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What if Botox Was Mixed with Sterile Water Instead of Saline?

Doctor Answers 10

April 27th, 2013

Saline versus Sterile WaterT

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There should not be any difference in the action of Botox if sterile water was used instead of saline. However, there was probably more pain. The official Allergan recommendation is to use non-perserved  normal saline. Very few injectors use this variety, preferring normal saline that has been preserved with Benzyl Alcohol. Benzyl Alcohol is a mild anesthetic, besides being a preservative.

Interestingly, I have a patient who broke out each time, I injected her with Botox. I determined she was allergic to Benzyl Alcohol.  Curiously, though the non-preserved is the indicated diluent, I found it very difficult to locate this and had to find it in a hospital pharmacy. This shows very few of my colleagues are following the Allergan recommendation. 

The injections would be a bit more painful because 1) the absence of Benzyl Alcohol and as Dr. Mills points out, the pH of normal saline is closer to body pH than water.

However, efficacy will not be affected.


Virginia Beach Dermatologist

April 27th, 2013

Botox mixed with Water rather than Saline

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Mixing Botox with sterile water rather than saline makes no difference in the effectiveness or duration of action of the Botox. It is, however, much more painful when injected.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

April 27th, 2013

Botox mixed with sterile water?

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There is nothing wrong with mixing Botox with sterile water except that i stings when injected. The results will be he same and it wil work for the same amount of time.

Jo Herzog, MD

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April 28th, 2013

Botox Injections with Sterile Water

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Thank you for the question. In terms of the Botox effect, there should be no difference. However, the sterile water has a different mineral concentration and level of acidity (pH) than saline.  Saline is chosen because it generally more comfortable (i.e., won't cause a burning sensation when injected).

Learn more: http://www.sanfranciscofacialplasticsurgery.com/botox-cosmetic-and-dysport.php

Evan Ransom, MD
April 27th, 2013

Botox mixed with sterile water

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The botox injection is much more painful if mixed with sterile water but it should still work well.  You could add some saline and make it more dilute.  This should make it a bit more comfortable. Hope this helps.

Elizabeth Piantanida, MD
Colorado Springs Dermatologic Surgeon

April 27th, 2013

The hypotonic sterile water is a problem.

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The body fluids contain salts.  The salt solution (normal saline) is carefully balanced to matter the concentration of salt in the body fluids.  If one injects more or less concentrated solution,  significant pain is caused as fluids shift to correct the salt imbalance.  Normal saline is profoundly more comfortable when injected than sterile water for this reason.  Diluting Botox with sterile saline almost always the unpleasant cause of painful Botox treatments.  Don't allow yourself to be injected by someone who dilutes their Botox with sterile water.  The treatment will be unnecessarily painful and it suggests the injector does not read or follow directions.

Kenneth D. Steinsapir, MD

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

April 26th, 2013

Sterile water vs saline with Botox

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It is recommended by the manufacturer that Botox be mixed with sterile sodium chloride solution (i.e. saline).  Despite this recommendation, the difference between the two solutions should be relatively minimal.  The most noticeable difference would be in the pain associated with the injection of sterile water.  Saline has a pH that more closely matches that of your body and therefore it stings less than sterile water when injected.  However, the function of the Botox itself should be the same.

Paul B. Mills, MD
May 7th, 2013

Botox reconstitution

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If it was reconstituted with anything other than the company's recommendation, it would sting, hurt, and cause general discomfort, upon injection.

Sam Naficy, MD, FACS
April 29th, 2013

Botox with sterile water

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Mixing Botox with sterile water doesn't affect the efficacy of the Botox, but it will hurt A LOT during injection.

F. Victor Rueckl, MD
April 28th, 2013

Saline or water for Botox dilution

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It is recomended to use sterile saline without perservative. Sterile water is not a balanced solution and may burn upon injection.

Steven Wallach, MD

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.