Advertorial: How to Perfect Flat Blanching in Fine Lines using BELOTERO Balance

19 Apr 2021

Dr Kim Booysen shares a case study on how fine line correction with BELOTERO Balance is one of her most popular clinic treatments.

Perhaps it’s the longevity of up to a year or perhaps it’s the natural feel of the filler, but most likely it’s the ability to almost instantly give an airbrushed appearance, giving patients a refreshed and rejuvenated appearance.

I started using this product in patients who had allergies or aversions to other wrinkle treatments and I haven’t looked back. Patients will now request this treatment for fine lines, ahead of other traditional wrinkle treatment modalities. In this article I will explain why I use BELOTERO Balance1 and what techniques I employ to get the best results for my patients.

An ideal fine line filler?

An optimal intradermal filler should be resilient, inject easily, restore structure, induce neocollagenesis and has no reports of Tyndall2 effect. I have found that BELOTERO Balance1 meets all these requirements.

Filler resilience can be clearly demonstrated using a stretch test. Simply inject a small thread of BELOTERO Balance1 onto a surface and stretch the filler, you will see how far you can pull the thread and how well it stays together. This is due to the Cohesive Polydensified Matrix (CPM) technology that gives the product cohesivity, that ability to stick together.2 This property also reduces the risk of Tyndall effect when injected superficially.2 The CPM® technology has also shown to produce minimal inflammatory response.2 Once injected the 22.5mg of hyaluronic acid’s hydrophillic nature and support of the surrounding collagen and elastin, results in a lifting effect in the tissue. BELOTERO Balance1 has a low viscosity and injects easily through a 30G needle, making intradermal injection very comfortable and easy to perform.

Flat blanching technique

When treating fine lines, we need to remember we are injecting intradermally and when using the flat blanching technique, the aim is to place the product in the superficial reticular dermis. This is a bit harder than you initially think. To inject into the superficial reticular dermis in the average patient, the target tissue depth is 0.2mm. Personally, I try and ensure just the bevel length of the needle is in the skin. To be able to inject this superficially, an injection angle of less than 12 degrees, holding the needle almost parallel to the skin is advised. The bevel up is my preferred method, but placing the bevel down can help prevent loss of product through pores or along a previous injection point. A light depression of the plunger with enough product expelled to cause a small cream or white appearance to the skin, without raising a bleb is the ideal end point. The cream/white appearance of the skin is known as blanching and is the result of pressure placed on the loop arterioles in this superficial skin. This may take a little practice to get right in the beginning. Massage may help reduce any excessive placement of the filler. Slight tenting of the skin can also help prevent over treatment.

Product quantities

BELOTERO Balance1 comes as a 1ml syringe but is also rebranded as BELOTERO Lips3 Contour and comes as a 0.6ml, giving you flexibility to choose the correct amount of product for each individual patient. It also allows you to regularly maintain this treatment using a smaller amount of product if the lines return over time. On average I find that deep lines in the periorbital region requires two treatments, two weeks apart and I utilise a 1ml - 1.6mls at the initial injection session followed by a 0.6mls - 1ml repeat treatment at the two-week review. If treating less pronounced folds in the crow’s feet then a single one millilitre syringe may be required for the first session and 0.6mls for the second session.

The perioral region may require between 1 and 2mls of filler depending on the extent and number of the fold lines in this region. A repeat treatment is also required in this region to ensure optimal treatment outcomes. Be sure to advise your patients on the need for repeat treatments and include this in the treatment plan and costings.

Anatomical considerations

When injecting in the fine lines of the perioral and periorbital regions, a review of the anatomical positioning of the superficial blood vessels is essential, as these areas are high risk due to the vascular connections that can endanger the eye. Recent studies have also shed light on the positioning of vessels away from wrinkle fold lines. As such practitioners attempting these procedures should be well versed in emergency management of filler complications and have an above average anatomical knowledge of the face. As we are aware anatomy is not consistent and each individual is different so extreme care must be taken when injecting these areas.

Follow up and maintenance

After a treatment the patient will notice multiple small red puncture marks. This resolves after a few days. Some swelling in the lips may be noted if the blanching travels in a tissue plane. Bruising is always possible and I make use of ice packs if needed. Maintenance treatments can be performed at six months or one year depending on the patient. Multiple studies have shown superficial placement of BELOTERO Balance can last up to one year after initial treatment if the patient follows advice such as sunscreen use and smoking cessation.

Patient Preparation

The deeper the lines, the more product will be needed to correct the skin scarring as a result of the wrinkle fold lines. There is also a physical limit to the amount of that can be placed in the treatment area in one injection session. Therefore, a review, two weeks after the initial treatment is required. Additional treatment is often required at this time. The patient’s pain tolerance may diminish with time. I find the 1ml of BELOTERO Balance1 does go very far and I can spend about 20 minutes using up one syringe. Thus, you may wish to numb the skin prior to treatment as this improves tolerance and comfort. Changing the needle during the treatment is also recommended as the blunter the needle, the less accuracy and indeed the less superficial you are able to place the product over time.

Patient considerations

A careful medical history and physical assessment is essential before any treatment. Patient selection is also important and treatments should be avoided around the eyes in patients who report morning puffiness, have festoons, poor snap tests and poor skin quality in the proposed treatment area. Expectation management is also essential as areas with high movement or patients with severe sun damage, who fail to adopt lifestyle modifications, may not achieve the desired results. Advice on skincare and the factors affecting filler longevity is needed before treatment. Use of the Merz Aesthetic Scales to grade the severity of the wrinkles prior to treatment can also help create realistic expectations and satisfied patients.

Conclusion

This technique I only perform using BELOTERO Balance1 as I believe the rheological properties make it the ideal filler for such superficial filler placement. The lack of complications and longevity of results using this filler has also made it a firm favourite.


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