MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.

"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.

The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.

For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.

"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.

Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.

To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.

Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.

"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.

On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.

"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.

The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:

– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."

– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.

– Expect the results to last at least 6 months before beginning to fade.

– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.

– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.

Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

Where Belotero Balance excels in cosmetic dermatology