How to dissolve Belotero?

Another public forum question which I attempt to answer for fun.

Blue puffy bags after Belotero in tear trough + older Juviderm on inner orbit rim. Will Vitrase dissolve both at the same time?? Had bad reaction to Vitrase 2 years ago but can’t wait it out…it’s appalling.

Thank you for asking your question.  My answer is just an academic exercise in producing a discussion regarding a hypothetical situation.  My answer is not directed medical advice.  Please see your doctor in person for medical advice.

​​So how do we dissolve Belotero and Juvederm which caused blue puffy bags in the tear trough under the eyes?

​About the sensitivity to Vitrase issue:

​Vitrase isn’t the only hyaluronidase available in the USA.  I believe that other formulations are Hydase, Wydase, Amphadase and Hylenex.  All of them are animal derived hyaluronidase products except for Hylenex which is derived synthetically from recombinant human product produced by genetically engineered Hamster Ovary cells in a laboratory.  Because it is not derived from an animal and it is the human form of hyluronidase, there would be less reactions from it.  Consider using Hylenex.  This is what is available in my office.  ​For a patient with previous Vitrase reaction, I would try Hylenex.

​About dissolving both Juvederm and Belotero at the same time:

​Yes, Juvederm and Belotero are both hyaluronic acid fillers and will be affected by Vitrase, Hylenex, or other hyaluronidase products.  However, Juvederm will be a bit more resistant to dissolving.  Thus if a very small amount of hyaluronidase is use, the Belotero would dissolve first.

​Regarding the Bluish tint = Tyndall effect:

​That is probably from the Juvederm.  I have had the same problem before when using Juvederm in the tear trough.  But I still use Juvederm in that location but only for patients with thicker skin or darker skin.  I had to learn from some of these problems which I’ve also had.  I have only had one patient who reported a Tyndall effect with Belotero and thus I consider the Tyndall effect to be very rare with Belotero.

​Another possible suggestion – using dilute Hylenex:

​Much of what we do as doctors are considered off-label FDA use.  Much of what we are discussing here is off-label FDA use.  For some of my Hylenex cases, I dilute the Hylenex with Saline.  My formula varies with the application, and thus I have been able to thin out the problem to an appropriate degree and thus have a happy outcome without having to reinject filler or to have a complete loss of filler in a particular area.  This is a tricky process, and I sometimes manage this in a staged approach – meaning multiple sessions.

​Calvin Lee, MD
​Modesto, California Belotero Injector

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What I love about Belotero Balance

What I love about Belotero Balance

I have been an avid user of Belotero Balance for a few years in my cosmetic injection practice. Last month, April 2015, I injected about 4640 units of Botox and 75 syringes of fillers. 20% of the fillers I use is Belotero Balance. Much of what I do with Belotero is considered off-label FDA use. I am a frequent user of cannulas in my filler practice which includes the spectrum of Juvederm available in America and Radiesse.  Juvederm dermal fillers in my Modesto practice include: Juvederm ultra, Juvederm ultra plus, Juvederm ultra xc, Juvederm ultra plus xc, Juvederm Voluma xc.

Briefly about my Modesto Practice

I spend half of my clinical time personally performing cosmetic injections. I think I would be a bit busier if I spent more time on the Botox/filler side of the practice but I have plastic surgery assisting duties (my wife is a plastic surgeon, I am a general surgeon with trauma experience), a small cosmetic vein practice, and I also have an acupuncture practice which I love. After clinical hours, I am an administrator for our plastic surgery practice. I feel that I spend about 80 hours per week on our practice clinical+administrative.   Of course there is room for me to be more efficient.

Belotero is great for

Belotero is great for tear troughs and around the eyes
I use a cannula and lay down Belotero for tear troughs. It works well for many tear troughs, and flows very well through a cannula. I’ve learned over the years to tell the patients that the duration in that area seems to average about 6 months. Of course this varies from patient to patient. I was a Juvederm user for almost all tear troughs before and ran into some trouble with swelling for a few patients. I still run into some swelling issues with Belotero but it is much less. It also works well for building up a little bit of the cheek above the zygoma laterally.

Great for forehead lines
Some fine forehead lines are amenable to Belotero filling. It is especially useful for those patients who want a smoother forehead with less brow drooping which can happen with overzealous Botox use on the forehead. It is also great for those wrinkles in the eyebrows.

Great for a touch up on the oral commissures
Belotero is wonderful just as a small touch to a slight downturn in the oral commissure. I’m not talking about the entire marionette line, but just the corner of the mouth and injected superficially.

Great for crows feet
I need to be careful with the bruising in this area but it works well for some of the fine crows feet lines. It works well with Botox to battle those light static lines.

Great for neck lines
Those horizontal lines – belotero becomes very labor intensive but well worth it. The patients get a bit of bumpy look for the first 2-3 weeks, but it settles and the Belotero works well to integrate into the skin.

Great for chest
Or some call it decollatage area. These crinkles thicken up well, with belotero for many patients, I have to bend the needle to get the angle I need.  It really does look like it integrate into the skin after two weeks.

Serial Puncture method
Yes, this is useful, and can at times reduce bruising because the needle doesn’t go in very deep. A wrinkle is injected several times about 2 mm apart and the needle just barely goes into the skin. For most of what I like to do with Belotero, except for the tear troughs, I am injecting very superficially. If I’m threading the needle through (ie, in neck lines), I can see the needle through the skin. This superficial needling probably has an added collagen induction characteristic for the patients – similar to microneedling.

Superficial injections for longer lasting effect
Superficial injections lead to longer lasting effect. I have found that deeper injections in areas with movement seem to eat up the Belotero in 3 months. But 5-6 months can be derived from superficial injections.

I would recommend Belotero to other injectors
I like Belotero and would recommend it as part of our creative set of tools for beauty. It’s like a very thin paintbrush. And Belotero works well with other fillers in a layered approach.

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Restylane or Belotero under the eyes

A tear trough filler question (under the eyes)

A patient recently called me (who lives relatively far away from Modesto) to see if I can give her a second opinion regarding restylane under the eyes.  She has a local injector (local to her) who wants to inject restylane under her eyes and she wanted to know why we don’t do restylane under the eyes.   Here are some thoughts I had.

I would tell her that I think that any product could work well under the eye in the tear trough region with a skillful injection artist.  The more important factor is the artist who injects under the eye.  There are so many things you can do with a filler (off-label FDA) – such as dilute the filler or add lidocaine/epinephrine or inject deep or use a cannula, etc.

The filler product is like the violin without the violinist.

Restylane in my hands is excellent under the eyes – I have even used it before quite frequently and was very happy with the results.  I personally prefer Belotero because in my hands currently because it results in a smoother contour.  The edges are not as aparent to me if I have some superficial injections.  My technique is usually to inject deep.  But some patients need a thicker fill under the eyes, and thus they would be better served with Restylane – which also lasts longer than belotero under the eyes.

Because of the smoother contours, I prefer belotero under the eyes rather than Restylane.  This is only a personal preference and it is my current preference which can/will change with time and further experience and further feedback from patients.

The reason I don’t carry Restylane, it’s because it’s a product that is very similar to Belotero and Juvederm.  Similar enough that I don’t really see a point in having it in my practice, and I have received poor customer service from the Restylane company in the past, and thus I chose not to carry their products for the past 6 years.

Juvederm under the eyes, in my opinion causes a bluish hue (tyndall effect) in the hands of many surgeons/doctors/injectors including myself.  I have rarely experienced this problem, but because other surgeons have reported this more often than I’d like to hear.  Thus I tend to stay away from Juvederm for under the eyes.

The under eye filling with any filler is consider off-label FDA usage, and thus there won’t be a ton of information about this because companies are technically prohibited from advertising off-label FDA uses of products.

I think she would be fine getting Restylane if she trusts her injector.  I am not able to comment on the skills of other injectors because I don’t know how they inject.   Please continue to see your injector in person for detailed information.  I would welcome another visit to our office to continue the conversation if that were convenient.

Disclaimer:  The above is medical information.  It’s not intended to be advice.  Please see your doctor/injector in person for personalized advice.