Reconstitution / Dilution

11 Reconstitution / Dilution





Several situations have been implicated in affecting the potency of BoNT. For this reason, different recommendations have been made aiming at not interfering with its efficacy or duration. In this chapter, published information on various methods of reconstitution, including mixtures of toxins with several substances, agitation or foam formation, will be reviewed as well as the impact of volume on botulinum toxin performance.



Reported substances used in the reconstitution process


OnabotulinumtoxinA is provided as a vacuum-dried powder, whereas incobotulinumtoxinA, abobotulinumtoxinA, and BoNT-A from Lanzhou (China) are presented as lyophilized powders (Fig. 11.1). RimabotulinumtoxinB is provided as a ready-to-use sterile liquid and no reconstitution is required.








Epinephrine and / or lidocaine


Hantash et al tested the effect of epinephrine (EPI) 1 : 100 000 on onabotulinumtoxinA efficacy in periorbital rhytides in 14 patients, evaluated for up to 6 months. They found that EPI promoted a faster onset of action and enhanced short-term efficacy of onabotulinumtoxinA. Gassner & Sherris, in a double-blind, randomized, controlled study with 10 volunteers for cosmetic indication, showed that when onabotulinumtoxinA was reconstituted with 1% lidocaine with 1 : 100 000 epinephrine, all components retained their function. Similar results were found by Haubner in two cases, using 2% lidocaine with 1 : 200 000 epinephrine.


A cocktail composed of abobotulinumtoxinA, 2% lidocaine with 1 : 100 000 epinephrine and hyaluronic acid (Perlane®, Medicis, Scottsdale, AZ) was recently described. The combined product was injected in five patients for periocular and / or glabellar areas and the author reported no compromise in efficacy or safety, but only periocular post-treatment photographs were showed.


A study conducted in 29 patients, compared side by side, onabotulinumtoxinA reconstituted in 2% lidocaine or normal saline for axillary hyperhidrosis and found similar effectiveness in both the short and long term. As the lidocaine-admixed solution was associated with significant pain reduction, it might be preferable for treating axillary hyperhidrosis.


A fatal case of anaphylaxis after the injection of onabotulinumtoxinA and lidocaine mixture in a woman for chronic neck and back pain was also reported. Since it was not possible to determine which drug was responsible for the reaction, it is advisable to consider that lidocaine may increase the possibility of an anaphylactic reaction.





Mar 12, 2016 | Posted by in General Surgery | Comments Off on Reconstitution / Dilution

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