Practice matters


Botulinum toxin dilution


In this video, I want to show you how I reconstitute the botulinum toxin in my clinical practice. As you know, the manufacturer’s recommendation is to reconstitute with 2.5ml of normal saline in a 100 unit vial. However, I prefer a much more concentrate product, and I like to use 1ml of saline in the 100 unit vial. One of the reasons for this is that we use a lot of the toxin for full face Botox indications, and particularly in the lower face, we like to use very precise units, sometimes 1 or even 0.5 units. The product and device that I use is this syringe, which is a 0.3ml syringe, and when I use this, one notch equates to one unit of Botox.


So I have here my vial, and my brand of botulinum toxin here is Botox, made by Allergan. This is the brand I use in the clinic. I also have some bacteriostatic saline, a 1ml syringe, 21 gauge needles, a proprietary 32 gauge 0.3ml needle syringe, and some decappers. The first thing I will do is open up the Botox vial – you will notice it has some writing on it, this is purely for stock tracking purposes in the clinic. I open it from the side and remove the summary of product characteristics brochure and then remove the vial of Botox. You will notice that it appears empty, and this is because the formulation is a freeze dried powder which is attached to the bottom. Next I will take the 1ml syringe, and to that I will attach the 21 gauge green needle. I use this to insert into the vial of bacteriostatic saline, and I draw up exactly 1ml. We prefer to use bacteriostatic saline as there is some anecdotal evidence that it causes less pain for patients when we inject the Botox. When you use smaller dilutions like I’m using here, it’s absolutely vital to be meticulous as possible with your quantities, so you’ll notice that I’m exactly at 1ml here. I proceed to take the Botox vial and pop off the lid, and then insert the needle into the vial. You will notice that without any pressure on the syringe, the vacuum in the vial will drive the plunger down automatically. It’s important to make sure that this happens, as it indicates that the vacuum in the vial is intact. If you don’t see this happening, do not use the vial, and report it to the manufacturer.


Don’t shake the vial, simply agitate it slightly, and that is all that is required to mix up the Botox. Next, I will proceed to decap the vial. The reason for that is that my needle that I will be using is very short, and it wouldn’t reach the bottom of the vial. You can obtain these proprietary decappers online, and you firmly apply pressure from the sides to remove the foil. This then allows me to remove the bung, however I will keep it in place until I remove my needle and syringe. This is a 0.3ml syringe, so at a dilution of 1ml per 100 units, each notch will be exactly 1 unit, and the syringe will allow me to use 30 units. As I take the cap off, you will see that the needle at the end is a very small 32 gauge needle, which allows for a more comfortable injection. To fill it, I simply remove the bung from the vial of Botox and turn it to the side. It’s important that you are careful not to damage the end of the needle, as it is very fragile and can blunt easily. I simply draw up the amount of Botox that I require into the syringe, this can be tricky because the needle is so thin. Invariably, there will be an air bubble, and you will need to just flick the syringe to bring the air bubble to the top. You can then just use the plunger to ensure that you have only product in the syringe, and no air bubbles. I now have 10 units of Botox ready for injection. In this case, every time I push the plunger one notch, that will be one unit of Botox.