Recommendations and current practices for the reconstitution and storage of botulinum toxin type A Austin Liu, MD, a Alastair Carruthers, MD, FRCPC, b Joel L. Cohen, MD, c William P. Coleman III, MD, d Jeffrey S. Dover, MD, FRCPC, FRCP, e C. William Hanke, MD, f Ronald L. Moy, MD, g and David M. Ozog, MD a Detroit, Michigan; Vancouver, British Columbia, Canada; Englewood, Colorado; New Orleans, Louisiana; Chestnut Hill, Massachusetts; Carmel, Indiana; and Los Angeles, California Background: Current guidelines from the Centers for Disease Control and Prevention (CDC) regarding the reconstitution and storage of botulinum toxin type A (BT-A) differ from those of the Centers for Medicare and Medicaid Services and current clinical practice. CDC guidelines require single-patient use of BT-A vials. Strict adherence to these guidelines creates waste and a significant financial impediment, and does not confer increased protection from infection, assuming standard safe injection practices are followed. Objective: This study examines current clinical practices and provides expert consensus recommendations regarding the reconstitution and storage of BT-A. A review of the literature on the sterility and efficacy of BT-A stored beyond the recommended time period of 4 hours is also presented. Methods: An Internet-based survey was used to analyze the current practices of physician members of the American Society for Dermatologic Surgery who administer botulinum type A toxins. Results: After reconstitution, the majority of physicians (68.6%) routinely store BT-A for a period of greater than 1 week and safely use each toxin vial for more than one patient. Not a single case of infection was observed. Limitations: This was a single survey with a 32.2% response rate. Conclusion: A single vial of BT-A can be safely administered to multiple patients, assuming standard safe injection techniques are followed. After reconstitution, Our data suggest that BT-A can be stored beyond the recommended time period of 4 hours. ( J Am Acad Dermatol 2012;67:373-8.) Key words: Botox; Botox reconstitution; Botox storage; botulinum toxin; botulinum toxin consensus recommendations; botulinum toxin reconstitution; botulinum toxin storage. B otulinum toxin type A (BT-A) is widely used today for both cosmetic and noncosmetic purposes. It is the most common nonsurgical intervention for facial rhytids. The current product labeling regarding reconstitution recommends this to be performed using preservative-free saline. However, recent studies have found improved tol- erability with less pain upon injection when From the Department of Dermatology, Division of Mohs Micro- graphic Surgery, Henry Ford Hospital, Detroit a ; Department of Dermatology and Skin Science, University of British Columbia b ; AboutSkin Dermatology and DermSurgery, Englewood c ; Depart- ments of Dermatology and Plastic Surgery, Tulane Health Sciences Center, New Orleans d ; SkinCare Physicians, Chestnut Hill e ; Laser and Skin Surgery Center of Indiana f ; and David Geffen School of Medicine at the University of California at Los Angeles. g Funding sources: None. Conflicts of interest: None declared. Disclosure: Dr Hanke served as an investigator for Allergan, Medicis, Merz, and Galderma, receiving grants. Dr Coleman served as a consultant for Allergan and Merz, receiving grants. Dr Carruthers has been on the advisory board and served as an investigator for Allergan and Merz, receiving honoraria. Dr Cohen served as a consultant and investigator for Allergan, Medicis, and Merz, receiving grants and honoraria. Dr Moy served as an investigator for Inamed, receiving grants and is a stockholder of Claro. Dr Dover served as an investigator for Allergan, receiving grants. Drs Liu and Ozog have no conflicts of interest to declare. Accepted for publication October 6, 2011. Reprint requests: David M. Ozog, MD, Department of Dermatology, Division of Mohs Micrographic Surgery, Henry Ford Hospital, 3031 W Grand Blvd, Suite 800, Detroit, MI 48202. E-mail: dozog1@hfhs.org. Published online November 7, 2011. 0190-9622/$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2011.10.008 373