Are There Different Grades and Potency of Botox?

Question

A doctor that I had used for Botox recently retired. The 2 doctors that I have visited since have injected the same amount with much less effect.Also, when being injected, the Botox solution causes a very painful contraction/cramp in the tissue it is being injected into. Can Botox be diluted? What is it being diluted with? Thanks.

Harold J. Kaplan, MD · Answer

Hi Sugardoughnut.  While there are not two different grades of Botox, there are alternative dilutions.  Botox comes to your practitioner in a vial that contains 100 "units" of Botox powder.  This powder is then mixed with saline solution according to your injector's preferences.  Some injectors mix the product with more saline, some with less.

	Although we cannot explain the cramp you are speaking about, we will speak to the effectiveness.  One of a couple things could be happening.  

	
		Either the second and third injectors are not very skilled and are not getting the product to the right place in the muscle tissue and therefore the results are poor.
	
		The second and third injectors may also be using less overall "units" of Botox and this could be causing you to lose your results more quickly than with the original injector.


	We would recommend that you request your medical records from your initial injector to find out what was injected (number of units) and then also request the medical records from your new injectors to compare.  If the number of units is the same, then there is a technique issue.  If the number of units is lower with the second and third injectors, it may just be an issue of not getting enough product.  Good luck.

Ron Shelton, MD · Answer

Botox is diluted always as it comes in a powder. The physician dilutes it with sterile saline (salt water). Painful contraction and cramping is extremely rare. The amount of saline used to dilute the Botulinum Toxin is different amongst physicians. The dose, or number of units given, is the important variable . Make sure you are comparing units per zone rather than amount of liquid.

Trevor M. Born, MD · Answer

Dear Sugardonut, The amount of BOTOX is important for the overall effect and the length of effect. Also, There are 2 toxins available now- Dysport and BOTOX  Cosmetic- they require different amounts of toxin for effect.
Also, very important is the agent used to dilute the BOTOX- "NON- preserved saline" has as little alcohol in it and it is much les painful for the injection of the BOTOX.
Finally, the needles need to be fresh- i use a different needle for each site- a BD 31 gauge needle- very sharp so it hurts less.
With Warm Regards,
Trevor M Born MD

Kenneth D. Steinsapir, MD · Answer

Dear Location 98004, 
It is important that you are aware of what works for you. Unfortunately not every office is honest about how much BOTOX you are getting in a syringe. The product comes dry in the vial and then is reconstituted by the doctor. Typically office use 2.5 to 4 milliliters of saline to dilute the BOTOX. However, some office dilute much more. I am aware of one office that dilutes their BOTOX with 20 ml of saline so each syringe contains just 5 units of BOTOX. This office offers free touch ups if you are not happy with the results but then there is essentially no BOTOX in the syringe. In Los Angeles, it is also clear that some offices sell BOTOX by the unit but do not actually give a full unit. The product is very expensive so it should not be surprising that this goes on.
 
It is important to recognize this. Be certain when you are treated that you find out how many units of BOTOX you are being treated with. Write this down and keep track. That way if you go to another office and they claim to treat with the same amount of BOTOX, you can compare treatment effects. Treatment effects should last about 4 months. Results that only last a few weeks are the results of inadequate amounts of BOTOX. If you have had good results with one office but results that only last a few weeks at a second office or on a second service at the original office suggest that less product was used.
 
Finally with regard to comfort. Diluting BOTOX with preserved saline is slightly more comfortable that unpreserved saline. I tend to use numbing cream on the skin an unpreserved saline. Occasionally, individuals have allergies to the preservative so I avoid this type of issue using unpreserved saline. However, the discomfort you are describing is the results of diluting the BOTOX with sterile water. The sterile water is hypotonic and it pull salt out of cells and this results in profound discomfort like someone stuck you with a rose thorn. Only bozos dilute their BOTOX with sterile water (my apologies to BOZO the beloved television clown).

Tanveer Janjua, MD · Answer

Botox can give variable results with different dilutions and techniques. If you used to get good result with less pain, then mention it to your physician. She/He should be able to modify the technique to cause less pain and good results.
Here is a summary of dosage by units that I use for Botox or Dysport:
Glabella 20units botox, 50units dysport
Crows feet 20units botox, 50 units dysport
Forehead 20units botox, 50 units dysport
I use 30 gauge needle which is very small and ask patients to apply Emla cream one hour before injections.
Regards

Steven J. Pearlman, MD, FACS · Answer

Botox is a single product that comes freeze dried from the Allergan company. Each physician chooses to dilute it according to their training and experience. It is not the dilution, but the number of units (plus the skill of the doctor) that really determines effectiveness. As for burning, this is unusual, but it is a small needle being used. Some patients can be helped by ice or topical anesthetic prior to injection. However, I have found that using diabetic syringes and a low dilution minimizes injection discomfort.

Otto Joseph Placik, MD · Answer

Ceertainly the botox can be diluted and that can vary from one physician to another. In regards to the pain, this can be related to the diluent. Package inserts recommend unpreserved saline which can actually sting more than preserved saline.

Jeffrey Zwiren, MD · Answer

A unit of botox is not a unit of measurement but a unit of efficacy. The standard recommended dilution is 2.5 cc of saline per 100 unit vial. This will yield 4 unit of botox per.1cc. Ask how it is prepared and how fresh the mixture is. Botox will lose some of its effectiveness after one week.

Christopher L. Hess, MD · Answer

Botox is delivered as a freeze dried toxin that must be reconstituted with saline in order to be injected. Practitioners can dilute the toxin any way they want. I and many other use 2cc of saline so that each .1cc has 5 units of toxin. But regardless you should be paying for the number of units and this would give you an idea of what the surgeon is doing.

Steven Wallach, MD · Answer

Botox is a brand name for one form of botulinum toxin.  If Botox is being injected, it is the same material.  There are other forms of toxin including that provided in Dysport.

Are There Different Grades and Potency of Botox?

Answers (12)

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