The boom has been seismic. The regulation, less so. We’ve long spotlighted the board-certified experts behind in-office cosmetic treatments. Now we’re turning the lens on the medspas themselves—where millions go for lasers, injectables and more. What separates a practice worth trusting from one you should avoid? We investigate.
When Last Week Tonight With John Oliver put the medspa industry under the microscope last summer, the segment traveled fast, ricocheting through group chats, waiting rooms and industry Slack channels. It gave mainstream airtime to one of aesthetics’ most complicated realities: Medspas have grown faster than the guardrails meant to keep the category safe.
The American Med Spa Association (AmSpa) lists more than 15,000 active medspas in its database, a number quickly closing in on Starbucks’ U.S. footprint. But, a growing presence does not guarantee a shared standard of care. “All you’d need to open a medspa is to rent a place and say it’s a medspa,” says La Jolla, CA plastic surgeon Robert Singer, MD. The gray areas multiply from there.
In an April study published in Aesthetic Surgery Journal, Dr. Singer and three colleagues described the current medspa landscape as “the Wild West of retail medicine,” where “patient safety has taken a back seat.” Their concerns have numbers behind them: A 2020 survey by the American Society for Dermatologic Surgery found that 70 percent of surveyed dermatologists had treated patients for complications arising from procedures performed at medspas.
But, what gets lost in the alarm is that not every medspa is part of the problem. “Most of these procedures are very safe when performed by a qualified, trained practitioner working within the scope of their qualifications,” says Portland, OR plastic surgeon Mark Jewell, MD, one of Dr. Singer’s co-authors. Many physician-led practices with real oversight have been operating responsibly all along—and they’re often the loudest voices calling for industry-wide standards.
Now, the industry is beginning to put structure behind the scrutiny. As of March, patients finally have something concrete to look for: a new accreditation program from QUAD A, a physician-founded nonprofit that has been vetting surgical facilities since 1980. It’s a legitimate standard, which matters because not every “accreditation” actually means anything. “There will be some entities who want to enter this space and get a certificate for filling out a form and sending in a fee,” Dr. Singer warns. QUAD A is a way to know an inspector actually walked through the door.
Until that kind of oversight becomes standard, your best protection is doing your own vetting. It shouldn’t be on you—we agree!—but for now, it pays to know which questions to ask, the answers to expect and which red flags should send you straight out the door.
When the ‘Med’ in Medspa Gets Murky
Most people assume a medspa has a doctor calling the shots. Often, that is true: In many states, a physician serves as the medical director, but the title can be misleading. According to research published in Dermatologic Surgery, only 41 percent of medspa medical directors are trained in dermatology or plastic surgery, and just 6.5 percent are on-site, despite being legally responsible for supervising every treatment.
“Outside of dermatology, plastic surgery and a few other specialties, most MDs do not receive any training during medical school, internship or residency on popular cosmetic treatments offered at most medspas,” says Altamonte Springs, FL plastic surgeon Thomas Fiala, MD, one of the four authors of the Aesthetic Surgery Journal study, alongside Drs. Singer, Jewell and Salt Lake City plastic surgeon Renato Saltz, MD. Put plainly: It’s fair to ask who is supervising your treatment, and what qualifies them to do it.
Credentials only go so far if the doctor is nowhere to be found. Under the new QUAD A standards, a medical director can oversee no more than three locations, which is a limit designed to keep oversight from drifting too far from the treatment room. “They need to be available in person or through telemedicine in a very short period of time if any issues that come up,” says Dr. Singer. Without that access, the medical director role is symbolic at best.
Then there is the person actually holding the syringe, laser or device. At a well-run medspa, that provider should be licensed, specifically trained and working within the limits of their credentials. However, those limits shift by state, procedure and provider. For example, in New Jersey, advanced practice nurses work under joint protocols with collaborating physicians; in Florida, nonphysicians performing laser or light-based hair removal need appropriate training and direct physician supervision. Translation: A title tells you what someone is called. It does not tell you what they are trained—or legally allowed—to do.
That is where QUAD A certification can help. But if a medspa does not have it, the next best filter is you, and the questions you ask before anyone gets near your face. The most important ones, Dr. Fiala says: “Who is the medical director, and are they on-site? Which specialty is their board certification in?” To the provider, “How many times have you performed this specific procedure?” “What is your training background in aesthetic medicine?” and “How do you handle complications or side effects?” The providers who take this seriously tend to appreciate the questions. The ones who don’t tend to make that obvious.
The Fine Print Before the Filler
Questions come first; the needle comes later. AmSpa founder and chairman Alex Thiersch says prior to any treatment, there should be “an appropriate evaluation, a review of the patient’s health history, a discussion of risks and benefits, informed consent and a treatment plan ordered by a properly licensed provider.” Often called a “good faith examination,” this is the step that separates a medical visit from a beauty appointment with better lighting.
Informed consent is supposed to be part of that process, too. This is a signed document confirming your provider has explained the procedure and its potential risks and expected outcomes before you agree to move forward. “In many of these facilities, there are none,” says Dr. Singer. Requirements vary wildly by state. California and Texas mandate specific disclosures about practitioner qualifications and procedure risks, but many states set vague standards or don’t enforce them. This leaves medspas to decide what, if anything, you’re told before treatment begins.
The stakes climb when what’s being offered is less established. “There are many things done off-label by many physicians,” Dr. Singer says, “but they need full informed consent.” Some procedures, like exosome infusions and certain peptide injections, were never FDA-approved. Other physicians use approved products in ways regulators haven’t cleared. Either way, you’re outside tested territory, so full disclosure becomes critical—but, it doesn’t always happen. And when consent gets skipped, so does your shot at understanding the actual risk. Without it, you’re making decisions in the dark.
Safety Is Not a Vibe
A medspa can look like a spa and market itself like a lifestyle brand, and many do this quite well. But, polish is not a substitute for medical process. “Legally and clinically, it still must operate like a medical practice,” says Thiersch. “That means the needs of the patient come first, not the business’s bottom line.”
Price is often where the illusion cracks. A deal for Botox that dramatically undercuts the market should prompt questions: Is the product authentic? How many units are being used? Who is injecting it? And what happens if there is a complication? In aesthetics, a bargain should never be the whole reason to book.
One way to find out: Ask. “If you’re getting fillers or botulinum toxin, you want to see the package,” Dr. Jewell says. FDA-approved products such as Botox Cosmetic and Restylane come with batch numbers and intact seals, which are signs that they were sourced directly from the manufacturer and not from a third-party reseller or what Dr. Jewell calls “the gray market.” If the staff can’t show you that, or won’t, that should sound alarm bells.
It’s also fair to ask a medspa how its products are stored. Injectables require specific temperatures to remain safe and effective, and improper storage can result in lost potency or contamination. A practice that takes the clinical side seriously won’t flinch at either question.
Dr. Singer has seen what happens when a convincing brand is mistaken for a competent practice. “You can get some cutesy images off Getty and make yourself look like you’re a real entity,” he says. “And yet, no one is trained or manage an adverse event if it happens.” Plastic surgeons, dermatologists and ophthalmologists have documented cases involving visual losses, infections and scarring.
Complications are rare, but possible, and the response matters as much as the treatment itself. “If there is an emergency, you just can’t ship it off to the ER because they may not be equipped to handle it,” Dr. Jewell says. The question isn’t just whether a medspa can perform the treatment—it’s whether they have a plan for complications and can walk you through it upfront.
If something does go wrong, request your full treatment records, including the product name, lot number and the name and license of the person who performed the procedure. File a complaint with your state medical or nursing board. The medspa industry isn’t going anywhere, and neither should your standards. A paper trail speaks louder than a Yelp review. Document everything.
