By now just about everybody knows something about facial fillers.  They’ve been around for 30+ years, but the newest types have proven to be safer and more effective at creating natural improvement in the appearance of facial lines.  There are several types of fillers available, and it pays to educate yourself on what filler is best for each part of the face and what the possible side effects and complications are. First, you need to know what filler materials are.  The most popular products currently are Juvederm® and Restylane®, which are both made of hyaluronic acid (HA). HA is a substance produced naturally by your body as part of the matrix of your skin. It is injected to fill in fixed wrinkle lines and add volume to the lips, cheeks and other areas. Other materials have been used in the past. These include silicone, which has been abandoned because it is very difficult to remove and can cause scarring and skin changes. Human fat has also been used, but tends to reabsorb quickly and unevenly. Human or animal-derived collagen has uneven absorption and is not long-lasting.

When considering if you need HA filler and what type, keep the following 5 things in mind:

1. What am I trying to correct with this treatment? Fillers are recommended for fixed facial lines, such as the nasolabial folds (the folds at the edges of your mouth that extend to the sides of your nose), but also are used in the nasojugal groove (the tear trough), the cheeks and the lips.  They work wherever a crease is present, which doesn’t disappear when the face is totally relaxed.  A dynamic wrinkle, or one that comes and goes with facial expression, may need a neurotoxin like Botox® or Dysport®.

Facial filler before and after

2. Is the treatment safe in the area I want it? The FDA has very narrow indications for all of the available facial fillers.  This means the companies likely only did extensive (i.e. expensive) clinical trials to show the filler was effective and safe to be injected in one particular area, usually the nasolabial fold.  Thus, they are only truly approved for these areas.  Some, including Radiesse®, are only approved for facial atrophy in HIV patients.  However, as with a majority of drugs, physicians have found ways to safely use these drugs “off label”.  The key is to find an experienced physician who understands the affects and limitations of the medication.  If he/she tells you there are no side-effects or all their patients have had good outcomes, look for another doctor.  They should be mentioning that fillers will cause swelling and possible bruising that can last 1-2 weeks after the injection.  The filler material may feel hard or lumpy in the beginning, although this almost always improves in a few weeks.  Rarely, people can have allergic reactions to the medicine, sometimes causing breathing problems.  Injection into the tear trough has, in rare instances, led to filler getting into a vein which caused a blood clot.  This is a potentially life threatening complication and injection here must be performed by someone very familiar with facial anatomy. And those with a history of cold sores can develop severe outbreaks after injection.

Also consider the timeless maxim, “less is more”.  No one wants to look like they’ve had an injection, yet  many patients feel like they haven’t gotten their money’s worth if they don’t walk out with larger than life lips.  Remember, the physician can always add more filler later on if you aren’t satisfied with the volume changes, but removing filler is not as easy, involves injecting a different enzyme that breaks down the material, and can be unpredictable.  Adding filler gradually will give the most natural results.

3. What is the cost? Filler is sold to the physician by the vial and cannot be shared between patients.  The vials are quite small and most patients on their first visit will need at least 2 if they plan to have their nasolabial folds and lips done (you can get away with less for a smaller area).  Most physicians charge around $550 to $800 dollars per vial depending on the material and the injection locations.

4. Can I afford to keep up with this? As filler isn’t permanent, it will need to be repeated, generally in a year to 18 months, depending on the material and location.  Budgeting for it will be a must and should be considered before getting started.  That being said, most physicians agree that fillers seem to delay the need for more invasive procedures, like a face lift, which are much more costly.  If you are dropping a hundred dollars here or there on facial creams that have little evidence of doing anything significant for your skin, filler may be more economical and effective in the long run.  If you are the type that prefers to buy shampoo at the dollar store and thinks spending money on smelling nice is an unnecessary luxury, chances are you stopped reading this article a while ago.

5. Is there a cheaper/safer alternative that will bring me similar results? The best medicine is preventive. If you don’t want lines to appear, treat your skin with respect.  Refer to our previous article on the subject by clicking here.  The main point we stress is avoiding unnecessary sun exposure and keeping up with regular exercise.

As with all cosmetic procedures, don’t rush in until you have all the facts and have weighed all your options.  When performed by a skilled physician in the proper setting, facial fillers can be a nice way to rejuvenate the face, but as always, use caution and keep realistic expectations.  Call us at 801.264.4420 for a consultation, or visit us at



We’ve all seen the boom in medical spas over the past few years.  Maybe you’ve been to one and received great care. There are, however, some troubling trends here in Utah and in other states where physicians without any experience  or facial cosmetic training are performing and overseeing delicate procedures.  Most of these procedures, if not performed properly, can have dire permanent consequences.  A recent story that appeared on KSL and, mainly dealing with laser skin procedures, highlights these dangers.

[Click here to read the story and see the video]

With regard to facial fillers and neurotoxins, like Botox and Dysport, there are plenty of places offering these services, but are the people performing these services qualified and do they have proper oversight?  In order for a spa to use the “medical” moniker, they have to have a medical director in charge or a physician who directly performs the procedures.  Most states, including Utah, don’t yet have strict laws regarding the qualifications of a medical director.  In most cases, they just need a medical degree.  There is no requirement that they have facial plastic surgery training.  This means physicians with no training in facial injections, and their possible complications, could be overseeing or performing your injection.  What are the risks?  Well, skin infections from Botox and fillers, while rare, can cause serious scarring of the skin.  Allergies to these medications also can result in serious local and systemic reactions. Is your provider prepared to deal with these occurrences? Improperly placed fillers can cause facial disfigurement may not always be reversible.  Even when they are reversible, an equally skilled injector must perform this procedure.

So what should you do to keep yourself safe? Don’t be afraid to ask questions and be observant.  Here are  4 questions to ask before you make your appointment, and a few more things to consider while talking with the doctor and once you are in the chair receiving the procedure:

  1. Who is the medical director or doctor performing the service and what are their qualifications? (Look for a physician specifically trained in performing the procedure you seek.  Ask if he/she was trained in residency, received training at a weekend conference, or hasn’t received any formal training.  Obviously the more training the better.  You can also search out the doctor’s name for any good/bad reviews or look at their state licensing board to make sure they haven’t had any actions against them in the past.  This is good advice for anyone seeking out any medical care).
  2. If an auxiliary staff person (Nurse Practitioner, Nurse, Physician Assistant or aesthetician) is performing the injection, what is their experience and qualification? (There is a reason these medications are not available over the counter and must be dispensed by a physician.  Ensure the practitioners injecting have been trained and licensed).
  3. Will the doctor be present if they aren’t performing the injection? (Many “medical directors” are not present when procedures are performed and cannot easily respond to patients having problems.  They may also not be present because the nurse or PA knows more about the procedure than the doctor).
  4. If I have a complication, early or late, who can I contact? What about in the middle of the night? (Any physician in active care of patients is available 24/7 through an answering service, or has a call group in which other physicians cover for him when he’s not available.  If this isn’t the case with your medical director, look elsewhere).

Once you are satisfied that a trained physician is performing your procedure or directly supervising, consider the following:

  1. Is the doctor offering reasonable results and not watering down the potential risks? (It is always easy to glaze over the risks of a procedure while promising excellent results. Any physician experienced in cosmetic procedures knows that complications can and do occur.  Not mentioning them shows a lack of experience or interest in the patient’s welfare).
  2. Is sterile technique being practiced? (While you may not be totally familiar with what constitutes sterile technique, making sure the doctor washes his/her hands and wears gloves, uses new needles and properly cleans your skin with alcohol or other sterilizing solution.  These simple precautions make infections very unlikely).

Medical spas, when run with the patient’s best interest in mind, can be very calming and relaxing places to receive elective medical care.  Asking the right questions and being observant of the techniques used will ensure your spa is also a safe place for treatment.

When looking at other people’s faces, the first thing our eyes are drawn to are their eyes.  The eyes and the skin around them can tell us a lot about a person, or so we think. When we see dark circles or bags under the eyes we may assume the person is tired or possibly ill.  This has led people with this problem to search out all sorts of remedies to improve their appearance.  Dark circles under eyes affect both men and women, usually starting in adulthood, although children can develop dark circles under their eyes as well. A common reason for dark circles is fatigue, but they may still form in a well rested person. Sometimes, what appear to be under-eye circles are just shadows cast by puffy eyelids or hollows under your eyes that develop as a normal part of aging.  First, we need to understand the causes of bags and circles, then we can try to eliminate them.

The Mayo Clinic lists the following as causes of dark circles:

  • Allergies
  • Atopic dermatitis (eczema)
  • Heredity — dark under-eye circles can run in families
  • Lifestyle factors, such as physical or emotional stress, smoking, or chronic alcohol use can take a toll on your appearance
  • Nasal congestion (which can dilate and darken the veins that drain from your eyes to your nose)
  • Pigmentation irregularities — these are a particular concern for people of color, especially blacks and Asians
  • Rubbing or scratching your eyes (see allergies)
  • Sun exposure, which prompts your body to produce more melanin, the pigment that gives skin its color
  • Thinning skin and loss of fat and collagen — common as you age — can make the reddish-blue blood vessels under your eyes more obvious
Discoloration of the skin is not always the problem, however. Changes in the skin and underlying fat around the eye can cause dark shadows to appear, which are mistaken as dark circles, but will disappear if the skin is pulled taut. As we age, fat around the eye and the fine tissue that supports it gets stretched out.  The skin also looses its elasticity.  This combination leads to a puff of fat beneath and sometimes also above each eye coming forward, i.e. baggy eyes.  This will cast a shadow forming a dark circle.  In addition, the area called the tear trough, between the nose and the cheek, deepens as facial fat decreases and moves downward.  This also causes a crease and shadow to appear.
tear trough deformity

Now that we know what causes these changes, what can be done about them? First, to be sure you have dark circles, look in the mirror and pull down on the skin of the lower eyelid.  You truly have dark circles, not bags, if the circle still remains when the skin is tight.  For mild to moderate dark circles due to discoloration of the skin, there are some simple and inexpensive treatments that may work

  • Bring in the cold- Try two chilled teaspoons, an ice pack or a bag of frozen peas wrapped in a soft cloth to temporarily reduce dilated and discolored under-eye blood vessels. Cooled cucumbers or used teabag have also been recommended, just remember it is the cold that helps, not the tea or some aspect of the vegetable.
  • Elevate your head – use two or more pillows to prevent puffiness that develops when fluid pools in your lower eyelids.
  • Protect yourself from the sun – Although a tan might hide dark circles in the short term, in the long run, the extra pigment it produces can make circles worse. Use a daily sunscreen and wear sunglasses.
  • Treat allergies and sinus problems. Use a daily allergy medication, such as Allegra or Zyrtec, if seasonal allergies are a problem.  Rinsing your sinuses with a saltwater solution (mix 1/4 teaspoon sea salt with 2 cups warm water) or over-the-counter saline spray can help relieve nasal congestion.
  • Get your beauty rest – lack of sleep makes you paler and more hollow-eyed, so shadows and circles you already have are more obvious.
  • Find a good eye cream – There are hundreds of skin creams that claim to reduce or prevent under-eye circles, but you should shop wisely. The results of one study in the Journal of Cosmetic Dermatology showed that cream, among other things, the Brazilian suma plant, significantly improved the appearance of dark circles under the eyes
  • When all else fails, cover up – Find the right colored concealer to hide dark circles.  For example, if the circles under your eyes are bluish, use a peach-colored concealer, not one that’s white or gray. Make sure the product is safe for use around the eyes.  Stop using it if you get any eye irritation

When these fail, consider speaking with a dermatologist, who could recommend various skin treatments with chemicals such as hydroquinone or kojic acid, which can lighten the skin.  Also, many laser treatments have been successful in lightening the skin, but again, these should only be performed by a dermatologist experienced in use of lasers around the eye.

If you truly have bags under the eyes, no amount of eye cream of concealer will eliminate these changes, and lasers are usually only effective for the most minor of changes. You now need to consider a cosmetic procedure to get the most benefit.

  • Blepharoplasty is a procedure that involves removing the redundant fat beneath the eye (and above when necessary) as well as removing some excess skin in certain individuals. This leads to a more natural transition from the cheek to the eyelid and a younger appearance.  Consider this  middle aged patient before and after upper and lower lid blepharoplasty.  A small change to her lower lids makes a dramatic difference.

  • Injectable fillers: The tear trough deformity shown above can now be treated with fillers, such as Juvederm, which can soften or eliminate its appearance for 12 months or more.

If you are fed up with those baggy lower lids and no amount of home remedies have helped, contact us for a consultation and we can discuss your options.

Just to get introduced, I’m Mat Harris.  I am an oculoplastic surgeon and ophthalmologist in Salt Lake City, Utah and owner of Utah Oculoplastic Consultants.  My partner, N. Branson Call, MD and I practice oculoplastic and reconstructive surgery, as well as general ophthalmology, from our office on 4400 south and 700 east (suite 130 of the Rocky Mountain Eye Center).  This blog serves as a medium where we can share the latest information regarding surgery around the eyes and face as well as new methods of facial rejuvenation and aesthetics.  We will also be sharing new developments in our clinic and our humanitarian work.

To start, our biggest news is the remodel we are about to undertake.  Our office has served us well, but is in need of some updates.  We will be making some changes this week including new paint, countertops in the reception area, new waiting room furniture, an updated decor, and new flooring.  We hope the updates will make our office even more inviting. Before and after pictures will be placed shortly (as soon as “after” occurs).

Another change we are making is the use of electronic medical records.  This will allow us to keep a better record of your health, send electronic prescriptions, give you a portal to review your medical records from home, and allow us to more easily communicate with the doctors that refer you.

Lastly, this blog will serve as a place where we can offer special promotions and discounts to our blog followers, including discounted pricing on facial injections and fillers.  So follow along if you are interested, and share our blog with your friends.