Botulinum toxin (Botox) in Baghdad and Karbala: what it treats, how long it lasts and how to stay safe

What botulinum toxin does, and what it does not do

Botulinum toxin blocks the signal that tells a muscle to contract, so the treated muscle relaxes for a few months ^[1]. That is why it works on dynamic lines: the frown between the brows, horizontal forehead lines and crow's feet at the corners of the eyes. Deep lines that are visible even when your face is relaxed, and folds caused by volume loss or sagging, respond only partly ^[1][16]. Those may need other treatments.

BOTOX is a registered brand name of onabotulinumtoxinA. Other brands of botulinum toxin type A exist, and their units are different, so doses cannot be swapped one for one between products ^[20]. On this site we say "botulinum toxin" for the treatment and use "Botox" only as the familiar name.

Approved cosmetic uses and a natural result

In the United States, the FDA approved BOTOX Cosmetic for frown lines in 2002, crow's feet in 2013 and forehead lines in 2017, all in adults. A further approval in 2024 was for vertical neck bands (platysma bands), not the forehead ^[2]. Each approval is worded as a temporary improvement in the appearance of moderate to severe lines ^[1].

Our aim is a rested, natural look, not a "frozen" face. The dose is planned for your muscles and the way you move your face. A natural result depends on dose and technique, so it is a goal we plan for rather than a promise.

Medical uses: approved and off-label

"Off-label" means a use outside the product's official licence. Some off-label uses are common and accepted practice, but the evidence is usually weaker. Before any off-label treatment we explain the evidence, the risks and the alternatives, and you decide.

• Heavy underarm sweating (axillary hyperhidrosis): an approved, well studied use for severe sweating that topical antiperspirants have not controlled ^[3]. In a trial of 145 patients, sweating in the treated underarm fell far more than in the underarm given placebo ^[4]. One treatment usually controls sweating for several months.
• Sweaty palms and soles: commonly used and supported by smaller studies, but off-label ^[5][6]. The injections are uncomfortable, and temporary hand weakness is possible. Evidence for the soles is weaker than for the palms ^[6].
• Chronic migraine (15 or more headache days a month): an approved preventive treatment for adults, not for occasional migraine. It is given by a set injection protocol every 12 weeks, as part of a headache plan with your neurologist ^[3][7][8].
• Raynaud's phenomenon: some specialists use botulinum toxin for severe cases that have not responded to standard treatment. This is off-label and the research is mixed. In the largest randomised trial, in 90 people with scleroderma, the improvement was not significantly better than placebo ^[10]. In another trial, blood flow fell more in treated hands at one month, with no difference at four months ^[9]. Reviews call for a larger, definitive trial ^[11]. It is considered case by case, usually together with your rheumatologist.
• Shoulder ("trap") contouring: an off-label cosmetic use with limited research, mostly small studies such as a 22 patient series that measured smaller trapezius muscles for up to 6 months ^[12]. Results are temporary, and some people notice shoulder fatigue or weakness when lifting. It is not a treatment for neck pain or headaches.

Other off-label uses: what the research shows

These uses are outside the product licence. They are offered only after a consultation that covers the evidence, the risks and the alternatives, and the evidence for each is weaker than for frown lines or underarm sweating.

• Jaw slimming (masseter reduction) for a square lower face or clenching: low-level evidence. A systematic review of 20 studies, all but one prospective and many small and without a comparable control group, reported a smaller masseter muscle and a narrower jaw lasting months, with repeat treatment needed to keep the result ^[22]. A 2013 Cochrane review found no randomised or controlled trials at that time ^[21]. Some randomised trials have been published since ^[23], but the best dose and the long-term effects are still not well studied ^[22][23]. Chewing force falls for a while after treatment, and smile asymmetry can occur if nearby muscles are affected ^[23].
• Gummy smile (too much gum showing when you smile), when it is caused by overactive upper lip muscles: low-level evidence. A systematic review of 15 mostly non-randomised studies found that gum exposure fell by about 2.5 mm at 2 weeks and about 2.2 mm at 3 months, and the effect is temporary ^[24]. Dr. Tehami treats gummy smile with botulinum toxin in his practice. As with other Botox treatments, the result wears off gradually as the muscle recovers, so repeat treatment is needed to keep it. Other causes of a gummy smile, such as the shape of the jaw or gums, need dental or surgical assessment instead.
• Micro Botox (very small doses injected into the skin rather than the muscle) for oily skin and pores: preliminary evidence. A systematic review of 10 studies (5 randomised trials, 153 participants) found improvements in oil production, pore size, redness and skin texture, but not hydration, and concluded that more high-quality research is needed ^[25].
• Keloids and raised (hypertrophic) scars, as an add-on to standard scar treatment: moderate evidence from small trials. A meta-analysis of 11 randomised and 4 controlled trials found botulinum toxin injection more effective than steroid injection or placebo, with less pain, although most studies came from Asia ^[26]. A network meta-analysis of 20 randomised trials (1,114 patients) ranked it among the more effective injections for keloids ^[27]. It is not a standard first treatment, and recurrence remains possible.

When it starts working and how long it lasts

You may notice a change after 2 to 3 days. In one study of frown line treatment, about half of patients noticed an effect by day 1 and more than 9 in 10 by day 3 ^[13]. The full effect usually shows at about 2 weeks, which is when we review you ^[15].

Results usually last about 3 to 4 months, sometimes shorter or longer, and then muscle movement gradually returns ^[15]. A pooled analysis of four trials found a median of about 4 months for frown lines ^[14]. When the effect wears off, lines return to how they were before treatment.

Can it prevent wrinkles? What we can honestly say

With regular treatment, frown lines that are visible even when your face is relaxed often become softer over several sessions ^[16]. Research on true long-term prevention is limited: it comes from one pair of identical twins and from a 12 month analysis of repeated treatment, not from long-term controlled trials ^[16][17]. So we do not promise prevention, and we do not recommend starting young "to prevent wrinkles".

Sun, squinting and why sunscreen still matters

Sunlight is one of the biggest causes of early skin aging. Ultraviolet (UV) rays break down the collagen that keeps skin firm and smooth, which leads to wrinkles, uneven tone and dark spots ^[18]. In strong sunlight we also tend to squint and frown, and those repeated movements deepen expression lines over time. That last point is common sense rather than a research finding: no controlled study has measured it.

Botulinum toxin and sunscreen do different jobs. Toxin relaxes the muscles that fold the skin. Sunscreen protects the skin itself from UV damage. During Iraq's long, intense summers, daily sunscreen, a hat and UV protective sunglasses remain part of any plan.

Safety: side effects and who should not have it

Common, temporary effects are small bruises, tenderness or swelling where the needle went in, and a mild headache. Some people notice a slightly drooping eyelid or brow for a few weeks, or some asymmetry, and occasionally a muscle does not respond ^[1][15].

Very rarely the effect can spread beyond the treated area and cause general weakness, double vision, drooping eyelids, or difficulty swallowing, speaking or breathing, hours to weeks after the injection. This is the boxed warning on the product label. Serious cases are rare and mostly reported with higher, non-cosmetic doses ^[1]. Seek urgent medical help if you have any trouble swallowing, speaking or breathing after a botulinum toxin injection.

In 2024 the US FDA warned about counterfeit Botox that put people in hospital ^[19]. Treatment should only use genuine, licensed product from a regulated supply chain. You are welcome to ask to see the product before your treatment.

• Not during pregnancy or breastfeeding ^[1]
• Not with a neuromuscular condition such as myasthenia gravis, Lambert-Eaton syndrome or motor neurone disease, and with care if you take aminoglycoside antibiotics or other medicines that affect nerve and muscle signals ^[1]
• Not where there is an infection at the injection site, or if you are allergic to any ingredient ^[1]
• Cosmetic treatment is for adults (18 and over) only. As a pediatric dermatologist, Dr. Tehami does not give cosmetic botulinum toxin to children or teenagers ^[1]

On the day and afterwards

We start with a consultation: your concerns, your medical history and medicines, and how your face moves. If treatment suits you, we explain the plan, the expected result and the risks, and you receive written aftercare instructions. We review you at about 2 weeks.

Frequently asked questions

References

1. [1] Allergan/AbbVie. BOTOX Cosmetic (onabotulinumtoxinA) Prescribing Information, including the boxed warning on distant spread of toxin effect. Source
2. [2] US FDA approval history of BOTOX Cosmetic (onabotulinumtoxinA): frown lines 2002, crow's feet 2013, forehead lines 2017, platysma bands 2024. Drugs.com approval history and Healio report, 21 October 2024. Source
3. [3] Allergan/AbbVie. BOTOX (onabotulinumtoxinA) Prescribing Information: chronic migraine and severe primary axillary hyperhidrosis indications. Source
4. [4] Heckmann M, Ceballos-Baumann AO, Plewig G; Hyperhidrosis Study Group. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. 2001;344(7):488-493. Source
5. [5] Lowe NJ, Yamauchi PS, Lask GP, Patnaik R, Iyer S. Efficacy and safety of botulinum toxin type A in the treatment of palmar hyperhidrosis: a double-blind, randomized, placebo-controlled study. Dermatol Surg. 2002;28(9):822-827. Source
6. [6] Weinberg T, Solish N, Murray C. Botulinum neurotoxin treatment of palmar and plantar hyperhidrosis. Dermatol Clin. 2014;32(4):505-515. Source
7. [7] Dodick DW, Turkel CC, DeGryse RE, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. 2010;50(6):921-936. Source
8. [8] Bendtsen L, Sacco S, Ashina M, et al. Guideline on the use of onabotulinumtoxinA in chronic migraine: a consensus statement from the European Headache Federation. J Headache Pain. 2018;19(1):91. Source
9. [9] Bello RJ, Cooney CM, Melamed E, et al. The therapeutic efficacy of botulinum toxin in treating scleroderma-associated Raynaud's phenomenon: a randomized, double-blind, placebo-controlled clinical trial. Arthritis Rheumatol. 2017;69(8):1661-1669. Source
10. [10] Senet P, Maillard H, Diot E, et al. Efficacy and safety of botulinum toxin in adults with Raynaud's phenomenon secondary to systemic sclerosis: a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheumatol. 2023;75(3):459-467. Source
11. [11] Geary E, Wormald JCR, Cronin KJ, et al. Toxin for Treating Raynaud Conditions in Hands (The TORCH Study): a systematic review and meta-analysis. Plast Reconstr Surg Glob Open. 2024;12(6):e5885. Source
12. [12] Park JY, Park S, Lee JS, Lee DH. Efficacy and safety of incobotulinumtoxin-A for trapezius muscle reduction: quantitative evaluation with imaging studies. Plast Reconstr Surg Glob Open. 2025;13(5):e6782. Source
13. [13] Beer KR, Boyd C, Patel RK, Bowen B, James SP, Brin MF. Rapid onset of response and patient-reported outcomes after onabotulinumtoxinA treatment of moderate-to-severe glabellar lines. J Drugs Dermatol. 2011;10(1):39-44. Source
14. [14] Glogau R, Kane M, Beddingfield F, Somogyi C. OnabotulinumtoxinA: a meta-analysis of duration of effect in the treatment of glabellar lines. Dermatol Surg. 2012;38(11):1794-1803. Source
15. [15] NHS. Botox injections (cosmetic procedures). Source
16. [16] Carruthers A, Carruthers J, Fagien S, Lei X, Kolodziejczyk J, Brin MF. Repeated onabotulinumtoxinA treatment of glabellar lines at rest over three treatment cycles. Dermatol Surg. 2016;42(9):1094-1101. Source
17. [17] Binder WJ. Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins. Arch Facial Plast Surg. 2006;8(6):426-431. Source
18. [18] Fisher GJ, Kang S, Varani J, et al. Mechanisms of photoaging and chronological skin aging. Arch Dermatol. 2002;138(11):1462-1470. Source
19. [19] US FDA. Counterfeit version of Botox found in multiple states. Drug Safety and Availability alert, 17 April 2024. Source
20. [20] FDA new established names for botulinum toxin products (onabotulinumtoxinA, abobotulinumtoxinA, rimabotulinumtoxinB) and units that are not interchangeable, 2009. Dermatology Times. Source
21. [21] Fedorowicz Z, van Zuuren EJ, Schoones J. Botulinum toxin for masseter hypertrophy. Cochrane Database Syst Rev. 2013;(9):CD007510. Source
22. [22] Ghatge AS, Ghatge SB, Mehta V. A review on bigonial width reduction by botulinum toxin injections in masseter. Bioinformation. 2023;19(3):272-277. Source
23. [23] Ferrillo M, Sommadossi E, Raciti L, et al. The role of botulinum toxin for masseter muscle hypertrophy: a comprehensive review. Toxins (Basel). 2025;17(2):91. Source
24. [24] Rojo-Sanchis C, Montiel-Company JM, Tarazona-Alvarez B, et al. Non-surgical management of the gingival smile with botulinum toxin A: a systematic review and meta-analysis. J Clin Med. 2023;12(4):1433. Source
25. [25] Rahman E, Rao P, Philipp-Dormston W, et al. Intradermal botulinum toxin A on skin quality and facial rejuvenation: a systematic review and meta-analysis. Plast Reconstr Surg Glob Open. 2024;12(8):e6084. Source
26. [26] Bi M, Sun P, Li D, Dong Z, Chen Z. Intralesional injection of botulinum toxin type A compared with intralesional injection of corticosteroid for the treatment of hypertrophic scar and keloid: a systematic review and meta-analysis. Med Sci Monit. 2019;25:2950-2958. Source
27. [27] Yang HA, Jheng WL, Yu J, Huang JY, Cheng KY, Lee JJ. Comparative efficacy of drug interventions for keloids: a network meta-analysis. Ann Plast Surg. 2024;92(1S Suppl 1):S52-S59. Source

This content is general medical education and does not replace a personal consultation. Any prescription must be coordinated with your local doctor.