Belotero (Merz) has become the treatment of choice and standard of care for the cosmetic treatment of fine, etched-in facial lines, according to a dermatologist Cosmetic Surgery Times interviewed on the topic in 2012.1
Derek H. Jones, M.D., clinical associate professor of dermatology, University of California, Los Angeles, and founder and director, Skin Care and Laser Physicians of Beverly Hills, says he uses the highly cross-linked hyaluronic acid filler to treat vertical, etched-in perioral and fine, superficial etched-in radial cheek lines.
But there is a caveat: Belotero requires injection know-how.
“It does take some experience because it is injected differently [than other hyaluronic acid fillers],” he says.
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Dr. Jones says he transfers all of the product into a 1cc BD syringe. The particular syringe has a Luer lock, which allows the dermatologist to use a fine 32-gauge needle, without concern that the needle adapter will fly off under higher pressure with injection.
He injects with the 32-gauge needle, using a serial puncture, superficial dermis technique.
An advantage of using Belotero is its Cohesive Polydensified Matrix (CPM) technology feature. The technology allows Belotero to smoothly and homogeneously integrate into the dermis a day or two after superficial injection, according to Dr. Jones, an investigator and consultant for Merz and an investigator in the 118-patient trial that led to Belotero's FDA approval.
“We have seen that with histologic studies. It has been confirmed by ultrasound studies, and we see it clinically,” Dr. Jones says.
According to Dr. Jones, when injected correctly, Belotero does not form the pools and lakes that can result after Restylane [Galderma] and Juvéderm [Allergan] injections. Injecting too much superficially, however, can result in some beading of material, he says.
A Closer Look at the Data
Two recent studies suggest Belotero’s technology makes a difference.1, 2 UCLA researchers reported in May 2014 in the Aesthetic Surgery Journal that high-resolution ultrasound shows hyaluronic acid gel fillers with differing production technologies show distinct spread and distribution patterns in the periocular tissues.1
“Restylane-L formed a localized hypoechoic image within the tissue, with some spread into bubbles or pearl-like configuration. Belotero Balance spread more widely into the tissue plane and diffused into an elongated or spindle-shaped hypoechoic image,” according to the study’s published abstract.1
Researchers published a study2 in October 2013 in Plastic and Reconstructive Surgery suggesting Belotero resulted in greater evenness than Restylane at four weeks. And a five-year retrospective review of 317 patients treated with Belotero Balance showed no adverse events, including no persistent nodules or granulomas.
A study performed in 2012 comparing Belotero Balance with Juvéderm and Restylane showed the fillers perform equally well when used traditionally in usual volumes, according to Dr. Jones.3
One downside of Belotero, however, is its longevity.
“Since we’re using very small aliquots, high up in the skin and superficially, longevity may not be as great as with some other types of volumizing fillers. Generally, I tell patients six to 12 months, and that holds true in my clinical practice,” Dr. Jones says.
Take Caution: Belotero Bruises
Because clinicians use a superficial serial puncture technique, Belotero patients are likely to have swelling and bruising for the first couple of days. Dr. Jones says he avoids using Belotero or any other filler a day or two before a patient has a big social event.
It’s too early to tell whether Restylane Silk [Galderma] might be option in these cases, according to Dr. Jones.
“There has been some burgeoning interest in Restylane Silk. It’s new on the market,” Dr. Jones says. “Some of my colleagues like Restylane Silk quite a bit, but I think we need to develop our experience a bit more in terms of fine line treatment compared to Belotero.”
Petrou, I. Newly approved Belotero filler appears to rival leading dermal products, clinician says. Cosmetic Surgery Times. Published August 1, 2012. Available at: http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/modernmedicine/modern-medicine-feature-articles/newly-approved-belotero-
Goh AS, Kohn JC, Rootman DB, Lin JL, Goldberg RA. Hyaluronic acid gel distribution pattern in periocular area with high-resolution ultrasound imaging. Aesthet Surg J. 2014;34(4):510-5.
Lorenc ZP, Fagien S, Flynn TC, Waldorf HA. Review of key Belotero Balance safety and efficacy trials. Plast Reconstr Surg. 2013;132(4 Suppl 2):33S-40S.
Prager W, Wissmueller E, Havermann I, et al. A prospective, split-face, randomized, comparative study of safety and 12-month longevity of three formulations of hyaluronic acid dermal filler for treatment of nasolabial folds. Dermatol Surg. 2012;38(7 Pt 2):1143-50.