Bright eye area with natural smile lines · periorbital region · practice of Dr. Thomas Ackermann

Crow’s feet

Individual cost plan after consultation

The fan-shaped smile lines at the outer corner of the eye are caused by the circular muscle around the eye. Botulinum toxin type A relaxes its outer portion in a targeted way — injected superficially, at a safe distance from the orbital rim, dosed conservatively. Duration of effect about four months, documented in pivotal trials with over 1,300 participants. Often combined with frown lines or forehead in the same appointment. Treatment provided by a board-certified anesthesiologist.

Expression lines · Orbicularis oculi muscle · Eye area

Crow's Feet

The fan-shaped smile lines at the outer corner of the eye are caused by the circular muscle around the eye. Botulinum toxin type A relaxes its outer portion in a targeted way — the smile stays, the lines soften. The eye area is the most anatomically delicate region of the upper face: what matters here is not the dose alone, but the distance to the eye and the amount placed at each point.

Duration of effectapprox. 4 monthsMedian 119–148 days across two pivotal trials. Individual range 3–6 months.

Treatment time10–20 minBoth sides. Often combined with frown lines or forehead in the same appointment.

Onset2–5 daysFull effect after 10–14 days. Follow-up appointment falls within this window.

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In short

Crow's feet are expression lines folded into the skin by the outer portion of the circular eye muscle when you smile. Botulinum toxin type A interrupts the signal from nerve to this part of the muscle for several months; the skin above smooths out because it is no longer folded with every smile. The smile itself is produced by other muscles and remains unaffected. The treatment has been studied against placebo in two large pivotal trials with 445 and 1,362 participants. If you want to understand the anatomy in more depth: the in-depth page on the orbicularis oculi muscle explains the muscle's dual role as eyelid closer and brow depressor. Reading time about 8 minutes.

Dr. Thomas Ackermann's practice · Clinical approach

The eye area is the most anatomically delicate region of the upper face. Here I inject superficially, keeping distance from the bony orbital rim, needle tip pointing away from the eye. I dose deliberately conservatively in this region — swelling under the eye is the most common side effect here, and it is easier to prevent than to treat.

— Dr. med. Thomas Ackermann · Board-Certified Anesthesiologist

Safety profile

What you can realistically expect

A note on terminology: Many patients search for “Botox” — a brand name of one single product that has become a colloquial umbrella term. The active substance is botulinum toxin type A, contained in several licensed medicinal products. All of them are prescription-only and are injected exclusively by the physician after a medical examination. This page uses the substance name throughout — it refers to the same treatment commonly known as a Botox treatment.

Observation	Frequency	Duration
Swelling under the eye ("pseudo eye bags", eyelid oedema)	most common treatment-related effect in this region; significantly more frequent than placebo in the pooled analysis	2–6 weeks
Bruising at the injection site	common — the eye area is rich in small vessels	5–10 days
Pressure or tightness	common	1–2 days
Lift of the outer eyebrow	occasional — desirable or not depending on the starting position	as long as the effect lasts
Asymmetry when smiling	occasional	2–6 weeks, adjustable at the follow-up appointment
Residual lines with a static component	occasional, more common in sun-damaged skin	persistent — other methods needed
Double vision	very rare (spread to the eye muscles)	4–8 weeks
Outward turning of the lower eyelid (ectropion)	rare, in pre-existing eyelid laxity or after eyelid surgery	variable

Frequencies according to Brin et al. 2009 (pooled data from 9 pivotal trials, 1,678 participants) and the Sommer/Bergfeld/Sattler 2007 consensus recommendations. Swelling occurs when relaxing the lower part of the muscle temporarily slows lymphatic drainage. More detail in the safety overview.

Common reasons patients come in

Does this sound familiar?

"In photos, all I see is the lines"

What started as smile lines is now visible in photos even without smiling. Sun exposure and declining skin elasticity accelerate the shift from an expression line to a permanent one. Many patients notice this change around age 40.

"I always look tired"

Pronounced lines at the outer eye area can make a face look exhausted — even after a good night's sleep. The treatment relaxes the region and softens this impression without changing your expression.

"Before an important occasion"

The effect needs 10–14 days to fully develop and lasts about four months. If you are planning for a specific date, it makes sense to come in 3–4 weeks beforehand — enough time for the follow-up appointment and any fine adjustment.

Important to know

What crow's feet treatment is not

It does not remove every line under the eyes. Treatment addresses the outer portion of the circular muscle, lateral to the outer corner of the eye. Fine lower-lid lines, tear troughs and volume loss are separate concerns that call for other methods.
It is not a brow lift — but it can produce one. The outer portion of the circular muscle also pulls the eyebrow down. When relaxed, the outer brow can lift slightly. Some patients welcome this (see Brow Lift), others don't — which is why brow position is part of the assessment before every treatment.
It does not fully smooth permanent lines. Deeply etched crow's feet have a skin component (loss of elasticity, collagen breakdown). The expression-line component is markedly reduced; the remaining texture in the skin needs other approaches, such as skin regeneration or hyaluronic acid.
It is not suitable for everyone. After lower-eyelid surgery (blepharoplasty) or with weak eyelid support, the risk of an outward-turning lower eyelid is increased. That's why I check eyelid tension (the "snap test") before treatment and plan the lower third conservatively or not at all.

The process

Why this practice

Easy to inject. Hard to dose correctly.

Whether crow's feet treatment has succeeded shows up when you smile: does it look genuine — or as if something is missing. Anatomy decides this: which part of the muscle pulls how strongly, how the fan pattern runs on your face, where your brow sits. An analysis of 1,392 study participants found four different fan patterns — there is no one treatment that fits everyone.

As a board-certified anesthesiologist, I work daily with nerve pathways and muscle anatomy. I am a certified member of the DGBT (German Society for Aesthetic Botulinum Toxin Therapy) and hold the additional qualification in emergency medicine. I also treat patients who received a result elsewhere that they are not happy with — being able to correct a result changes how you dose from the outset.

How I think about the individual muscle groups: Overview: wrinkle treatment with botulinum toxin · Correction with ultrasound-guided hyaluronidase

How your appointment works

History and assessment of the eye area. Lines at rest and when smiling, the course of the fan pattern in the upper, middle and lower third, skin elasticity, eyelid tension, brow position. Previous eyelid surgery is specifically asked about. Please disclose blood-thinning medication in advance — and never stop it on your own. Whether and how it is taken into account is discussed together; the eye area is prone to bruising.
Dose planning by fan pattern. Usually 3–4 points per side, in a crescent 1–1.5 cm lateral to the outer corner of the eye. The pivotal trials used 12 units per side; in daily practice the dose varies below or above this depending on sex, muscle strength and fan pattern. I start conservatively and adjust at the follow-up — too little dose can be topped up, too much cannot be undone.
Superficial injection, directed away from the eye. Strictly under the skin, not deep. Minimum distance of one finger's width from the bony orbital rim, needle tip always pointing outward. As an extra safeguard, a finger rests on the orbital rim. Small volumes per point.
Immediately afterward. Cooling, no downtime. Make-up after about 4 hours. On the day of treatment: no exercise, no sauna, no rubbing the eye area, no prolonged bending forward.
Follow-up appointment after 10–14 days. Assessment of symmetry and brow position, minor touch-up injection if needed. If swelling has occurred: gentle lymphatic drainage outward. If the brow lifted more than desired: targeted balancing at the lateral forehead muscle.

Detailed guidance for the first 24 hours and 14 days is in the aftercare overview.

The next step

First the assessment. Then the decision.

In your initial consultation, we clarify whether this treatment makes sense for you — and what is realistic to expect. Private practice in Herzogenaurach, twelve minutes by car from Erlangen.

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Frequently asked questions

About crow's feet treatment

Will this make my smile look unnatural?

Not with the right dose. Only the outer portion of the circular muscle is treated; the smile itself comes from the cheek muscles, which are not touched. A "frozen" smile results from too high a dose or points placed too far inward — which is why I dose conservatively in this region and prefer to add more later if needed.

Why do I get swelling under my eyes?

The circular eye muscle supports lymphatic drainage of the lower eyelid. When its lower portion is also relaxed, fluid can accumulate — the so-called pseudo eye bags. They resolve within 2–6 weeks; gentle outward lymphatic drainage and slightly elevating your head at night can help. Prevention: treat the lower third conservatively or not at all.

How long does the effect last?

Across two pivotal trials with 1,362 participants, the mean duration of effect was 119 to 148 days — roughly four months. Some patients see less, others notably more. With repeated treatment, many patients report a gradually longer-lasting effect; this is not solidly proven.

What is the snap test?

A simple clinical test of eyelid tension: the lower eyelid skin is gently pulled away from the eyeball and should snap back into place immediately on release. If it returns slowly or incompletely, treatment of the lower third of the eye area should be planned conservatively — otherwise there is a risk of the lower eyelid turning outward.

Does the treatment affect my eyes?

Not with correct technique. Superficial injection at a safe distance from the orbital rim prevents the substance from reaching the eye muscles. Very rarely, injecting too deep or too high a dose can cause temporary double vision, which resolves on its own within 4–8 weeks. In the pooled analysis of the pivotal trials, no serious treatment-related events occurred.

Can this be combined with other treatments?

Yes, and this is the usual case: crow's feet are often treated in the same appointment as frown lines and forehead lines. This combination has been studied in a pivotal trial with 787 participants. For permanent lines in the skin, hyaluronic acid or skin regeneration may be a useful addition — this is assessed during your consultation.

What am I not allowed to do after treatment?

First 4–6 hours: no rubbing or massaging, no sauna, no exercise, no prolonged bending forward. Make-up from about 4 hours onward. Sun protection as usual. Full detail in the aftercare overview.

I take blood thinners — can I still be treated?

Usually yes. Please disclose all blood-thinning medication in advance — including supplements such as omega-3 or ginkgo. Do not stop anything on your own; whether and how we proceed is discussed together. With very fine needles, small volumes and cooling, the risk of bruising can be well controlled even under blood thinners.

What if I have eyelid surgery planned?

I generally do not treat before a planned blepharoplasty — the toxin's effect would change the baseline the surgery is planned around. After surgery, treatment is possible again once wound healing is complete, usually after 6–8 weeks.

What does the treatment cost?

Physician services are billed according to the German fee schedule for physicians (GOÄ). What applies to your treatment — depending on the number of points and combination with other regions — is discussed transparently during your consultation beforehand.

Evidence base

What the studies show

Carruthers A, Bruce S, de Coninck A et al., 2014. Efficacy and safety of onabotulinumtoxinA for the treatment of crow's feet lines: a multicenter, randomized, controlled trial. Dermatol Surg 40(11):1181–1190. PMID 25347451. Pivotal trial: 445 participants with moderate to severe crow's feet, 24 units versus placebo. At day 30, 66.7% (investigator-rated) and 58.1% (self-rated) achieved a "none or mild" result at maximum smile, versus 6.7% and 5.4% under placebo.
Baumann L, Dayan S, Connolly S et al., 2016. Duration of Clinical Efficacy of OnabotulinumtoxinA in Crow's Feet Lines: Results from Two Multicenter, Randomized, Controlled Trials. Dermatol Surg 42(5):598–607. PMID 27110893. Analysis of 1,362 participants: mean duration of effect 119–148 days. Basis for the duration figure on this page.
Carruthers J, Rivkin A, Donofrio L et al., 2015. A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of Repeated OnabotulinumtoxinA Treatments in Subjects With Crow's Feet Lines and Glabellar Lines. Dermatol Surg 41(6):702–711. PMID 25993609. Repeat treatment of crow's feet alone or combined with frown lines: response rates of 56.5% and 63.6% versus 1.1% under placebo, with an unchanged side-effect profile.
Kane MAC, Cox SE, Jones D et al., 2015. Heterogeneity of crow's feet line patterns in clinical trial subjects. Dermatol Surg 41(4):447–456. PMID 25789814. Analysis of 2,699 photographs from 1,392 people: four fan patterns (full, lower, central, upper), varying with severity, age and sex. The authors conclude that treatment should be adapted to the individual pattern.
De Boulle K, Werschler WP, Gold MH et al., 2018. Phase 3 Study of OnabotulinumtoxinA Distributed Between Frontalis, Glabellar Complex, and Lateral Canthal Areas for Treatment of Upper Facial Lines. Dermatol Surg 44(11):1437–1448. PMID 30096106. 787 participants; simultaneous treatment of the forehead, frown lines and crow's feet in one appointment was effective and well tolerated — the basis for combination treatment.
Brin MF, Boodhoo TI, Pogoda JM et al., 2009. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1,678 participants. J Am Acad Dermatol 61(6):961–970. PMID 19744746. Pooled safety data from 9 trials. Treatment-related eyelid oedema was significantly more common than under placebo; no serious treatment-related events; side effects decreased with the number of treatment cycles.
Camargo CP, Xia J, Costa CS et al., 2021. Botulinum toxin type A for facial wrinkles. Cochrane Database Syst Rev 7:CD011301. PMID 34224576. Systematic review of 65 randomized trials with 14,919 participants, 7 of them on crow's feet. Efficacy versus placebo supported with moderate to high certainty; the authors note a lack of long-term data across multiple treatment cycles as a gap.
Sommer B, Bergfeld D, Sattler G, 2007. Consensus recommendations on the use of botulinum toxin A in aesthetic medicine. J Dtsch Dermatol Ges 5 Suppl 1:S1–S29. PMID 17229195. German-language consensus on injection technique in the eye area and on preventing and managing swelling.

Study details researched via PubMed. The studies cited describe the state of the scientific literature and do not constitute a claim about the outcome of any individual treatment. The pivotal trials were funded by the manufacturer.