an emptier space due to aging, replacing volume around the cheek can sometimes improve the orbital lines considerably.
For those patients whose muscle is constantly active, a tiny amount of toxin dropped in might make the muscle more relaxed at rest, reducing the fine lines that persist even when they are not smiling.
Widening the Eye and the Jelly Roll
Now we come to a different injection point—one that is not in the same place as the first. This is the orbital part of the orbicularis oculi, still underneath the eye but further out. Relaxing this muscle can make the eye look rounder. This is particularly popular in Korea and the Far East, where some believe a rounder eye is more beautiful. In the West, we tend to like almond-shaped eyes, but that is an interesting side point. By relaxing the muscle in the midline just under the pupil, you can create a more rounded appearance. This is not about lines and wrinkles; it is simply about widening the eye slightly.
The next reason to treat under the eye is to soften a jelly roll. This is when the skin bunches up under the eye when the orbicularis oculi contracts during a smile. Interestingly, this is also considered beautiful in the Far East, where it is called the aegyo sal treatment. You can actually put filler to create that look, but we are often trying to do the opposite: soften it. This treatment requires a slightly higher dose and covering more area, because you are trying to stop all the upward pull of the orbicularis oculi so that the skin bunches up less. The only downside is that if you decrease cheek elevation enough, the smile can look less real—it becomes a synthetic, fake smile instead of a genuine Duchenne smile.
The Story of Julie and the "Psycho" Smile
There is a well-known clinician, Julie Bass Kaplan, who once shared a story about a Botox treatment that made her look like a “psycho.” She said: “I had Botox under my eyes here and didn’t realize that my time was over for Botox under my eyes. Every time I smiled, I smiled like a psychopath.”
Whenever a patient uses an analogy like that, you must Google it. Because often they are capturing a whole load of complexity in one visual image. So I Googled “psychopath” and looked at the images. What I saw in many of those pictures were wide eyes. Maybe Julie’s eyes were too wide lower down when she smiled. Normally, when you smile, your eyes narrow. But if you relax the muscle too much, you may get too much sclera showing when smiling, instead of it disappearing. That could be the cause.
Some other images also showed a medial brow drop, but that is not what she described. Still, it is a useful tool: when a patient says something like that, you can show them images and ask, “Is this what you mean?” because it is often difficult to recreate the look.
The other great learning from this is the difference between how you look in a picture and how you look in the real world. Your mirror moment before work is different from your dynamic facial function. Patients who are on stage or do TV work will pick up things you never see in the mirror or in your consulting room. You need to gather that information to make better treatment plans.
Julie also said that her time was passed for that treatment. This is a very useful insight: these treatments do work, but only in certain patient groups. It gets harder as people get older. As I have discussed before, Botox in older people is trickier because the balance point is narrower. When you are young, Botox is like balancing on a nice curved surface—there is lots of room for error. As you get older, it turns into a tightrope. A little too much or too little and you fall off the good result. Great treatments do not work on all age groups.
Complications and Risks
Let us talk about complications. I include both aesthetic complications—things that look worse than no treatment—and medical risks. On the far end, the least likely thing to happen, is ectropion. This is when the eyelid skin hangs outwards, the eyelashes emerge, and you can see the pink part of the eye. It is very unpleasant. This would only happen if the only thing holding the eyelid against the globe is muscle activity itself, which usually means a very old patient. It is unlikely, but it is on the list.
The next step is sagging—a little like what Julie described. If you have more white showing under your eye, you look sallow, unhealthy. It is the same aesthetic we associate with stress or shock—or as Julie described, a psychopath. This happens in the early stage of overtreating under the eyes, probably more in people in their 40s, 50s, and above.
Then there is the dynamic difference when you smile. This is actually super common—one of the Botox looks that people realize makes them look like they have had too much. You have relaxed the orbicularis oculi muscle all the way around except for the medial part, which now pulls every time you smile. You get a pinched appearance. The muscle pinches the nose, you get lines on the nose and under the eye, and the eyes narrow medially but not laterally. It creates something that we just know is not natural. Most patients will not see it in the mirror—they only see it in a picture or video of a natural smile.
Are There Benefits? Would I Do It?
There are benefits, but only in a very narrow patient group. The harder you try with Botox, the more likely you are to get some weird look, even if it is not a proper complication. It just does not look quite right when you have relaxed the entire muscle. So as I get more and more inferior, I use lower and lower doses, and eventually I will not use any at all. Typically, I prefer not to treat beyond the lateral canthus inferiorly about this point. But there are occasions when I will treat a little more in certain patients, with many caveats. Small doses, warnings of potential side effects, and allowing the patient to run a little experiment: “Let’s try one unit. We’ll see you back in two weeks. If you are happy, we can do that for a while. But be prepared—five years from now, it is probably not going to suit you anymore because of decreased skin integrity as you get older.”