How to do Neurotoxin Reconstitution

Years back, a rep came into my first practice and mentioned that the most popular dermatologist in town for administering Botox had a very specific reconstitution for each area of the face. I thought to myself, “that’s nonsense, he is weird and wants to be known as eccentric.” However, now, I do understand the method to his madness and believe specific areas of the face require different reconstitutions for greater neurotoxin results. Perhaps, now, both of us are weird!

Currently, reconstitution has to be performed because all our FDA neurotoxins on the market are freeze dried (Dysport) or vacuum dried (Botox). The vials are useless unless saline is added. The amount and type of saline added to the vial is the variant.

Customizing neurotoxin treatments to the specific patient will give cutting edge results. Explaining to the patient that you are tweaking the treatment for their specific needs allows them to realize that only you can give them that beloved result.

My recipe for reconstitution using bacteriostatic saline

Note, preservative-free saline is the FDA approved saline for reconstituting Botox; however, it burns more with injection. In 2004, a Consensus Statement recommended preserved 0.9% saline as the preferred diluent.

bactHave you noticed that I haven’t used the word “dilution” yet? Never mention “dilution” to patients as they will think you are thinning down the kool aid, so to speak. According to Webster, reconstitution is defined as “restoring to a former condition by adding water.” Dilution is defined as the “thinning of a liquid.” Patient believe “diluting” Botox means weakening its potency. Reconstitution, however, does not imply thinning out of product. An important concept to remember!

Here is my general rule for reconstitution:

  • 1:1: glabella, nasalis, ala, DAO, masseter (one unit of botox for every one unit of saline)
  • 2:1: frontalis, mentalis (one unit of Botox for two units of saline=one unit of Botox in every two hashmarks)
  • 3:1: crows feet (one unit of Botox for three units of saline= one unit of Botox in every three hashmarks)
  • 4:1: hyperhydrosis (one unit of Botox for four units of saline=one unit of Botox in every four hashmarks)

Listen closely, this doesn’t mean I have 4 vials of various reconstituted Botox sitting around. I reconstitute all my vials 1:1, meaning I add 1cc of bacteriostatic saline into a 100u vial of botox. This formula yields 1 unit of saline for every 1 unit of Botox. (Remember, there are 100u in 1 cc or 1mL)

My secret to the creation of various reconstitutions is counter reconstitution within my syringe. When I inject neurotoxins, I use 3/10 cc insulin needles. For a 1:1 reconstitution, each hash mark is 1 unit of Botox.
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Every hash mark is 1 unit, so if I want 20 units of Botox, I pull up to the 20 unit hash mark. See picture below. This is how I would treat the glabella area, for example. Four units, or four hash marks, into five different locations.

botimgIf I want to treat a broad frontalis with 8u of Botox, I would use a 2:1 reconstitution. I would draw up 8u (8 hash marks) in my 3/10 cc insulin syringe. Then, I would draw up another 8u of bacteriostatic saline into that same syringe. So, when done, I would have 16 hash marks total of solution and it would be 8u of Botox in a 2:1 reconstitution. Every one unit is two hashmarks. This way I can add 0.5u (one hashmark) to the lateral frontalis and soften the “spock effect” without too much toxin to cause brow ptosis.

If I want to treat fanning crow’s feet,I would chose a 3:1 reconstitution because it will gives greater “spritz” effect. I learned this word from Dr. Deb Sherman, the queen of Allergan’s “Lose your Eleven” campaign years ago. “Hammer” the glabella with a 1:1 and “spritz” the frontalis with 2:1; however, for crows feet I like a 3:1 for even greater spritz! Therefore, to treat crow’s feet with 10u of Botox, I pull up 10 hash marks of 1:1 Botox into my 3/10 cc insulin syringe, then I pull up another 20u (or hash marks) of saline. In total, I have 30u of solution, yielding 10u of Botox, a 3:1 reconstitution.

There are a few exceptions to my reconstitution weirdness. If someone has a short frontalis, I stick yo a 1:1 reconstitution steering clear of brow ptosis. Brow ptosis is going to happen, it’s a fact of life in this business. Be conservative in your dosing and know you can always add more Botox in two week…you can’t take it away!

As a side note, I reconstituted Dysport the EXACT same way as Botox. I add 1cc of bacteriostatic saline to a 300 unit vial of Dysport. If I want to treat a glabella, I pull up 20 hashmarks on the same 3/10cc insulin syringes. This reconstitution gives me 60u of Dysport within those 20 hashmarks. Every 1 hash mark is 3 units of Dysport. Thereby, I triple my Dysport dose in comparison to Botox. I will cover this in another blog!

If I had to choose one golden reconstitution that I always used, it would be 2:1.

What is your favorite, go-to reconstitution?

2017-03-06T19:42:28+00:00 By |Tips & Tricks|13 Comments

About the Author:

Haley Wood, offers her cosmetic patients a unique combination of experience, knowledge and personal attention. With almost a decade of experience in the field of Aesthetic Nursing, her areas of expertise include non-surgical facial rejuvenation with her distinctive injection technique.

13 Comments

  1. Jessica Barker June 4, 2015 at 2:32 pm - Reply

    Haley- When adding more saline to your syringe (i.e for crow’s or frontalis), how do you ensure the Botox and saline are properly mixed?
    Thanks!

    • Haley Wood July 8, 2015 at 10:32 pm - Reply

      Hi Jessica! Great comment! In fact, I wondered this myself so I do a kitchen test! I mixed blue dye into my normal saline. I drew up the blue dye saline into my syringe filled with 0.1cc clear saline, which would mimic Botox. The suction of drawing up the blue dye saline into the 0.1cc syringe of normal saline caused the total mixture within the syringe to completely mix.

  2. Kristina September 11, 2015 at 9:56 am - Reply

    This is genius! I have the same question about it being mixed in the syringe.
    Can I ask how long ago you started this practice and have been implementing it?
    And you’ve had it work fine all this time then?

    • Haley Wood October 7, 2015 at 2:56 pm - Reply

      Hi Kristina,
      I have been using this system of reconstitution for over 5 years. I use it on every patient practically with great results.

  3. Kristina November 3, 2015 at 7:13 pm - Reply

    Thank you Haley! I love your Website and videos!

  4. Jayna April 23, 2016 at 3:39 pm - Reply

    Hello, Just a quick question. How long is a vial of reconstituted Dysport diluted with bacteriostatic saline good for? Versus non-bacteriostatic? I have a 500 Unit vial of Dysport and want obviously won’t use all of it the first time, so how long can I store it refrigerated for?

    • Haley Wood April 27, 2016 at 6:08 pm - Reply

      I will be honest and tell you that I don’t have clinical experience in using preservative-free saline for reconstitution; I only use bacteriostatic. I can keep a bacteriostatic reconstituted vial for 30 days with noted efficacy. Where I have seen the problem with efficacy is if the product does not stay refrigerated for more than a day. I always keep reconstituted product chilled.

  5. Chelsey August 19, 2016 at 9:48 am - Reply

    Wow that was unusual. I just wrote an very long comment but
    after I clicked submit my comment didn’t appear. Grrrr…
    well I’m not writing all that over again. Regardless,
    just wanted to say excellent blog!

  6. Sandie October 3, 2016 at 1:51 pm - Reply

    By reading the dysport mixture, I assume that I can just mix dysport like botox and say if I inject 24 hashmarks to bilateral crowsfeet area, I will just tell my client, I did 24 u x 3 = 72 units of dysport?
    Since Dysport spread more than botox, do you still do the 3 : 1 mixture for the crowsfeet? By diluting the crowsfeet botox down, will that affect how long the dysport will last in that area?

    • Haley Wood October 15, 2016 at 2:14 pm - Reply

      Hi Sandie,
      If you reconstitute a 300u Dysport vial with 1cc saline, and then withdraw “24 hashmarks,” then yes, you would have 72u Dysport. I have not noticed that the efficacy of Dysport has diminished by reconstituting it with 1cc saline, as I do Botox.

      Hope this helps!

  7. Sandie October 21, 2016 at 6:09 pm - Reply

    Haley,
    Thanks for your answer. It makes sense that you mix 1ml to 300U of Dysport. Think about it, if 3 U of Dysport is about 1 U of botox then there is nothing wrong mixing Dysport the same way as Botox!
    By the way, I think you are awesome! I learn so many tricks from you. One thing I started doing is putting juvederm in insulin needle. Excellent idea! I have perfect lips every single time! I am wondering if you do dental block for lips? I have done a few times but seems like the top lip is never totally numbed. I need to hit the right nerve! It will be great if you can share you expertises on that!
    Thanks a lot for your website!
    Sandie

  8. JZ November 20, 2016 at 4:04 am - Reply

    Hi, I was wondering if it is possible to somehow split the vacuam dry botox? I mean literally opening up the vial with say a Kapoff tool and say reconstituting only a half or a quarter and doing the rest later?? Is this possible granted complicated but doable? Also if the botox powder is refrigerated or even frozen then who’s to say that it will spoil just because exposed to air when nor exposed to saline… Hope my question makes sense? Thanks!

    • Haley Wood March 28, 2017 at 1:37 pm - Reply

      To my knowledge, there is no way to “split the powder” and I would not suggest do that. You can purchase 50u vials of Botox and I would suggest that as a better option for you.

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