Juvederm Ultra and Juvederm Ultra Plus are two of the most renowned dermal fillers from Juvederm, a distinguished brand of soft tissue implants manufactured by Allergan. These implants consist of hyaluronic acid molecules that are extracted from the biofermentation of Streptococcus species of bacteria and subsequently purified. The molecules are of uniform molecular weights are homogenized with each other via patented Hylacross technology. The chemical cross-linking agent used in the making of both fillers is 1,4-butanediol diglycidyl ether (BDDE). The resulting implant gels are colorless, transparent, pyrogen-free, homogenous, and tissue-friendly with the ability to be resorbed into the surrounding tissues. Each box of Juvederm Ultra comes with two 0.55ml prefilled syringes that contain 0.55ml of this filler and two sterilized and disposable 30G1/2” needles. Each box of Juvederm Ultra Plus comes with two prefilled syringes that each contain 1ml of this filler and two sterilized, single-use, and disposable 27G1/2” needles. Both implants are co-packed with four patient traceability labels and a package insert.
Juvederm Ultra vs Juvederm Ultra Plus: Rheological properties
The main difference between these two fillers lies in their thickness. Though both Juvederm Ultra and Ultra Plus are made of 24mg/ml of cross-linked hyaluronic acid, the latter has a thicker texture and greater viscosity compared to the former. This is because Juvederm Ultra Plus contains 11% of cross-linked hyaluronic acid compared to Ultra, which is only made up of 9% of chemically reticulated hyaluronic acid molecules. Nevertheless, the presence of freely suspending molecules is important, as they act as a lubricant to improve the ease of injection. Besides having the same concentration of hyaluronic acid, both fillers also contain 0.3% lidocaine, a type of fast-acting anesthetic agent that can help to alleviate pain associated with the injection process for each filler.
Juvederm Ultra vs Juvederm Ultra Plus: Aesthetic indications for use
Both Juvederm Ultra and Ultra Plus have been approved by the U.S. Food and Drug Administration (FDA) due to the remarkable results demonstrated in a multicenter, randomized clinical study. In that study, 439 subjects with nasolabial folds were randomly treated using one of three different variations of hyaluronic acid-based fillers from Juvederm: J30, 24 HV, and 30 HV. These fillers were used on one side, and cross-linked bovine collagen was used in the other side. The results show that all three different variations of Juvederm hyaluronic acid implants delivered significant nasolabial fold corrections that lasted longer than bovine collagen. Furthermore, 90% of the subjects who were treated with the 30 HV filler, which was later renamed as Juvederm Ultra Plus, and 88% of the subjects who received the 24 HV implant, which was later renamed as Juvederm Ultra, still retained significant clinical improvements 24 weeks after the initial treatment session. The long-lasting effects of the Juvederm fillers were very noticeable, especially when only 36% to 45% of patients who were treated with bovine collagen showed lasting improvement after 24 weeks. This clinical data led to FDA approval of both Juvederm fillers for the correction of mid-to-deep facial wrinkles, such as marionette lines and nasolabial folds. They can also be used to non-surgically augment thin and undefined lips in patients over the age of 21. That being said, these soft tissue fillers are also used in an off-label manner to correct tear trough deformities like hollowness and dark eye circles and to volumize atrophic skin and acne scars. It is very important that only accredited and experienced physicians who are thoroughly familiar with the anatomy of the proposed treatment area(s) conduct a treatment session with either of these fillers to minimize side effects.
Juvederm Ultra vs Juvederm Ultra Plus: Injection technique
Before the fillers can be administered, a patient’s medical history (e.g. underlying medical conditions, medications and/or supplements taken, history of aesthetic procedures, etc.) must be reviewed thoroughly. Patients must also be made aware of the potential side effects and appropriate aftercare methods for the filler they are using. Once patients are deemed ready for treatment, the proposed treatment regions must be cleaned and disinfected. An additional topical or local numbing agent may be administered if required by patients. Both Juvederm Ultra and Ultra Plus can be administered into the mid-to-deep dermis layer if treating wrinkly skin or into the mucous membrane if treating the lips. Both fillers share the same injection dosage, as detailed below:
- Initial treatment: 1.6ml of filler gel per injection site
- Repeat treatment: 0.7ml of filler gel per injection site
- Maximum limit: 20ml of filler gel per 60kg body weight per year
The injection techniques that may be employed with these fillers include the nappage, serial puncture, linear threading, crosshatching, fanning, and/or a combination of the five. Overly superficial or deep implantation of these fillers must be avoided, as it can cause undesirable results. The longevity of Juvederm Ultra is estimated to be about six to nine months, while Ultra Plus has a higher longer residence time of up to a year. The long duration of action of these fillers is due to their high degree of cross-linking. The cross-links act as effective physical and chemical barriers to protect the fillers from premature degradation caused by hyaluronidases and free radicals. Since these implants are made of hyaluronic acid, patients also have the option to prematurely dissolve implantations of them using hyaluronidase enzyme injections.
Can Juvederm Ultra and Juvederm Ultra Plus be injected concomitantly?
Yes, with varying degrees of consistency, both dermal implants can be injected concomitantly to simultaneously smoothen the skin and provide volume restoration deep in the skin. This mixing of fillers can help to deliver comprehensive yet natural-looking aesthetic improvements. Besides that, these Juvederm implants can also be combined with other dermal procedures such as laser therapy and microdermabrasion. In fact, many aesthetic practitioners administer Botox, a type of muscle-relaxing medication, with dermal fillers in a technique known as a liquid facelift. While the dermal filler helps to restore volume to areas that are starting to sag or appear sunken, Botox temporarily freezes dynamic lines. Treated areas end up appearing smooth and radiant.