Recently approved by the Food and Drug Administration, Belotero Balance (Merz) appears to rival other longer-standing dermal fillers in efficacy and safety, offering physicians and their patients a new treatment option for the aesthetic correction of moderate to severe facial wrinkles and folds, says Derek H. Jones, M.D.
"In my experience, Belotero Balance can do exactly what the other leading hyaluronic acid (HA) fillers can do, both in terms of its ability to correct wrinkles and folds and volumize the face and lips. Moreover, its duration is also equivalent to both Juvederm (Allergan) and Restylane (Medicis), two cornerstone HA filler products," says Dr. Jones, clinical associate professor of dermatology, University of California, Los Angeles, and founder and director, Skin Care and Laser Physicians of Beverly Hills.
Some of the characteristics that differentiate HA fillers include their degree of crosslinking, their concentrations, gel hardness and their cohesivity, Dr. Jones says. Belotero Balance is a monophasic double crosslinked HA gel based on Cohesive Polydensified Matrix (CPM) technology that creates a low-viscosity gel product with variable densities of crosslinking in one cohesive structure, he explains.
The variable zones of cross-linking allow for the product to integrate nicely into nooks and crannies in the dermis and the subcutaneous layer, Dr. Jones says, resulting in smooth, natural-looking augmentation outcomes. According to Dr. Jones, the very elastic and cohesive properties of Belotero Balance allow for the gel to be injected evenly and spread homogeneously across the targeted area and into the surrounding tissues.
"Compared to Juvederm and Restylane, Belotero Balance is a newer-generation HA that is molecularly tweaked in such a way that we can use it in very superficial fine lines and wrinkles without having to worry as much about lumps and bumps and the Tyndall effect," Dr. Jones says. He was also an investigator in the 118-patient trial that led to the product's FDA approval.
When injected too superficially in the dermis, most hyaluronic fillers will create the Tyndall effect, a bluish discoloration due to the optical properties of the filler used. This unwanted side effect is a non-issue with Belotero Balance because of the filler's homogenous tissue integration pattern, Dr. Jones says.
BELOTERO BALANCE USE According to Dr. Jones, Belotero Balance can be used much the same way older collagen implants such as Zyderm (Allergan) or CosmoDerm (INAMED) were used before they were taken off of the U.S. market.
"Many of us felt that it was quite unfortunate to lose those products because they were really excellent fine line fillers, and there has been a void in the U.S. market place for fine line fillers. I think that Belotero Balance will come in and fill that void," he says.
When treating fine lines and wrinkles with Belotero Balance, Dr. Jones performs a serial puncture technique and places his injections very superficially high up in the dermis, resulting in a little blanching at the target area. He says he will also sometimes slightly over-correct the targeted area and gently massage the filler to better integrate and spread the product.
"Caution is warranted, however, when over-correcting because beading could still occur with Belotero Balance if a larger bolus is injected superficially in the dermis. As HA fillers are hydrophilic, some initial swelling may occur, as well as some minor erythema after the injection, which may persist for one to two days following the procedure," he says.
In contrast to some other filler products currently available on the market, Belotero Balance does not come premixed with lidocaine, which, according to Dr. Jones, may be viewed as a disadvantage to some physicians.
"For me, it does not make a difference because I often like to mix lidocaine with some epinephrine in the products I use and find that this mixture works very well. I like a little bit of epinephrine because I believe that it helps reduce the potential for bruising and swelling, and though this has never been proven in good studies, many of us believe it to be the case," he says.
According to Dr. Jones, Belotero Balance can be used across a wide range of aesthetic indications and can be considered an ideal filler for etched-in, more superficial lines and wrinkles. For deeper lines and folds, Dr. Jones says that other HA fillers such as Juvederm and Restylane may be the better choice.
"Compared to other products that we have had in the U.S. marketplace, we really haven't had a good competitor to either Juvederm or Restylane until the arrival of Belotero Balance, particularly when addressing finer lines and wrinkles. I believe that Belotero Balance can compete equally with other lead hyaluronic acid fillers such as Juvederm and Restylane, and I think that we will see that manifest in the literature in the near future," Dr. Jones says.