Cohesive Polydensified Matrix Hyaluronic Acid for Fine Lines

Background: Fine lines and crepey skin are dermal manifestations of multilevel, age-related volume loss. It is, therefore, logical to combine intradermal volumetry for fine lines with subcutaneous volumetry for contours. This publication provides evidence- and experience-based rationales for application of cohesive polydensified matrix hyaluronic acid filler (Belotero Balance). Methods: Evidence level II data demonstrate efficacy of this product and longevity for up to a year or more with intradermal, superficial blanch injection. Its softness, flow tendencies, and homogeneous tissue integration are informed by low elasticity (G′) and viscosity, high cohesivity, and high tan delta. Ultrastructural analysis confirms variable-density cross-linking, intended to confer resilience, and absence of detectable particles, minimizing Tyndall effect. Results: Scientific properties of Belotero Balance predict its 3-dimensional tissue expansion with prominent horizontal vectoring. We define this as superficial flow volumetry. High cohesivity and resilience can maintain structural integrity in typically mobile facial areas with strong muscular forces, uneven pressure, and significant hyaluronidase activity. This facilitates a natural appearance, both in repose and animation. Conclusions: Based on available evidence and experience, cohesive polydensified matrix hyaluronic acid is a notably efficacious fine line filler. The ideal fine line filler would restore dermis structurally and dynamicaly—moving as one with it, efficaciously expanding it, withstanding mechanical stress, swelling minimally, and potentially stimulating collagenesis. The relative contributions of space-filling, water binding, and collagenesis have implications for efficacy. A focus of current research is to determine the impact of filler cohesivity and tissue integration on these ideal qualities.