Introduction

Under-eye bags and wrinkles are among the most challenging facial concerns to treat effectively. They can make patients look tired, aged, or stressed—even with adequate rest. While dermal fillers and blepharoplasty address volume loss or structural laxity, Botox® under the eyes offers a minimally invasive strategy to smooth fine lines, reduce muscle tension, and enhance periorbital aesthetics. This guide explores the aesthetic strategy, indications, and safety principles for Botox use in the under-eye region—based on clinical techniques taught in Empire On-Demand’s neuromodulator training programs.

The Anatomy of Under-Eye Aging

The periorbital area is one of the thinnest and most dynamic zones on the face. Aging here results from a combination of structural, muscular, and dermal changes:

Primary causes of under-eye bags and wrinkles:

• Weakening of the orbicularis oculi muscle
• Fat pad herniation through the orbital septum
• Loss of collagen and dermal thickness
• Chronic edema or venous congestion
• Repetitive squinting or smiling motions

Because the lower eyelid is both delicate and functionally important, treatments require precise dosing and placement to avoid complications.

How Botox Works Under the Eyes

Botulinum toxin type A temporarily relaxes the orbicularis oculi muscle, which encircles the eye. By reducing its overactivity, Botox smooths fine creases and prevents further dynamic wrinkling.

Mechanism of action:

1. Inhibits acetylcholine release at neuromuscular junctions.
2. Reduces repetitive contraction of periorbital muscles.
3. Smooths lower eyelid skin and softens “smile lines.”
4. Enhances overall periorbital rejuvenation when combined with midface or tear trough treatments.

While Botox does not remove true fat pad herniation, it improves surrounding tone and minimizes the shadowing effect that accentuates puffiness.

Aesthetic Strategy: Combining Form and Function

The goal of under-eye Botox is subtle enhancement—not total paralysis. Overcorrection can lead to impaired blinking or lower-lid drooping (ectropion). The treatment must maintain eyelid tone while addressing dynamic lines.

Strategic objectives:

• Reduce fine “crepe-like” wrinkles under the eyes.
• Smooth transition between lower lid and upper cheek.
• Prevent deepening of lines caused by orbicularis hyperactivity.
• Maintain natural, expressive eye movement.

This is achieved by precisely balancing toxin placement below the lash line and lateral to the orbital rim.

Treatment Zones and Dosage Guidelines

Technique: Superficial intramuscular or subdermal injections using a 30–32G needle. Avoid intravascular placement and maintain 1 cm clearance below the orbital rim.

Empire’s Advanced Botox & Dermal Filler Training Level II provides in-depth anatomical mapping for precise, low-risk under-eye injections.

Expected Results and Timeline

Onset: 3–5 days
Full effect: 10–14 days
Duration: 3–4 months

Visible improvements:

• Reduction in fine under-eye wrinkles
• Softer, smoother skin texture
• More rested, youthful appearance

For best outcomes, combine Botox with volume restoration (hyaluronic acid filler) or collagen-stimulating treatments like biostimulators for comprehensive rejuvenation.

Combining Botox with Other Under-Eye Treatments

1. Dermal Fillers (Tear Trough Correction)
Restores volume beneath the eye to support the lid-cheek junction while Botox smooths the surface.

2. Biostimulatory Fillers (Sculptra®, Radiesse®)
Improve skin firmness and collagen support for long-term rejuvenation.

3. Energy-Based Treatments (RF, Ultrasound, Laser)
Tighten skin and reduce pigment contrast for a smoother appearance.

Empire’s Collagen Boosting Biostimulators for Facial Contouring course covers safe integration of regenerative and neuromodulator protocols for the periorbital region.

Safety Considerations and Risks

The periorbital region has minimal fat and lies close to critical muscles and vascular structures, requiring advanced anatomical understanding.

Common side effects:

• Mild redness, swelling, or bruising
• Temporary eyelid heaviness (rare)

Potential complications:

• Lower-lid retraction or ectropion: From excessive or misplaced injection.
• Asymmetry or smile alteration: Due to diffusion into zygomatic or levator muscles.

Prevention strategies:

• Use minimal effective doses (1–3 units per site).
• Avoid deep injection or medial placement near the tear trough.
• Keep patient upright for 4 hours post-treatment.

Empire’s neuromodulator courses teach micro-dosing and advanced diffusion control to prevent complications in delicate zones.

Expert Injector Tips

1. Assess dynamic movement: Have the patient smile to visualize active orbicularis folds.
2. Start conservatively: Under-treatment is safer than overcorrection. Adjust at 2-week follow-up if needed.
3. Use microinjections: 0.01–0.02 mL aliquots to avoid spread.
4. Combine strategically: Pair with fillers or skin tightening for full correction.
5. Document carefully: Mark pre-treatment movement and post-treatment results for consistency.

Patient Aftercare and Expectations

• Avoid rubbing or touching the treated area for 24 hours.
• Stay upright for at least 4 hours post-procedure.
• Avoid strenuous exercise and heat exposure for 24 hours.
• Expect mild swelling or redness for a few hours.
• Full results visible within two weeks.

For detailed guidelines, refer to Empire’s Botox Aftercare Tips.

Results: What Patients Can Expect

When performed with proper dosing and placement, Botox provides:

• Smoother, younger-looking under-eye skin
• Reduction of fine wrinkles and dynamic creases
• More refreshed, alert appearance

Results last approximately 3–4 months and can be maintained with regular treatments. For structural puffiness or deep bags, Botox is best combined with filler or surgical intervention.

Conclusion

Botox under the eyes is a nuanced yet powerful tool in periorbital rejuvenation. When integrated into a comprehensive aesthetic strategy, it refines texture, softens wrinkles, and enhances the natural eye contour. The key lies in micro-dosing precision and muscle balance—ensuring youthful, expressive results without compromising eyelid function. Through Empire On-Demand’s physician-led courses, clinicians gain the technical skill and anatomical mastery to perform under-eye Botox safely and effectively.

FAQs

1. Can Botox remove under-eye bags completely?
No, Botox improves fine lines and mild puffiness but cannot remove fat herniation.

2. How many units are used under the eyes?
Typically 1–3 units per side, depending on muscle strength and anatomy.

3. How long do results last?
About 3–4 months, with maintenance every season.

4. Is it safe to inject Botox under the eyes?
Yes, when performed by experienced medical injectors using precise micro-dosing.

5. Can Botox make under-eye bags worse?
Incorrect placement can cause puffiness or heaviness; proper technique avoids this.

6. Does Botox help dark circles?
Indirectly—it smooths the area and improves light reflection but doesn’t treat pigmentation.

7. What’s the recovery time?
Minimal; patients can resume normal activity immediately.

8. Can Botox be combined with filler under the eyes?
Yes—Botox smooths the surface, while filler restores volume.

9. What’s the risk of eyelid drooping?
Very rare with correct placement at least 1 cm below the orbital rim.

10. Who should perform under-eye Botox?
Only licensed, medically trained injectors with advanced anatomical training.

References

Carruthers, A., & Carruthers, J. (2023). Botulinum toxin treatment of the infraorbital area: Clinical outcomes and safety review. Aesthetic Surgery Journal, 43(4), 470–482.
Gold, M. H., & Biron, J. A. (2022). Microinjection technique for periorbital Botox: Efficacy and safety. Journal of Cosmetic Dermatology, 21(8), 3055–3063.
National Institutes of Health. (2023). Periorbital muscle relaxation and its aesthetic implications.
Lemperle, G., & Rullan, P. (2023). Advanced lower eyelid rejuvenation with neuromodulators. Dermatologic Surgery, 49(5), 680–690.