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reconstituting onabotulinumtoxinA with 2% lido-
caine with 1:200,000 epinephrine.
Recently, a brief communication described the
injection of a ‘‘cocktail’’ composed of abobotuli-
numtoxinA, 2% lidocaine with 1:100,000 epineph-
rine, and hyaluronic acid (Perlane, Medicis,
Scottsdale, AZ) for rejuvenation of the upper face.
To mix all products, two syringes were connected,
and at least 10 back-and-forth mixings were
performed. The combined product was injected into
five patients in the periocular and glabellar areas in
linear threads, small boluses, or serial punctures, and
the author concluded that there was no compromise
in efficacy or safety.
36
Another study compared side by side, in 29 patients,
onabotulinumtoxinA reconstituted in 2% lidocaine
with normal saline for axillary hyperhidrosis.
37
They
concluded that it was equally effective over the short
and long term. Because injections with lidocaine-
reconstituted onabotulinumtoxinA were associated
with significantly less pain, it might be preferable for
treating axillary hyperhidrosis.
There has been a report of a fatal case of anaphylaxis
after the injection of an onabotulinumtoxinA and
lidocaine mixture in a woman for chronic neck and
back pain.
38
It was not possible to establish which
drug was responsible for the reaction, but when
using lidocaine to dilute BoNTA, it is advisable to
consider that it may increase the possibility of an
anaphylactic reaction.
Hantash and Gladstone tested the effect of
epinephrine 1:100,000 on onabotulinumtoxinA
efficacy.
39
Fourteen subjects were treated and eval-
uated for up to 6 months. The authors concluded
that epinephrine might accelerate the rate of onset of
action and enhance the short-term efficacy of
onabotulinumtoxinA for the treatment of periorbital
rhytides. Other articles reporting authors’ personal
experience
40,41
have recommended the addition of
epinephrine to saline for the reconstitution of abo or
onabotulinumtoxinA.
Bupivacaine
Yen and colleagues
42
conducted a randomized,
double-blind study with 16 patients treated for
glabellar furrows. OnabotulinumtoxinA reconsti-
tuted with 0.75% bupivacaine was injected into
one corrugator, and the contralateral muscle received
the same product reconstituted with unpreserved
saline. At 1 week, the side treated with bupivacaine-
reconstituted toxin showed greater muscle weakness.
At 1 and 3 months, there were no differences
between the sides. They concluded that bupivacaine
did not affect efficacy or duration of onabotuli-
numtoxinA but could result in a less-painful
procedure. They attributed the faster onset of the
paresis to a possible synergistic effect of bupivacaine-
induced myotoxicity.
Sterile Water
BoNTA will work if dissolved in sterile water, but this
causes intense short-lived pain at the injection site.
43
Albumin
Bigalke and colleagues
44
demonstrated that human
albumin supplementation of abobotulinumtoxinA
could allow a dose reduction without decrease of
therapeutic efficacy. In another study,
45
106 patients
were treated with abobotulinumtoxinA (diluted in
0.1% albumin solution to a concentration of
25 U/mL) over 5 to 10 years for cervical dystonia,
blepharospasm, and hemifacial spasm. The conclu-
sion was that long-term treatment with albumin-
supplemented BoNTA was safe, effective, and could
help reduce costs.
Foam During Reconstitution
To evaluate the stability of fragments of BoNTs (light
chain and the binding domain of the heavy chain)
in response to mild agitation, Toth and colleagues
46
performed several in vi tro tests. They used endo-
genous trypsin-like protease to cleave the 150-kDa
toxin into a 50-kDa N-terminal light chain (Lc) and
a 100-kDa C-terminal heavy chain. The latter was
further proteolyzed into a 50-kDa N-terminal
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