A couple of years ago, like many thirtysomething women who live in big cities and spend time on the internet, Caroline, a real estate agent who lives in Los Angeles, got interested in skin care. She’d never cared about the subject before, but suddenly, it seemed to be everywhere. She started following Rio Viera-Newton’s column on the Strategist and began stocking her bathroom cabinets with serums and essences.
Eventually, though, Caroline came to a point where progress stalled: Her face stopped looking better and better with each new product. “I plateaued,” she says now. “And I was like, I guess injectables are the next step.”
So she went to see Dr. Jason Diamond, a Beverly Hills plastic surgeon who’s been featured on shows like Dr. 90210 and has treated everyone from Katy Perry to Chrissy Teigen. Dr. Diamond injected a filler called Voluma into Caroline’s cheeks, which not only made her cheekbones look higher and more pronounced, but pulled the skin upward to minimize the appearance of laugh lines around her nose and mouth. He also plumped up her top lip with a different filler, and then injected Botox into her forehead to paralyze the muscles as a preventive measure against developing wrinkles.
“I couldn’t even tell you how much it cost,” Caroline says. “Because I basically blacked out when I saw the bill.” Still, she liked the results enough that, after Dr. Diamond’s work wore off several months later, she sought out a less expensive practice in Manhattan Beach to continue getting fillers and Botox done.
Diamond is one of a handful of plastic surgeons and cosmetic dermatologists who’ve made names for themselves on Instagram for their ability to work what looks like magic with nothing more than numbing cream and syringes. On these doctors’ social media pages, where follower counts range from the tens of thousands into the millions, you can watch them inject their patients — largely, though not exclusively, young women — with fillers meant to sharpen their jawlines, make their noses appear straighter and more symmetrical, and pump up their pouts. Results that used to require spending tens of thousands of dollars on surgery (and risking its sometimes-grisly consequences) are now available to anyone with half an hour and a couple thousand dollars to spare.
Results that used to require spending tens of thousands of dollars on surgery are now available to anyone with half an hour and a couple thousand dollars to spare.
The relative ease of injectables — especially compared to surgery — are likely part of why “having work done” is now treated by many as a piece of lifestyle content, as shareable as a shopping trip or session in a makeup artist’s chair, and no longer as a source of shame. Celebrities who were once hell-bent on convincing us that their beauty routines were no more complicated than drinking a lot of water and getting enough sleep have become eager to shower praise on their favorite practitioners: Kim Kardashian West posts Instagram stories about her late night-visits to Epione Beverly Hills, where she sees Dr. Simon Ourian, a cosmetic dermatologist, and Vanderpump Rules’ Lala Kent is a regular on Dr. Diamond’s Instagram.
Civilian women are less likely to share about their injections on social media, or at least less likely to hashtag when they do, but Caroline says she’s found that as soon as she starts talking about her experiences with injectables IRL — “I talk about it more than I should, probably,” she says, laughing — everyone wants to know more.
Injectables aren’t just changing our faces, creating a planet of girls with the same social media–approved full lips and sharp jaws. Their accessibility, shorter recovery time, and near-instantaneous results have encouraged people who wouldn’t normally consider having surgery to contemplate heading to doctors’ offices in their quest for a more perfect face. Add patients’ increasing willingness to disclose their procedures, and we’re rapidly heading into a world where fillers and Botox are considered in the same category as daubing on a little lipstick: Why wouldn’t you, if it makes you feel the way you want to feel, and look the way you want to look?
The FDA legalized the first injectable filler in 1981: It was bovine collagen, which was harvested from cows and required allergy testing before it could be administered to humans. It wasn’t until 2002 that Botox was approved for use in preventing wrinkles; the following year, in 2003, the government gave pharmaceutical companies the go-ahead to sell human collagen, and a few years later, hyaluronic acid–based fillers, which are now considered the gold standard.
Injectables have been steadily gaining in popularity ever since: The American Society for Aesthetic Plastic surgery has seen a 40.6% increase in the number of injectables being administered over the last five years. By their count, the US saw some 1.5 million Botox injections in 2017; for context, fewer than 200,000 people had laser hair removal that same year.
The American Society for Aesthetic Plastic surgery has seen a 40.6% increase in the number of injectables being administered over the last five years.
This is in part because injectables are super accessible: Whereas plastic surgeons have to be certified by the American Board of Plastic Surgery to operate, anyone with a medical license can buy fillers from the companies that manufacture them. They’re a natural fit at plastic surgeons’ offices, where doctors can offer them to patients to preview the results of future surgeries, or at dermatologists’ offices, where patients are already there to talk about their skin. But since payments for these procedures usually don’t go through insurance, they’re also an easy and lucrative payday, making them a popular side dish–type option everywhere medicine is practiced, from GPs’ offices to dentists or even OB-GYNs.
The availability and popularity of these kinds of treatments have helped create new categories of medical practitioner and treatment centers. Medical spas were a nearly $4 billion dollar industry in 2017, with 8% yearly growth expected going forward. Dr. Ourian describes himself as a cosmetic dermatologist — a hybrid term that suggests the practical, treatment-oriented work of a medical doctor, but also the aesthetic skill of an artist. There’s a comforting aura to it, this notion that injectables are about more than just vanity — they’re aligned with the things you do for your actual health.
“Dr. Ourian is all about keeping the quality of the skin good, because even if you have a great facelift, if you have skin that's crepey it's not going to have the desired result,” Lisa Vanderpump, an original cast member of The Real Housewives of Beverly Hills and longtime patient of Dr. Ourian’s explains over the phone. She sees the doctor for lasering, plus the occasional Botox and fillers. “I'm on television, and I'm 58 years old. My skin would not look as good as it does were it not for Dr. Simon Ourian,” she says.
Like many women who get Botox and fillers done, Vanderpump hopes that they will obviate the need for plastic surgery down the road: “I've always been a bit reticent really to go under the knife,” she says. “But the way things have changed, I don't think it's necessary. Well, none of it is necessary, clearly,” she adds, laughing.
The benefits of fillers over surgery are both obvious and numerous: For starters, these procedures are often cheaper, at least per visit, than their surgical counterparts. Dr. Ourian’s Instagram quotes between $2,900 and $5,900 for his facial contouring services, and promises that they will last anywhere from months to years; injections at lesser-known practitioners’ offices can dip into the low three figures. Surgeons’ offices, on the other hand, won’t give out exact pricing, but a survey of comparable practitioners in LA suggests that the floor on facial surgery is around $10,000.
Then there’s the recovery time that surgery requires — especially if you’re a person in the public eye for whom money is no object but time is a precious commodity; a nonsurgical nose job might seem like a minor miracle. There will be some bruising, but it’s only a few days’ worth compared to the weeks of recovery that surgery demands. “I'm on camera — I've got three shows on the air, I'm in the restaurant every night,” Vanderpump notes. “You could document me every day pretty much for the past eight years. I don't have time for that downtime.”
“I'm on television, and I'm 58 years old. My skin would not look as good as it does were it not for Dr. Simon Ourian.”
Additionally, for people who make a living at least partly off their faces, it’s critical that the temporary nature of fillers allows for the come-and-go of beauty trends, so you don’t end up stuck with permanent Angelina Jolie lips when the Meg Ryan comes back into style.
“From the ’70s to the ’90s, people liked that scooped, ski slope nose,” Dr. Diamond explains in an interview a few days after Oscar weekend, one of his office’s busiest seasons. In person, Diamond, 48, is tall, with big blue eyes and the well-preserved skin of someone who practices what he preaches. His Beverly Hills office is small but stylishly appointed; his desk is empty except for a gigantic Mac desktop computer and a copy of Chrissy Teigen’s first cookbook, Cravings, which is weighted down by a skull-sized chunk of quartz. “That ski slope look was the result of the techniques we were using; you couldn't really make a nose look good without doing that.” Now the ski jump has become as dated as oversize implants, he says, and his patients are looking for a more natural nose.
He also notes that fillers can help actor clients achieve temporary looks for particular gigs. If, for instance, someone comes in saying, “‘Hey, I've got this role, I need a real projected cheek, but then I want it to go away,’ well then nonsurgical is better,” he explains.
Finally, of course, there’s the plausible deniability issue: Since surgery still remains somewhat taboo, especially for bigger stars, fillers allow them to reshape their faces without ever having to lie about whether or not they’ve gone under the knife. Kylie Jenner recently told Paper Mag that she was “terrified” of the prospect of surgery — a common refrain, which makes the speaker sound relatably cautious — before admitting that the way her face has transformed since her teens is due to fillers: “I'm not denying that.”
All of that said, it remains unlikely that injections will ever actually replace surgical options. There are certain things they can’t do, first of all: They’re no good, for instance, if you’re looking to downsize an asset. Procedures like CoolSculpting might be able to mimic the effects of liposuction, but you can’t change a nose’s structure to make it smaller with injections alone.
Even when injections are a good start, they don’t last forever — three months for Botox and six to nine months for filler, in most cases — and they can ultimately have negative side effects. In a 2018 interview with Glamour UK, Dr. Lancer, whose clients include Beyoncé, noted that long-term Botox users end up with “muscle atrophy or loss of muscle mass. This can cause indentation in the temple and indentation in the forehead furrow line, which creates a shelf-like droop of wasted muscle.” There’s also a risk of scarring from repeated injections, he noted, since “it’s not the filler, it’s the needle” causing trauma to the skin.
And then there’s the skin itself, which, no matter how many lasers and Thermage treatments try to zap it tight, will eventually, inevitably, sag.
“On my younger patients, [Botox and fillers] are the gateway drug to surgery.”
Dr. Kevin Brenner, a Beverly Hills doctor who also does surgical as well as nonsurgical work on recognizable Hollywood names, sees fillers as a way to test out your options for eventual surgical intervention. “On my younger patients, [Botox and fillers] are the gateway drug to surgery,” he says over the phone. “They come in and they get hooked on it, and eventually they start needing surgery because it doesn't really have the same effect anymore, especially on the filler side. I use fillers a lot in combination with surgery, but I also use it as a bridge to surgery for different things. So it's great for patient retention.”
He offers a look into a woman’s life cycle as seen by her plastic surgeon: “Someone may have come in initially for Botox and fillers, and then they have kids, and they need to have their breasts done, or a tummy tuck, because they get diastasis of their muscles,” he explains. “And then as they get older they graduate into ‘Oh well, I was doing some filler and Restylane before, and now maybe I need some fat grafting,’ something a little bit more aggressive, eventually into face and neck lifts.”
And then, presumably, the grave.
It’s no surprise that reality TV stars, YouTubers, and Instagram influencers are the ones at the forefront of the changing conversation about injectables, since it was reality TV that first brought old-school cosmetic surgery, in all of its glory and gore, into American homes.
MTV’s True Life featured a 2002 episode called “I’m Getting Plastic Surgery” with an unforgettable turn by a guy named Luke, who truly believed he would be a perfect specimen once he had calf implants; Extreme Makeover, a show that revamped people’s wardrobes and also their bone structures, premiered the same year. In 2003 we were introduced to the fictional world of Nip/Tuck, which inspired 2004’s reality series Dr. 90210. Since then we’ve had MTV’s I Want a Famous Face and Fox’s The Swan, as well as Botched, Bridalplasty, Celebrity Plastic Surgeons of Beverly Hills, and even a short-lived plastic surgery talk show called Good Work, which RuPaul hosted for one season on E! in 2015.
Plastic surgery makes perfect reality content: It’s equal parts disgusting and fascinating. It’s near-impossible not to feel a little bit sorry for the people who are getting it (Luke obviously and eternally excepted): to witness someone who’s so unhappy with their face or body that they’re willing to pony up significant cash and undergo actual surgery, with its unavoidable indignities, in order to change it.
Nonsurgical procedures, on the other hand, are still a little gross and a lot mesmerizing, but since they don’t require anesthesia or incisions, they’re easier to sell as part of someone’s glamorous self-care package. Fillers are also approachable, which is exactly what celebrities want to be, especially in the digital age. Watch Amber Rose at the end of this nonsurgical facial sculpting procedure: the way she grimaces, and then smiles, like a kid whose face is stiff from holding a mug too long for dad’s camera.
If the procedures themselves are approachable, Instagram makes them accessible: Dr. Ourian’s 30-second before-to-after videos, soundtracked by classical music, usually receive between 500,000 and a million views each.
“As my social media presence has gotten bigger, I now have patients coming in saying, ‘I saw you put Restylane in someone's lower eyelids: I want that. I feel like I look tired and she looks great; can you do that for me?’” Dr. Brenner says. “Social media's been huge in the last five years. I love using it, because this gives me an avenue to reach out and contact patients directly, because a lot of people have one big question they want answered. They want to say, ‘Hey, is this something I can even consider doing?’ or ‘Let me see how it's done,’ or ‘Let me see how you do it,’ before they come in for an actual consultation” — which, depending on the surgeon, can cost between $500 and $1,000. (That money goes toward your procedure, should you choose to have something done.)
“Getting fillers done does seem less taboo for most people,” Dr. Diamond says. But “the thing is, really until social media became popular, no one talked about it.”
“When I see a new patient in the office,” Dr. Brenner continues, “they feel like they know me. Not like a celebrity-type thing, but they’ve gone to your Instagram; they're watching you talk, and watching you do procedures. So people feel like they're part of the practice before they even come in. I think it helps me market and sell whatever the procedure is to patients before they even get here, which is very different than how it used to be.”
There’s a domino effect to disclosure: Once a celebrity starts “real talking” their beauty routine, it makes it that much easier for others to follow in their footsteps.
“Getting fillers done does seem less taboo for most people,” Dr. Diamond says. But “the thing is, really until social media became popular, no one talked about it.” Now his patients “may not say what they do, but they'll take a picture with me and post it themselves, or take a picture walking out of my office. They may let people use their imagination to figure out what they've done, and they may say exactly what they've done. It's just opened it up.”
“Interestingly enough, too, they follow each other,” Diamond adds. “One of them will see that another one was in here, and they'll come in and say, ‘Oh I saw that Kim was in here, or whoever.’” (Kardashian West has visited Diamond for PRP, better known as vampire facials, and microneedling.) “They’ll tell me, ‘I'm good friends with her. I never ask her, but I saw she was here.’”
There’s also a generation gap at work: Younger people are more willing to talk about having any kind of work done, surgical or otherwise. Dr. Brenner notes, “My younger patients, millennials who were brought up with it, are way more open. There’s a big group of patients who are totally jazzed about me filming them, which is totally crazy to me. The older patients aren't necessarily wanting anyone to know about it; the younger patients are more inclined to do it.”
This generation gap, in fact, is perfectly encapsulated by a dustup on last season’s Real Housewives of Beverly Hills reunion, in which Lisa Rinna accused Lisa Vanderpump of lying about having had a facelift. Vanderpump denied it strenuously.
Over on Vanderpump Rules, however, the decades-younger employees of Vanderpump’s restaurant empire have had three nose jobs, a boob job, and countless Botox done — with all of the blood and bandages, the indignity and unpleasantness, captured by the show’s unblinking camera.
This level of honesty doesn’t necessarily carry into the rest of the world, however. On Instagram, you’ll find hordes of influencers geotagging themselves at cosmetic dermatology and plastic surgery offices, but very few nonfamous faces disclose that they have had injectables that publicly. Injectable memes suggest that a good proportion of patients don’t even talk to their husbands about what they’re having done. Patricia, a 34-year-old stay-at-home mom in Chicago, tells me she feels “guilty” about the $250 she pays for quarterly Botox injections: “I’m sure when my husband finds out, he will think it’s a waste of money,” she says. On the other hand, “I calculate it out to $65 a month. I could be wasting that on Starbucks…or Botox.”
Nikki, a 33-year-old Chicago attorney, takes the opposite view. “Generally I am a pretty open book,” she says about her injections. “I have other friends who have done fillers or Botox, and I don't really feel shame about personal decisions I make, and pay for, and live with.”
Cosmetic dermatology feels deeply of the moment: It plays better with the current crazes for ill-defined, buzzword-driven phenomena like wellness and empowerment than plastic surgery ever did. The watchwords of cosmetic dermatology and nonsurgical procedures are conservative, and above all natural — that’s how Dr. Brenner describes his aesthetic, as does Pawnta, a nurse whom Kylie Jenner recently thanked on Instagram for a last-minute lip touch-up. When someone asked Dr. Ourian via Instagram if he could make her beautiful, he responded, “You are already beYoutiful,” adding in the caption that “the highest aesthetic goal I have is to enhance and magnify the person’s own, unique and natural beauty.”
Dr. Ourian’s website tells patients in search of breast augmentation or reduction, “The painful truth is that our society is very image conscious and somewhat shallow and imposes its notions of what we find attractive on each and every one of us... As human beings we simply are not able to effectively ignore the physical appearances of the men and women that we meet.
“The cruel result of this natural tendency is that women with particularly abnormally tiny breasts, or with abnormally large breasts are judged more harshly, making it an entirely natural response for them to seek a breast augmentation or a breast reduction respectively.” (Emphasis mine.)
And while surgery still feels like the farthest thing from natural — in part because it remains visibly, unavoidably dangerous — Neustem, Dr. Ourian’s proprietary filler blend, is made mostly of hyaluronic acid, which our bodies produce all by themselves anyway! Why should our mental health suffer the pressure of consistent self-hatred, the theory goes, when, in a matter of minutes, we could inject our way to a stronger chin or plumper lip, and then go think about other things?
Especially when we see images of ourselves so often, what might once have been an annoying flaw can start to loom so large in our minds that fixing it begins to feel genuinely urgent. “I've seen my practice get younger and younger and younger as I progress,” Dr. Diamond says, “and it's, in general, people who are trying to look more ‘model-esque.’ A lot of who we're seeing are people who just want more angular faces. With Instagram and with all the social media, people are seeing their faces much more frequently than they used to. People are seeing their faces 100 times a day, from every different angle.”
“I say, ‘Do this, you'll feel better,’” Vanderpump explains of her pitch to potential patients. “A friend of mine was going on about needing a top lip forever, and I finally said, ‘Don't tell me about it. Do it!’ If something about your face makes you unhappy, just do it.”
Plastic surgeons and cosmetic dermatologists who do this work tend to talk about archetypes of classical beauty like Greek statues and the golden ratio in order to explain that what they’re doing isn’t adhering to an arbitrary standard; they’re merely following the human instinct for a particular type of symmetry. That’s natural in its own way, isn’t it?
But outside of cosmetic dermatologists’ and surgeons’ offices, there’s a rising concern that the omnipresence of social media has created a desire for a standardized “Instagram face” — that, instead of opening our eyes to the variety of types of beauty in the world, our extended social networks have crowded us all into a single tiny room with a poster of Kim K on the wall, crowned with a blinking neon sign that says, simply, “THIS.”
None of the doctors interviewed for this article were worried about Instagram face; they saw their work as perfecting the beauty of each individual to the extent they are able. “I don't specifically ask people [about what celebrity they want to look like] because I find it creates a lot of unrealistic expectations,” Dr. Brenner explains. “There's always limitations, and I tell all my patients, ‘You're going to get a much better version of your nose, a much better version of your lips.’ I have people do it all the time: They bring in pictures, like, ‘I want my nose to look just like this.’ And I'm like, ‘That's great, but it's not going to. That's a beautiful nose, I love her nose, but it's not going to work on your face.’"
Many patients are also confident that they’ll be able to avoid turning into a Kylie clone, in part because that’s not the look they’re going for. “I’m older than people who are just doing it to look like Kylie or anyone with that frozen robot look,” says Melissa, a 36-year-old nanny who’s been getting Botox injections to deal with wrinkles for the past three years. She admits that she’s tempted by lip fillers, “but I have talked a lot of shit about lip fillers because I think they are always so obvious,” she says. “So I’d be a hypocrite if I started doing it.”
“I’m older than people who are just doing it to look like Kylie or anyone with that frozen robot look.”
Nikki has more complicated feelings. “I think that the image we now have of what human women look like is so warped that it’s hard to fully look away,” she says. “When I look at a lot of influencers, in the moment, they look beautiful to me, but they also don't look like human beings.” Nikki has had Restylane injected into her tear troughs to smooth out undereye circles; she was interested in preventive Botox and some lip fillers, but her Chicago-area doctor talked her out of it. “Chicago has a different look,” she says.
But when she thinks about what she wants out of her injections, the question of what “better,” as in Dr. Brenner’s “better version of your nose,” might mean bothers her. “I do want to look attractive,” Nikki says, “but if we have decided influencers and the work they get done is the pinnacle of beauty, then what other track am I really on if I say I just want to look ‘better’?”
The doctors can’t deny that their work has some effect, especially since the look they deliver in their offices is broadcast around the world by highly followed Instagram accounts every day. They make people look better, and those people communicate to millions of other people what, exactly, “better” means.
Whatever better might mean in the long run — for our own faces, and for our cultural understandings of beauty — right now, it feels good. As Caroline says, “Sitting in the office with numbing cream is my happy place.” ●
Zan Romanoff is a freelance writer and author of A Song to Take the World Apart and Grace and the Fever. She lives and works in Los Angeles.
Melissa is 36-years-old and a nanny. An earlier version of this story misstated her age and career.