Belotero

What fillers do I use in the LIPS for injections and why?

Lip Injections by Calvin Lee, MD, My thoughts in 2020

This question is a bit like asking what type of how do I like to use for playing the violin. Sometimes it depends on my mood and sometimes it depends on what type of mood I’m trying to create. It also depends on what type of technical challenges I’m up against.

This discussion is limited to the syringes I have at my office.

Above collage are lip before and after pictures of my patients in the 4 weeks leading up to today 9/13/20. Pictures posted with permission. Bottom right pictures are of the Surgical Artistry team.

Dumbells vs Fillers?

Oh another analogy: Picking a filler might be a little bit like picking which kind/type of dumbells one might use for working out. There are different brands of dumbells and different weights.

Juvederm Volbella

Often I choose Juvederm Volbella XC to inject into the lips. The syringe itself is very ergonomic and has a good responsive feel when I inject it when attached to a 32 gauge needle. This needle gives me enough resistence so I don’t just pour it all out in one spot.

It is a soft filler (not very thick – or it has a lower G prime) made of smaller Hyaluronic Acid molecules. The molecules stack on top of each other very smoothly. So if I’m looking for a subtle and more smoother look, I choose Volbella. Many younger patients who have a nice vermillion border and philtral column do very well with Volbella but many times we need two syringes of Volbella for the younger lip. Volbella also has less swelling due to the vycross technology and uses a smaller needle which is a 32 gauge needle. In the older patient, Juvederm Volbella sometimes looks the most natural with softer edges for the lips. The tissue integration of this product is rapid and thus there would be less movement of the product after injection. This is a great filler for patients with thin skin for their lips. Volbella is also a relatively long lasting filler syringe wtih longer duration compared to Ultra and Ultra plus.

This product also doesn’t look too blue under the skin and thus can be used very nicely for those smoker’s lines. This is one of my favorite products to inject into smokers lines.

I recommend this Volbella syringe to the more extremes of age – youngest patients and oldest patients – and in patients who only want a very subtle change but want long lasting results.

Volbella is a medium-high cost syringe in the lineup of Juvederm products.

Juvederm Ultra

This is my most commonly used filler for lips. I have been doing lip fillers since 2008 and this filler just feels very comfortable to me in my hand. I like the way the filler syringe feels and I like the feel extrusion force. This filler is attached to a 30 gauge needle.

This is a filler that makes great borders of the lips, and I like to inject it close to the vermillion border, and use it for philtral column support. The results are beautiful and this tool is in my comfort zone due to my experience with this product. This filler however tends to swell afterwards.

This filler is also very good for lines around the mouth. I will sometimes take a second syringe of Juvederm Ultra and use it for perioral support and reduction of the lip lines. Sometimes patients don’t want fillers in the red part of the lip, they just want the perioral support and lip line reduction (smokers lines – or bar codes).

This is the lowest cost product of the Juvederm lineup of products. I don’t choose it based on cost, but I choose it because in my hands, I feel that the results are predictable and it creates beautiful borders with the versatility of creating a fuller, plumper lip. Overall, I feel that Juvederm Ultra is the most versatile filler product in my hands. It can create a nice body to the lip along with a nice border to the lip.

Juvederm Ultra Plus

I sometimes use this syringe for lip augmentation. I am not entirely used to the light extrusion force when attached to the native 27g needle. The syringe itself is a wonderful tool as with all the other Juvederm products, with rubberized grips in the right places.

This Juvederm Ultra Plus filler is good for creating volume. But in my opinion not that good for creating the borders and many times in my observation it seems to extrude out of the borders. This is a thicker filler like a thick jelly and isn’t great for the fine borders or philtral columns but is good for creating a stiffer and thicker body to the lip.

Juvederm Ultra Plus is the same price point as Juvederm Ultra – they are both on the low end of the price scale.

Juvederm Vollure

The extrusion force is on the lighter side, but I can definitely get used to it. I’m so glad it comes on a 30 g needle so that it is less traumatic to the lip. I love the ergonomics of this syringe. It has a nice violet color to the syringe that lets me know that I’m using the right syringe.

The Vollure Lip procedure is becoming one of my favorites for building a fluffy body to the lip. Vollure is a very spreadable smooth filler that has the Juvederm vycross technology which allows the filler to last longer. This isn’t a great filler for sharpening the borders or defining the filtral column but it is wonderful for volumizing the lip, and giving it a bigger look and having great mobility of the lip without looking stiff. This filler works great going through a cannula as well.

Juvederm Vollure is very versatile and may work well alternating or alongside Juvederm Ultra. Using Vollure for creating a fuller body and using Juvederm Ultra for creating the definition. The swelling is less for this filler than a Juvederm Ultra filler procedure.

This product also integrates quickly into the lip and doesn’t move or swell much afterwards.

Vollure is a medium-high price for the syringe.

Juvederm Voluma

I’ve used this for lips a few times, mostly at patient request. This is for someone who wants a stiff large lip which can sometimes look a bit wider. I usually use this syringe in the cheeks for a stiff filler. This is the stiffest filler in the lineup of Juvederms at this moment in 2020.

This syringe is not good at creating borders, but it is good for creating a stiffer, wider, and fuller look and feel.

Juvederm Voluma is the highest priced syringe in the Juvederm line up at this moment. It is also very long lasting.

Restylane Silk

This Restylane Silk is an incredible syringe for the lips. It creates a very soft look and feel and rarely forms bumps. It does unfortunately create a good deal of swelling afterwards. I like this syringe very much for helping with the lip lines around the mouth. This product also does not look very blue under the skin.

Restylane Kysse

I’ve only injected this filler syringe a few times. I do not have good motor memory with the use of the syringe. I’m not entirely used to the markings on the syringe itself – to give me a visual feedback of how much I’ve injected. This is mainly due to the fact that I’ve injected thousands of Juvederm fillers and very few Restylane Kysse syringes in comparison

The lip filler seems to be a very nice filler which isn’t the best in my hands for creating borders, but it is decent. Not bad for creating philtral column definition, but perhaps a bit thick. It is good at creating a nice fluffy body of the lip and many patients like the results. This product has a lot of potential. I think the thickness falls between Juvederm Ultra and Juvederm Ultra Plus.

Restylane Refyne

This is a lightweight filler that creates a soft change to the lip with flexibility. It is very popular with some of the patients and is asked for by name. I think it is very versatile.

Restylane Defyne

This is the thicker version of Refyne. This is a very versatile syringe and creates a result thicker than Kysse in my limited opinion. The lineup seems to be from thinnest to thickest: Restylane Refyne, Restylane Kysse, and Restylane Defyne. My patients who have gotten Refyne and Defyne for their lips seem to think that Kysse is better and just right for their lips.

Restylane L

This was my original lip filler syringe that I used back around 2006-2008. This syringe is still one of my favorites to use. It creates nice borders and stiffens and lifts the body of the lip. I like the feel of the syringe and it fits into my smaller hand very easily.

Restylane Lyft

I’ve actually not tried this in the lip, but I think it would be similar to my Juvederm Voluma Experience

This Belotero syringe does a very nice subtle change to the lip very similar to the Silk and Volbella changes, but the duration is pretty short. I only used it when it first came out, and it doesn’t have lidocaine built inside like all the other syringes mentioned earlier..

In Summary of Fillers for the Lips – how do I choose?

I choose based on familiarity – can I inject it with my eyes closed type of concept.

I choose the filler based on the physical syringe itself – can I visually see what ratios I’ve created easily, and will the syringe fall out of my hand? And when I push the product, will I get good tactile feedback regarding how much I’ve actually pushed? This is somewhat like the gas pedal of our cars. Some have a stiffer pedal and others, you might floor it without knowing – zoom! A lot of this is also based on familiarity too and some of it based on purposeful design.

I choose this based on age of the lip, thickness of the skin, and desired outcome.

For a patient who wants a very stiff thick lip – then Juvederm Voluma.

For patients who wants everything – nice borders, flexibility, more fullness – but is willing to be a little bit on the smaller size and knows that we can just add more syringes of the same product or other products to get a bigger size: then it’s my usual Juvederm Ultra. We can add more in a few months to get to the right size.

For patients who want a subtle change with long duration with less recovery: Juvederm Volbella

For patients who already have a nice vermillion border who knows they want a bigger lip but only wants to do one syringe with longevity then I choose Juvederm Vollure. This syringe creates more of a visual change as seen in pictures.

For my patients whom I’ve had from 2008 and have liked their lip results with Restylane, I continue on the Restylane track. The same for new patients who want to try something new or came from other practices who use more Restylane than I do. Restylane is a fine set of fillers.

There is a new filler which can be used in the lips which is RHA 2 and RHA 3. New to the USA. I’ve tried RHA 3 and it seems very nice too.

My most common to least common ranking of lip fillers used in my own practice:

Most common on top:

Juvederm Ultra
Juvederm Volbella
Juvederm Vollure
Juvederm Ultra with Volbella combination
Juvederm Vollure with Ultra combination
Juvederm Ultra Plus
Restylane Kysse
Restylane Silk
Restylane Refyne
Restylane Defyne
Belotero

In the end, it comes down to four things when I pick a filler to inject lips.

Injector factors – injector’s personal preference, familiarity, predictability of giving the right outcome, reliability and responsiveness of the filler company.
Patient factors – thin skin, age of lip, lack of border, patient desires.
Friends and family factors – what do they prefer when they look at your lips and does it matter to you?
Financial factors – cost to the patient and cost to the injector. Many fillers can give a similar look but can I as the injector make that desired outcome with the least amount of product? I call this efficient use of product.

Feel free to find me for a consultation regarding lip fillers in Modesto, CA: 209-551-1888.

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

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.

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.