Now, as a side bar, the preservative in bacteriostatic saline is benzyl alcohol. The original concern was that the alcohol would prematurely cleave the disulphide bond in the Botulinum Toxin A molecule. As you likely know from your training, it's essential that both the heavy and the light chain remain connected until they pass into the nerve cell. If they were to dissociate prematurely, the toxin would be rendered ineffective but we have at least 15 years of research which shows that the disulphide bond is unaffected by the benzyl alcohol and most, if not all, practitioners use it. Now, if you should choose to use the non-preserve saline, you need to use that toxin within 24 hours and anything remaining after that will need to be discarded. So, both Botox and Dysport will arrive at your office on dry ice. Your staff should promptly place those boxes into the refrigerator and they should be kept at two to eight degrees Celsius, which is 35 to 46 degrees Fahrenheit. Xeomin, however, doesn't require refrigeration prior to reconstitution and can be stored at room temperature.

So, here's what you're going to need for reconstitution. You'll need bacteriostatic saline, you'll need 70% alcohol wipes, a sterile needle and syringe (three CCS) and then of course, you need your neurotoxins. The CDC recommends that any medication preparation takes place in a designated clean medication area that's away from areas where potentially contaminated items are placed. Generally speaking, any item that could have come in contact with blood or body fluids shouldn't be in the medication preparation area and naturally, proper hand hygiene should be performed prior to handling any medications.

So, when you open the box of neurotoxin and depending on the formulation, the presentation will look slightly different. So, here you have Botox, which you can see a very faint little snowflake in appearance at the bottom, there's virtually no powder in there. Now, on the other hand, Xeomin has a fair degree of powder inside, hopefully, you can appreciate that there. As well as Dysport; Dysport is a powdery presentation as well. Okay. So, understand that the sterility of the rubber stopper on any of these toxins or any medication is not assured when you receive it from the manufacturer. So, prior to piercing it, you'll need to address it with some 70% alcohol. And another hard and fast rule of asepsis surrounding the use of multi dose vials, is how long they can be kept after being opened or accessed via a needle puncture and the CDC recommends that for our purposes, it's essentially 28 days and this is true for multi-dose vials of saline and lidocaine as well. So, it's essential to record the date that you've opened it on any bottle that you do open and I do that for Saline and lidocaine as well.

Let's take a moment here to discuss another concept that practitioners who don't typically use multi dose vials may not be familiar with, and that is the prevention of the formation of a vacuum in a sealed vial. So, a vacuum will form in a vial if you don't replace the liquid volume you're removing with an equal volume of air and this is what I mean. So, say I need 2 CC's of saline from this bottle, so before I start pulling the liquid out, I need to provide some positive pressure inside the bottle so I don't have to pull. The way I do this is by first injecting 2 CC's of air which is equal to the volume that I want to take out. You also need to be careful not to inject the air into the liquid, so don't have the bottle inverted when you're injecting the air because that simply creates more bubbles and it makes the volume more difficult to pull out.

Okay. So, that said, we'll begin by wiping this rubber septum on our Saline and I'll inject an equal amount of liquid. So, I've injected the air and now I'll invert the bottle and now you'll see because of the positive pressure that I have in here, okay, you'll see that it's actually pulled the volume out without myself applying any negative pressure, okay. So, I have the volume I need, okay. Now, I'll wipe the septum of my neurotoxin. Now, one thing I should note too here is that the top of your neurotoxin rubber stopper will have a circle on it, you should only make a habit of only piercing that central circle area with your needle and the reason is, the central area is the thinnest. If you look at the shape of the cork, you'll see that the cork has thickness on both sides, okay, and then in the centre here, it's thinner. So, you definitely want to have your needle going through that thin area. So, we have our Saline and our neurotoxin septum has been cleaned. So, now we're ready to add the Saline, okay. So, placing it into the centre, you'll see that the neurotoxin bottle comes with a partial vacuum, so it actually pulls the Saline in. Now, at this point, and with the vial upright, you can unscrew the syringe from the needle, being careful not to touch the hub, okay, and allow the pressure to equalize. Never invert the bottle with the needle sitting in the septum like this. After a moment, you can remove the needle. You should know that the CDC says it's unacceptable practice to leave the needle inserted in the septum of a medication vial for multiple medication draws. This would allow for a direct route of microorganisms to enter the vial and contaminate the fluid.

Now, you simply rotate the vial to mix, there's no need for vigorous agitation, which would only serve to create bubbles. So, with Xeomin though, it's really important to be sure that you invert the vial when you're mixing and this is because the manufacturer uses a special lyophilization process and the toxin often gets trapped up here inside the stopper area and if you don't invert the vial, you may have incomplete reconstitution, which would decrease the effect per volume that you'd get. Okay. So, now we need to write the date on the vial and it's ready for patient use. Any time the bottle is not being used, it should be in the refrigerator and don't leave it out on the counter.

And a few final things: the neurotoxin will come labelled as a single patient use file. Now, as long as you strictly adhere to aseptic technique, you can use that vial for more than one patient and before using it, always inspect the solution for particulate or cloudiness and if you should see either of those, you need to discard that solution.