On a recent trip to grab groceries in my New York City suburb, I drove by a small, simply marked door for Westchester Laser Associates, which is in the same plaza. A few steps away, a large sign between two awnings reads “Ject.” They’re two med spas competing for customers—although Ject would seem to have the upper hand, with a huge storefront and minimalist-chic aesthetic that’s practically screaming (or, rather, whispering) Jenni Kayne. Both blend seamlessly among the Chopt, SoulCycle, and Starbucks in the shopping center—grab a salad, go for a spin class, sip an Americano, get an injection of botulinum toxin.
Back in the car, I’m listening to a game on the radio that’s sponsored by another med spa—which, the DJ says, “does everything: Botox, filler, nails.” And when I pick up my daughter from day care, I stroll past yet another one—this time specializing in “body contouring,” according to a decal on the door. It’s housed in an enormous first-floor office suite, and I can glimpse the white lacquered reception counter inside.
There are almost as many med spas in America today as there are McDonald’s locations. The industry has mushroomed from roughly 1,600 med spas in the US in 2010 to about 10,500 in 2023, according to the most recent trend report from the American Med Spa Association (AmSpa), which was released in November 2024. It also predicts that there could be as many as 13,000 med spas by the end of 2026. (There were 13,557 golden arches in the country at the end of 2024.) In recent years, the med spa industry has grown by at least $2 billion annually, says AmSpa, which is not so surprising when you consider that demand for the types of treatments offered at med spas (injectables, lasers, radiofrequency—things that don’t involve a scalpel) was up 79% over the last five years, according to the American Society of Plastic Surgeons (ASPS). Med spas provide the supply, in most cases, more conveniently and at a lower cost than a board-certified doctor would.
Like McDonald’s, people keep going to med spas despite what a lot of health care professionals say—fast filler, like fast food, isn't generally recommended by doctors. Or by Allure. Our stance since med spas arrived on the scene in the late ’90s has been simple: Don’t have any procedure that crosses the skin barrier if there’s not a board-certified dermatologist or plastic surgeon present. It’s a position that’s aligned with that of those doctors, many of whom raise serious safety concerns about the med spa industry. Their argument: These businesses offer medical procedures that come with medical risks, not low-stakes aesthetic tweaks. They should be administered by the medical professionals most qualified to perform them—and to handle their complications.
But let’s face it, med spas also pose a threat to the lucrative nonsurgical and aesthetic arms of plastic surgeons’ and dermatologists’ practices. These doctors certainly have their own skin in this game. On one hand, they’re correct: When availing yourself of a syringe full of hyaluronic acid that could block an artery or laser beams that can sear flesh, your safest bet is to be in the presence of the most highly trained medical professional possible. On the other hand, it could be argued that there is also somewhat of a turf war at play here.
And the reality is that the majority of people who visit med spas do so without harm. One small survey published in the journal Dermatologic Surgery in 2023 found there was not a statistically significant difference between the rates of complications at med spas and doctors’ offices, though there was a numerically greater rate at med spas: 16.4% of med spa patients had at least one issue versus 11% of doctors’ office patients. These numbers get a little more interesting on a granular level: Minimally invasive skin-tightening procedures had a 77% complication rate at med spas compared to zero at doctors' offices. (The study does not mention any one treatment by name, but radiofrequency and ultrasound are most commonly used to tighten the skin without surgery.) Nonsurgical fat reduction (like CoolSculpting) had a complication rate of 80% at med spas, compared to 36% at physicians' offices.
But while serious complications at med spas are not common, they can be extreme. “I've seen the whole nose destroyed in a couple of people because [med spa injectors] block the angular artery, which feeds this area,” says New York City double board-certified plastic surgeon Melissa Doft, MD. After signing up for so-called liquid nose jobs, "their entire nose was killed." When filler cuts off blood supply to the tissue, the tissue dies (this is called necrosis).
Shopping around for the cheapest filler doesn’t mean you’ll lose your nose—this is a very rare complication—but you might get a cheap-looking effect. “I've had several patients do the consultation with me, go to a medical spa, have an awful result, and then come back to me to fix it,” says Sara Hogan, MD, a board-certified dermatologist in Washington, DC, who also has a master's degree in health care policy and does research on the subject. “It’s not even that something awful happened. They’re just not pleased with what the result looks like.”
America appears to be unfazed, for the most part, by any heightened risk that could come with visiting a med spa. As the standard of beauty shifted—lips got poutier, furrowed foreheads became taboo—med spas brought the look within reach. The public has had little interest in looking this gift horse in the mouth, and regulators have done little to control this whole new category of business that has managed to de-medicalize medical procedures in just a few years.
So we find ourselves living in Med Spa Nation. And Allure has spent the last year exploring this land—because sometimes stances need to shift from black-and-white to “here’s how to navigate the gray, if you choose to go there.”
“Does anyone have a friend who’s been to a med spa?” It was a question posed to a group of Allure editors, aged 24 to 48. Everyone raised their hand. And that is how I came to talk to Kristen, 42, who gets neuromodulator injections from a registered nurse every few months—but only goes to a dermatologist for her undereye filler (“It’s too close to my eyeballs”). And Lynda, also 42, who got her first Botox from a dermatologist in 2014 and paid $600. She’s gone to a med spa ever since—“Over 10 years later, it’s still only $500.” Lynda got a serious bruise and extremely swollen lymph nodes once after an appointment, but that nurse injector was gone the next time she went; there have been no issues since. Simone, 32, was a little nervous about the risks of laser hair removal on her melanated skin, but after starting with her bikini line at one large med spa chain she’s continued with her legs, underarms, and chin. She was comforted when, at her first appointment, the Black nurse practitioner told her she had done laser hair removal herself. And she finds the convenience unmatched—“I wanted something with locations close to my apartment and to my office so that I would definitely keep up with the appointments.”
Med spas tend to charge less than a doctor’s office, and in most parts of the country, they’re easier to find than board-certified dermatologists, who usually set up shop in and around major cities, according to a 2024 article in the Journal of the American Academy of Dermatology. That research found that Clovis, California, is one of the least dermatologist-dense areas of the country: In this city of 125,000 people, there were two dermatologists as of 2023. A recent Google search turns up at least eight med spas there. In the most dermatologist-heavy area of the country—New York City’s Upper East Side—there are 30 board-certified dermatologists, but you can still find at least 50 med spas not far from the upscale storefronts of Chanel and Hermès.
In New York City, the med spa chain Peachy “is right in the plaza where my office is, so I can go down and get Botox and be back at my desk in 15 minutes,” says Kristen. The nurse practitioner she sees most often has been, if anything, too light-handed, so she’ll sometimes go back for a touch-up. All told, she considers it pretty low-risk. “I feel like if your Botox is wacky, you can correct it,” she says. “It's just Botox.” (Actually, unless you just need to correct an asymmetry—by adding extra Botox to one side—you have to wait a few months for it to wear off.) And the convenience is unmatched: “I can walk right in.” Kristen used to get Botox from a dermatologist. Now, she pays $200 less and books online the same day.
The average wait time for any treatment is three days at med spas, compared with 11 days for dermatology practices, according to an article in Dermatologic Surgery in 2021. And one reason prices are usually lower at med spas is that many of them can buy injectables in bulk. “Prices are based on volume. These big national chains have great group purchasing power,” says Dr. Hogan. The rates are “significantly better,” says Alex Thiersch, the founder of AmSpa: “The more you spend, the better the deal you get.” Even smaller med spas that may not get discounted rates on injectables can have lower prices than a doctor’s office because “their overhead is likely lower,” says Steven Williams, MD, a board-certified plastic surgeon in Dublin, California, and past president of the ASPS, who runs a med spa alongside his practice. Smaller staff without a board-certified (and expensive) physician on site can save costs. But also, “That’s where you can start eroding quality of care and patient outcomes,” says Dr. Williams.
Cheaper, easier, faster—med spas have a lot going for them. Enough, for many, to trump the outsized headlines about very serious complications that have occurred at some. (“Counterfeit Botox Leads to Hospitalizations” is a much more compelling headline than “Suburban Mom Is Happy With Her Botox From Local Med Spa.”) In the last couple of years, there has been likely HIV transmission from “vampire facials” in New Mexico, disfiguring burns from peels and lasers in Massachusetts and Florida, and the very rare but very real deaths—in Texas, one woman experienced sudden cardiac death after receiving an IV drip at a med spa, and in Los Angeles, a woman died after getting liposuction from a pediatrician at a med spa.
Taylor, 31, has been going to Tiev med spa in Costa Mesa, California, for several months and getting neuromodulators in her forehead, around her eyes, and in her jaw. When she heard of the spate of counterfeit Botox last summer, causing side effects like breathing and vision problems, weakness, and incontinence in people who had been injected in non-medical settings, she says, “I did get nervous initially, but I did more research. I knew I wouldn't be affected by that, and I really do trust the medical people that I'm seeing.” She sees a registered nurse, whom she trusts “way more than just a normal injector.”
Who is a “normal injector”? Good question. Generally speaking, people with “prescriptive authority” (this usually means doctors, dentists, nurse practitioners, and physician assistants) can purchase injectables. But in terms of who can actually do the injecting? Or the lasering? Or the microneedling? I’ve been reporting this story for a year and can in no way give you a clear answer. I’m not alone. Dr. Hogan has been working on a paper that aims to lay out the med spa regulations in every state of the union: “Who can do what where,” she says. She and her research team, two dermatology residents and a medical school student, have been at it for a full year and won't have anything ready to publish before 2026.
“It’s a patchwork quilt of laws and regulations,” says Renee Coover, JD, founder and owner of EngageLaw, LLC, who’s been practicing in this space for 15 years. “In some states, there’s as much of a gray area as there was 15 years ago. In others, there’s a lot more regulation. But it’s really impossible to say, ‘In the majority of states, the rules and regulations are this or that.’”
In New York, anyone can perform laser hair removal because it’s not considered the practice of medicine, but they can’t use other lasers. In New Jersey, you have to be a physician to perform many laser procedures. In Nevada, a person with an aesthetician’s license can legally operate a laser if they complete an additional 300 hours of training that includes a laser curriculum and there’s a licensed medical professional of some kind on site or reachable by phone. In Rhode Island, registered nurses can't perform chemical peels or radiofrequency treatments, but aestheticians can. In some states, aestheticians can do lasers but not microneedling, or microneedling but not neuromodulator injections. In Massachusetts, microneedling is considered the practice of acupuncture, so you need an acupuncture license.
You get the idea. “It shouldn’t be so confusing, but it is,” says Julie Bass Kaplan, a nurse practitioner who owns Disappearing Act med spa in Redding, California. There’s no tidy list of regulations by state that people who work at med spas or who frequent them can refer to. Some states are pretty good at proactively explaining their regulations around med spas and sharing resources about who can do what. In others, says Coover, “You call medical boards and they’re not always equipped to answer your questions. You can hear them googling stuff in the background.”
AmSpa is one of the few resources available to med spa owners like Kaplan who are looking for guidance on regulation. (Membership costs up to $845 per year.) The organization is also working on its own credentialing system for injectors, which can serve as a way to indicate that someone has proper training, says Thiersch. The exact prerequisites and vetting process are TBD, but the goal is to get at least “some baseline that folks can rely upon. There has to be some minimum.” Recently, “we put together actual practice guidelines to say, ‘This is what good practices look like,’” says Thiersch, calling out continuing education as an example.
One thing we can say with certainty from our reporting is that there are some states where physicians have the authority to determine themselves who is qualified to perform certain procedures under supervision. Texas is one example: Doctors there can delegate the administration of injectables to barbers, cosmetologists, and aestheticians they have deemed sufficiently trained in the procedure, as long as a physician, physician assistant, or advanced practice registered nurse is providing supervision (not necessarily on-site, but they need to be reachable). Some local legislators and the Texas Medical Board (TMB) have worked toward stricter rules and compliance, though Texas governor Greg Abbott recently vetoed a bill that would have explicitly prohibited cosmetologists, barbers, and aestheticians from administering injectables without proper licensing or authorization. (Abbott did sign a separate law this past summer regulating the use of elective IV therapy in the state after a related death.)
As of February, Texas med spa staff have to wear IDs showing their name and credentials, and in a bulletin on these revised rules, the TMB acknowledged that “the Board continues to encounter instances where individuals engaging in [med spa] business models either have no physician involvement or inadequate physician involvement.” Thiersch, for his part, thinks the headlines about the regulations can be more impactful than the regulations themselves. “It is announcing to the folks in Texas that, ‘Hey, you are in fact regulated, and there are in fact rules that you need to follow,’” he says. “This can no longer be the Wild West where you do whatever you want.”
Michael Byrd, JD, CEO of the business and health care law firm ByrdAdatto and a board member at AmSpa, says that in many states, “the laws are there for enforcement—if they choose to do it. Some states, like California, are very aggressive in enforcement, some historically haven't done much, and some are somewhere in between.” We spoke with one board-certified dermatologist who, early in her career, worked one day a week as an injector at a med spa to get more experience in aesthetics. “On more than one occasion it'd be like, 'That aesthetician just called in sick and that other one is busy and we need someone to do the laser treatment or the cryolipolysis [fat freezing]. Oh, that's fine, just get the receptionist to do it,'” she says. “That was definitely standard practice there.” She tried to get clarity on what exactly the regulations were in her state but ultimately came to: “It doesn't matter because none of it's enforced.”
After a med spa’s refrigerator is stocked with syringes, the supervising doctor is usually out of the picture, at least physically. A 2023 study in Dermatologic Surgery found that of nearly 130 med spas reviewed in the greater Chicago area, more than 80% didn’t have a doctor on-site. That’s a surprisingly large percentage, but maybe it’s a little less surprising when you consider the business model for multi-location med spas, which often share one medical director. It doesn’t take much to figure out that “if you’re a medical director for a chain of four or five med spas, you couldn't be on-site for all of them,” says Juliet Gibson, MD, a board-certified dermatologist in Dallas.
Specifics vary by state, but typically, a supervising physician is legally responsible for establishing proper protocols and training the staff. Though not generally on-site, they do have to be reachable, most importantly, of course, in the case of an emergency, like a burn from a laser or a blocked artery from filler. The definition of reachability varies, though. In some states, like Alabama and Connecticut, a physician who is supervising a physician assistant just needs to be available by radio. A required physical proximity between the supervising doctor and the med spa is not uncommon. “The licensed physician just has to be within X radius of wherever their spot is—25 miles, 50 miles,” says Gregory Greco, MD, a double board-certified plastic surgeon in New Jersey and New York. “That's all arbitrary.”
And, just as any licensed physician—whether a gynecologist or radiologist or allergist—can legally perform cosmetic procedures in their practice, the licensed physician who’s linked to a med spa can have any type of specialty. “I wish we could sit here and say that it's always a qualified individual that's trained in plastic and reconstructive surgery or dermatology, but it's certainly not,” says Dr. Greco. After all, consider the reverse: “Would I be the one you come talk to about hyperlipidemia and hypertension?” asks Seemal Desai, MD, a board-certified dermatologist in Plano, Texas, and previous president of the American Academy of Dermatology (AAD). “Yes, I had training in that in my intern year, but I'm not the expert on which blood pressure medication is the best for you.”
Whether this is an issue depends on who you ask. “I’m a radiologist,” says Kate Dee, MD, who left a decades-long career in breast imaging to open Glow Medispa in Seattle in 2014, and recently published Med Spa Mayhem, a book that takes a critical look at the industry. When I ask if she thinks she’s part of the problem—namely, the proliferation of providers without appropriate qualifications or proper training—she replies, “I got trained to do injectables, lasers, and peels, and I've done it full-time for 10 years.” That training entailed an eight-day course only open to and taught by physicians, which kicked off a “personal, self-directed residency in aesthetic medicine,” she writes in her book, referring to taking advantage of learning opportunities, like training courses with pharmaceutical companies, as well as hands-on experience injecting her own patients. It also included admission to the American Society for Laser Medicine and Surgery, which is open to any scientist, engineer, physician, health care professional, or individual who is “recognized as being significantly involved with the laser industry.” According to Dr. Dee, her med spa is a better bet than “a place where there's just an RN and their medical director is an anesthesiologist who's never there.”
Fair point. Because the rent-a-medical-license market seems to be booming. Last year, the American Society of Dermatologic Surgery released a statement on physician oversight at med spas, writing: “Our association has, on an ongoing basis, received a number of reports from our members who have been solicited to act as medical directors in name only in a medical spa or ‘med spa’ in exchange for a fee.”
Dr. Hogan has experienced this firsthand. “There are even websites that connect a nurse practitioner or PA with a collaborating doctor—it’s like a match service,” she says, adding that she’s been approached for such an arrangement. “I've also had colleagues and friends in non-core specialties who've been approached.” (“Non-core specialties” refers to those outside of dermatology, plastic surgery, facial plastic surgery, and oculoplastic surgery, the only specialties within medicine that offer standardized training in aesthetics after medical school.)
A study published in 2019 in Dermatologic Surgery found that of nearly 250 med spas reviewed, only 72% advertised a medical director on their website. Of that group, less than half were trained in either dermatology or plastic surgery. Another report found that 23% of single-owner medical spas were owned by nurse practitioners as of 2022. (According to AmSpa's 2024 trend report, 81% of med spas are not part of a chain. Only about 3% are owned by private equity, but investors are starting to snap up more and more of them.) This will not come as a surprise at this point, but state laws vary widely around who can own med spas. A few states limit ownership to physicians only; others allow NPs and PAs to own a med spa outright. Some allow NPs and PAs to own med spas as long as a licensed physician (who doesn’t necessarily have to set foot on the premises) is a co-owner, and several have no restrictions at all.
While dermatologists and plastic surgeons can give the side-eye to med spas, they, too, make money from injectables and laser treatments, which they may delegate to non-physician employees. More than a few own med spas themselves. “There can be some claim of hypocrisy,” says Dr. Williams. In his own med spa, simply named The Med Spa, one registered nurse and two physician assistants do injectables, lasers (for hair removal or facial resurfacing), microneedling, and more under his supervision—as in, his direct supervision—or that of his plastic surgeon partner. Because the med spa is right next door, its three practitioners can pop into his office to ask questions when needed, and “We’re on call for both our surgical patients and med spa patients 24/7. If a patient says, ‘My Botox wore off a little quicker than I’d like’ or ‘I have more activity on one side than the other,’ we consider those things complications and we’ll get the patient to the aesthetic look they want. That’s what you want from a high-quality practice,” says Dr. Williams. “We would argue that the supervision and the training and the ability to manage complications make all the difference. I have a profit incentive, but health care and patient care have to come first.”
Med spas started out much heavier on the “med” than the “spa.” The first ones were the invention of dermatologists and plastic surgeons, who saw them as extensions to their practice. Epi Center MedSpa, which opened in 1998 in San Francisco, is thought to be the first med spa, founded by Patrick Bitter, Sr., MD, a board-certified dermatologist. Juva Skin & Laser Center, founded by board-certified dermatologist Bruce Katz, MD, followed in 1999 in New York City. Kaplan founded her med spa (alongside her husband, a board-certified otolaryngologist) the same year in Redding, California. “We didn’t turn a profit for five years because back then everybody was afraid of lasers,” she says.
But then came Botox (2002). And Restylane (2003). And Kardashians to keep up with (2007). And Instagram filters (2010). Initially viewed as extreme vanity pursuits—botulinum toxin? in your face?—injectables rather quickly became seen as a “necessary part of self-care rather than medical care, a shift that’s occurred over the last 10 years,” says Vivian Diller, PhD, a psychologist in New York City who specializes in self-esteem and body image. Lasers soon became not so scary or “medical” either.
It’s not a coincidence that the aughts were also the same decade in which the med spa industry first grew exponentially. It was all made possible by Botox, says Dr. Williams: “Botox was the first thing that actually made a difference in how people looked. It was relatively easy to get, and it gained traction. This whole concept of med spas was built on Botox.” And even though Botox is a prescription medicine (fillers are technically not—they are classified as medical devices), many people just don’t think a doctor needs to be involved. “Physicians are associated with the treatment of disease, and women don't view beauty care as an illness,” says Dr. Diller. “It makes more sense to them to use med spas instead of dermatologists for cosmetic procedures.”
Even the way med spas look is de-medicalized. Their interior design has become an industry in and of itself. "We live in the age of TikTok and Instagram. Why not give clients a bit of runway?” one interior designer told Architectural Digest about a med spa hallway that he had strategically lit for selfies. The first time I ever sat in a med spa, I took notes for my future home renovation. It was the West Village location of Ject in New York City, and as I perched on an emerald-green bench, my skin was bathed in a light so soft that it looked like I didn’t even need the chemical peel I was there to get. (I got it anyway. Everything went well.) The scene was a far cry from my dermatologist’s office, with its handful of well-worn chairs and fluorescent lighting.
At Tiev, which describes itself as a “Design Haus for Medical Aesthetics,” Taylor can enjoy tea and dot essential oils on her wrists before a treatment. If you get a HydraFacial, “they give you a neck and shoulder massage at the end," she says. “It's very luxurious.” And like a high-end resort stay or business-class seat, the 2025 med spa experience may start before you even arrive. You can scope out “treatment menus” online with minimalist fonts that seem borrowed from the cool coffee shop in your town. At the end of your appointment, an injector might hand you a preprinted injectable after-care card (these are available on Amazon, by the way, along with hot pink “Let’s Tox About It” neon med spa signs). Instead of “Neuromodulators” or “Neurotoxins,” these services may be billed as “Wrinkle Reducers.” And perhaps you’re no longer a “patient” but a “client” or a “customer.”
“Language is everything, right? It frames the expectation, the perception of benefit and risk,” says Adam Friedman, MD, a board-certified dermatologist in Washington, DC. His hypothesis: “When you start referring to someone as a client, you’re trying to undercut the [medical] significance of these procedures.”
To many, that’s the appeal. Ever/Body, for instance, has “a very beautiful vibe,” says Katie, 32, who goes there for neuromodulator injections. “Millennial chic,” she describes it. And the vibe, it could be argued, serves an important purpose: to support the public opinion that the treatments offered in these spaces are luxurious and enjoyable, like a mani-pedi or a massage.
That approachability may also start with the injector. Stef Brower discovered Maeva founder Adriana Culling on TikTok, where the Austin, Texas, injector (a registered nurse) has over 70,000 followers. “One of the first videos I saw from her was breaking down a celebrity's injections, and it was like, ‘Look, everyone's going in for X, Y, Z filler that is not for every single face.’ And she talked about the reasons why and the structure of your face,” says Brower. “I gained pretty deep trust in her.” She booked a consultation and got filler in her mid-face as well as a neuromodulator and has been “very, very pleased” with the results thus far.
Not everyone is so lucky. In the same state, Adrienne*, met an injector through her friends, first getting neuromodulators for a year before going for filler, and she was happy with the results. But after her second time getting undereye filler at the injector’s med spa, she had such bad bruising that it looked like she had two black eyes. The injector, an aesthetician, “dissolved it, waited 10 days, and then put filler back in,” Adrienne says. This time, her eyes became puffy and swollen, so the injector then dissolved that filler over the course of multiple appointments for the next few weeks. “I actually got sent home from work one time because my eyes were still swollen,” she says. “My boss was like, ‘We have investors coming in today. I can't have you like this.’”
Four months after that filler injection, Adrienne went to a dermatologist, who told her that her only option was to wait it out while her undereyes healed from the repeated injections. The silver lining, sort of? “It became a medical trauma issue, so I could use my health insurance to cover some of [the cost], like the doctor appointments,” she says.
So what’s a med spa-curious client/customer/patient to do? Erick Brenner, the VP of aesthetics at Galderma, the manufacturer of Dysport, Restylane, and Sculptra, told us that you need to do your due diligence. “It's really important to understand who the medical director is,” he says. “So I think it's important that you do the work in figuring that out.”
But that can be easier said than done. The same 2023 study that found no supervising physician was on-site at more than 80% of med spas surveyed, also reported that staff only informed patients of this reality at 65% of them. So you need to keep the questions coming. And what you don’t want to hear is this: “‘I'm an aesthetic physician, who has a passion for this, who's done training,’ which are often weekend courses,” says Dr. Hogan. (For the record: “Aesthetic” and “cosmetic” have no regulated meaning when it comes to qualifications. They’re sort of like “clean beauty” in that there’s no one definition or standard, even when you slap the term before “physician” or “nurse” or “injector.”)
What you do want to hear is exactly what kind of training they did—and still do. “Scroll someone’s Instagram and see what kinds of conferences they’re going to. I want to see them sitting in the front row. I don’t want to see pictures of the parties they went to while they were there,” says Kaplan, whose own team “gets lots of training. I don't say no to anybody. If Merz or Galderma or Allergan wants to come into my practice, they're welcome, because I don't want my team just learning from me. I want them to learn from everybody.” (In reporting this story, we reached out to many of the major pharmaceutical companies producing the injectables and devices on offer at med spas. We spoke to representatives at Allergan Aesthetics and Galderma. Merz and Evolus declined interview requests for this story, and Revance did not provide a comment to our emailed questions.)
Alyssa Raines, a physician assistant who works at a plastic surgery practice and med spa in Connecticut, observed board-certified plastic surgeons doing injectables and operating skin-tightening devices for about four to six weeks. She then “enrolled in a certification course for neurotoxin and hyaluronic acid fillers, which was only eight hours—definitely not enough time, in my opinion,” she says. After that, Raines’ manager set her up with injectable training through pharmaceutical companies, including Galderma, Allergan (which manufactures Botox, Juvéderm, and Skinvive), and Evolus (which manufactures Jeuveau and Evolysse). Only then did she begin injecting patients.
Like plumbing or shoe cobbling, injecting involves an apprenticeship-type of learning, the comprehensiveness of which seems to be left to the injector. Annie Bruno, owner of the med spa Skin Charm in Scottsdale, Arizona, is a registered nurse and says she shadowed a board-certified plastic surgeon for two years, watching him inject over (and over and over) again “before ever touching a patient.” Bruno says she went to nursing school for the sole purpose of being able to inject patients. “I think I was ahead of the trend,” she says. Now, Bruno teaches other injectors through Allergan’s training arm, led by their medical director, double board-certified dermatologist Saami Khalifian, MD.
David Shafer, MD, a double board-certified plastic surgeon in New York City, also leads training for the Allergan Medical Institute, either in his office or at the trainee’s office. Most of these courses are in-person, with just two or three injector students. Each student will “have two or three of their own patients who agree to be a model—usually it's their relative or friend, a good patient of their med spa, or someone who maybe can't afford the treatment,” Dr. Shafer says. He might draw on the patient’s face exactly what he would do, inject one side, and then "the person learning will inject the other side while I'm watching them," he says. "So it's a see one, do one, teach one kind of situation." Some of the people taking the course have already been injecting at med spas. “Part of my job is to break them from bad habits or see if they have bad habits,” continues Dr. Shafer. Each session ranges from two hours (when no injecting is involved) to four hours when there are live demonstrations or hands-on learning.
Allergan also recently opened two new dedicated training centers, one in Irvine, California (where Allergan Aesthetics is based), and another in Atlanta. A third, in Austin, will be opening soon. Any provider who’s legally allowed to administer injectables in their state of practice can sign up for classes there. (Allergan has a team dedicated to vetting these providers before training them.) Courses are taught by physicians, registered nurses, nurse practitioners, and physician assistants and include hands-on opportunities, as well as classes on patient safety and basic facial anatomy. (There are fees for the courses, which can range from about $2,000 all the way up to $22,000 for an intensive four-month-long program.)
It’s a good thing that pharmaceutical companies making injectables have stepped in to help standardize training for non-physician injectors, which is certainly in everyone’s best interest. If someone gets a droopy brow or puffy eyes after being injected with their products, it’s not exactly a good look, literally or figuratively. “Training and education are by far the cornerstones of what we're doing as an organization," says Brenner, explaining that it’s one of the bigger areas where Galderma spends its money. “We need the injectors to feel comfortable injecting the products, and we need to ensure that the patients are getting outstanding, desirable outcomes.”
But you can’t assume an injector has a certain skill level just because they have taken pharma-hosted training. Meredith De Lello, a CANS-certified nurse practitioner who works with Kaplan at Disappearing Act, has attended numerous training sessions hosted by pharmaceutical companies over the years. She couldn’t have learned to inject based purely on this training, though, says De Lello, who shadowed Kaplan for six months before touching a patient herself. “The reps are going to cherry-pick the information that makes them look best; it’s a competitive market,” she adds. “I’m close with our reps and I do take their advice, but I take it with a grain of salt. A good example is a new neuromodulator that came out that was supposed to last six months, and I told all my patients, ‘I cannot speak to that yet.’”
This is all to say, “training by the company does not equal knowing how to do [the procedure],” says Dr. Williams. That goes for the courses manufacturers host on their radiofrequency, microneedling, cryolipolosis, and laser devices, too. “I have been involved as a medical board expert reviewer where someone said, ‘I wasn't licensed by the state to use this device, but the company said I was certified,’” says Dr. Williams. “And the company immediately turns around and says, ‘That doesn't mean anything. We have zero obligation to make sure this person is doing things safely.’” (A medical board expert reviewer weighs in on disputes, like lawsuits.)
As you do your due diligence, also keep in mind that many med spa owners and employees train on their colleagues. In fact, peer-to-peer procedures are so commonplace that looking at a med spa’s staff can be a good clue as to their skill. Heather Furnas, MD, a board-certified plastic surgeon in the San Francisco area, opened Allegro MedSpa in 2006, and says she gets treatments from her employees there—registered nurses, nurse practitioners, and physician assistants—every three to four months. “Sometimes it'll be fillers, sometimes it'll be a neuromodulator, sometimes it's a laser, sometimes it's intense pulsed light,” she tells me. Patients have told Dr. Furnas that they go to her med spa because her staff looks natural compared with other places where “everyone was so overfilled and over-injected,” she says.
Look beyond the faces, too. “Are they injecting in high heels with their hair all over their patient's face? Do they have bare hands with long, fake nails coming to a point? These are red flags,” says Kaplan of Disappearing Act. “You just can’t do a good job like that.” It’s neither professional, nor sterile, nor conducive to the type of meticulous work injecting well requires: “You want them to be in appropriate shoes, hair back, wearing new gloves.”
Another bright red flag: A med spa that claims they’ve never had a complication. “If I were sitting in an injector's chair and they told me they've never had a complication, I would find an excuse to get the heck out of there,” says Kaplan. According to her, it means they’re either inexperienced, aren’t telling the truth, or, as she puts it, are “so obtuse that they don’t know how to recognize it. We've all caused complications, but the best injectors see it and fix it right away so it doesn't lead to anything else.”
This is true of doctors, too. “It ultimately may happen to every injector if you inject enough people. I mean, I would be wrong to be sitting here and telling you that I've never had a vascular occlusion [blockage of a blood vessel],” says Dr. Greco. “I have, but I also recognize it and know how to treat it.” Another reason why you really want a med spa with a good medical director on-site: You might only have about 12 minutes to treat a vascular occlusion before it results in the most serious side effects of stroke or blindness, according to 2021 guidelines published in the Journal of Clinical and Aesthetic Dermatology.
Let’s say the worst happens after a med spa visit. Your vision is compromised from filler gone wrong; your legs are scarred after laser hair removal. You go to see a board-certified specialist and hopefully you heal, but do you have any recourse beyond a scathing Yelp review?
After Adrienne’s undereye-filler-gone-wrong, she filed a police report. They asked for the “paperwork,” said it checked out (remember, it’s not necessarily illegal for an aesthetician to do injectables in Texas), and went on their way, she says. Could she have tried to hire a personal injury lawyer and sued? Sure, but “one piece med spas are really good about is consent,” says Dr. Friedman. “I can guarantee you their consent forms are extraordinarily detailed so that they protect them when these things happen.”
No matter how velvety a med spa’s settees or sparkly their chandeliers, people need to remember: “This is the practice of medicine. These are medical treatments,” says Byrd, the health care attorney. Although the specific definition of the practice of medicine is different—you guessed it—state by state. (For the record, neuromodulator injections are considered the practice of medicine in all 50.) In the United States, the federal government delegates the regulation of the practice of medicine to the states, which aren’t racing nearly fast enough right now to catch up with the galloping med spa industry. The people who wrote state laws surrounding medical practice—many of which were first drafted more than 150 years ago—didn’t account for the proliferation of Instagram-friendly med spas offering to inject patients with botulinum toxin.
And there’s no food inspector or health inspector equivalent for med spas. A med spa is probably only going to be investigated if there is an adverse event and a complaint—and even then, there’s no real guarantee. “There are a limited number of resources to track what’s happening,” says Patricia Aronin, MD, a retired pediatric neurosurgeon and founding board member of TX400 and the Texas Physicians for Patients PAC, which are devoted to implementing physician involvement in medical settings like med spas. “In Texas, the state medical board has to rely on a complaint system.”
In a podcast conversation with Thiersch, Dr. Dee shared that part of her Washington State med spa is licensed to do facials—and in the past 10 years, she's had two inspections from the cosmetology board for the facial room. But “right in the next room is a laser that can actually do harm to people, and nobody’s inspecting that,” she says. “We do PRP, so we do blood draws…but nobody's inspecting that. So why is it that the cosmetology space has higher standards than med spas?”
Med spas should be regulated in the US as places where medical treatments are occurring, and in a perfect world, they would be. But—maybe in some part because they cater mostly to women, or they are cash-based, or they are written off as vanity ventures, or it’s not politically desirable to take away your constituents’ discounted filler, or all of the above—that’s just not the reality.
Business is booming for the med spas and for the companies providing them with devices and injectables, and there’s no major legislative overhaul around the corner. “These pharma companies are huge. They're not insignificant as far as lobbying power,” says Dr. Doft. “At the end of the day, they care about how many tubes of filler they're selling or how many lasers they're selling.” Especially if they’re publicly traded (which Allergan’s parent company, AbbVie, Galderma, and Evolus are). “Their job is to make shareholders happy, to grow the brand, to grow collective awareness,” says Dr. Hogan. “So they’re going to sell in markets where those goals are most achievable.”
When asked whether Galderma is in favor of stricter regulations on med spas, Brenner told us, “We partner extremely closely with medical congress societies’ professional organizations like the ASPS and the AAD, and local government, where decisions are made. It's a dynamic space, but at the end of the day, what we are in favor of is ensuring that people who get access to Galderma's products are well-trained, know how to use them safely, and can ensure that the patients that receive them have outstanding outcomes.” Brenner explains that Galderma “oftentimes puts standards on training and education on our products; we're committed to that.” We asked several pharmaceutical companies if they restrict who they sell to based on the customer’s training, rejecting some people even if they can legally purchase injectables and energy-based devices in their state, and none responded to the question.
Looking at the med spa industry from the inside, Thiersch sees the issue at hand as pretty straightforward: “We don't have enough skilled, trained providers to meet the demand, which is really why we see some of the accidents,” he says. “Those occur because you've got so much demand and you don't have enough qualified providers, and there hasn't been enough information and education put out there into the world to show what these treatments are.”
It’s hard to find a single place to lay accountability. And so it falls on the consumer to figure out whether a med spa’s medical director is on-site; to get clarity on what an injector's credentials, education, and training have entailed; and potentially to suffer the physical, emotional, and financial fallout of burned skin, a bruised face, a bacterial infection, or worse. “I’m not anti-med spa. I’m pro-patient,” says Dr. Hogan. “And they’ve been left on their own to navigate this world. I just want them to be able to make the best decisions so they don’t have complications.”
The med spa industry is giving people what they want: convenient, economical, and minimally invasive cosmetic procedures. And many med spas are operating responsibly and transparently. But others aren’t, with more arriving every day. So until the powers that be determine a solution that works for all involved—and then enforce it—all a client/customer/patient can do is proceed with caution and ask the right questions. After all, “patients are entrusting me to inject their face,” says Raines. “They should know I am qualified to do so.”
* Name has been changed for privacy.
Illustrations by Pablo Delcan
Infographic Designs: Allure; Source Images: Getty Images
