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.
Have 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.
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.
If 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?