How to prepare Botox (botulinum toxin) ready for injection
If you are new to medical aesthetics and injecting Botox®, you are probably finding it a bit daunting getting used to handling the vial and preparing the botulinum toxin ready for injection. Oh, and if you looked at the vial and thought it was empty, you are not alone, even Dr Tim did this the first time he saw one until his error was pointed out to him.
In this blog, Dr Tim Pearce will explain the best way to open the vial of Botox, how to mix in the saline, draw up the solution into your syringe, and remove air bubbles before use.
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How to minimise air bubbles when reconstituting Botox
When preparing a vial of Botox ready for injection, Dr Tim explains that the goal is to add the saline into the vial without causing additional bubbles, which can be troublesome when you are trying to fill your syringes later.
There is a vacuum within the vial which can cause the saline to be sucked back out quickly as you add it; hence, we must think about how to control that to avoid creating a frothy mess, like a badly poured pint of lager. However, if you do not manage to do this correctly, he reassures you that it will be okay because as soon as you release the vacuum most of the bubbles will go away, but it is preferable – and you will improve with practice – to achieve a more controlled mix of the saline to minimise bubble formation.
How to open a Botox vial and reconstitute it with saline
On the top of the vial is a small plastic bottle top which you should remove to open the vial. This is a tamperproof mechanism and will not go back on again afterwards once opened so a vial cannot be resealed to appear fresh.
Dr Tim likes to use a green needle to release the pressure from the internal vacuum. As you push the needle through the bung, you will hear a small hiss that tells you that the pressure has been neutralised. Using the same needle, he extracts 2.5mls of saline and slowly adds it into the Botox vial by positioning the needle on the edge of the vial, at an angle, and slowly trickling in the saline; much as you would when pouring a glass of beer, he points out.
Importantly, although the pressure has been neutralised before adding the saline, upon introduction of 2.5mls of volume into the vial, the pressure will build up again. If there was another needle in the top of the vial, you would hear a hiss as the saline entered and the pressure was released, but we do not need to place another needle in the vial, notes Dr Tim. Instead, you must take the needle back out of the solution once the syringe is empty of saline, otherwise it will back fill up the syringe again before you have had chance to remove the needle from the vial. You will find the syringe plunger wants to rise, so you should apply a little pressure to keep it empty as you remove the needle from the vial.
It is important to make sure the saline is mixed well with the botulinum toxin using a gentle, circular motion with your wrist to give the solution a little swish around in the vial. Because we want to avoid creating bubbles, a gentle swirling action is desirable rather than a vigorous shake.
How to fill a BD syringe with Botox from the vial
Now the solution is ready to use, you can start to fill the BD syringes ready for injection.
To avoid blunting the needles, remove the rubber bung from the top of the Botox vial. This will also make the solution more easily accessible for the syringes.
Next, find the gap in the paper label that surrounds the vial as this provides a view all the way down to the base of the vial and, more importantly, it means you can see the meniscus of the solution. You must make sure that the needle is under the line of the meniscus as you fill the syringe otherwise you will draw up air bubbles.
Dr Tim’s top tip at this point is to slide the BD syringe into the vial without the needle touching the glass. He points out that this is a common mistake. If you touch the glass with the needle, you will instantly blunt it. This will be very unpleasant for your patients when you inject them. In fact, you will hear a crunching sound as you inject, which many practitioners believe is normal, but which is a sign of a blunted needle often done when drawing up.
Once in place, underneath the meniscus with zero air in the syringe, Dr Tim pulls up the plunger using his thumb to fill it with the Botox solution. He admits that he probably makes that sound and look easy because he has done it thousands of times, acknowledging that many will struggle to begin with, often moving too much within the vial, until they get more confident with practice. Take your time, keep the needle away from the glass and within the solution – practice makes perfect.
It is important to check for bubbles within the syringe once it is filled with the Botox solution as these cannot be injected into the patient. Small, gentle flicks with the tip of your sterile gloves should be enough to dislodge any bubble up to the top of the syringe. A final top tip from Dr Tim is to pull the syringe back a little because the meniscus often allows the bubbles to pop which is a good way to get the last few out
For more help on preparing Botox for injection, read some of Dr Tim’s other blogs including:
For more guidance on the best botulinum toxin injection patterns, why not get your hands on Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin.
Did you enjoy this quick tutorial? Dr Tim loves to hear from his followers and share his anatomy knowledge; if you have any questions or ideas for topics he can cover in future videos, please drop him a comment on social media; you can find Dr Tim Pearce on Instagram.
Botox® is a registered trademark of Allergan Aesthetics plc.
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Aesthetics Mastery Show
How to prepare Botox for injection
In this episode, Dr Tim shares how to prepare my Botox for injecting, the reconstitution used, how to draw Botox, and his top tips for ensuring your needle stays primed and sharp ready for injection. In this video, Tim uses 2.5mls of Bacteriostatic Saline mixed with the botulinum toxin & a BD syringe.
- 00:45 The best way to open your vial
- 01:12 How to mix saline & Botox
- 02:13 How to get the solution into your BD syringe
- 03:11 How to remove air bubbles
Watch the full Aesthetics Mastery Show here.
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