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As a teenager growing up in the Midwest, the use of cosmetic injectables like Botox and filler seemed reserved for people in Beverly Hills and New York with massive disposable incomes… and maybe a role on reality TV.

I remember watching the tightly pulled and perfectly plumped stars of shows like The Real Housewives and Keeping Up With the Kardashians with a mixture of adulation, judgment and curiosity. They didn’t look like the people around me and to my shock, they spoke pretty openly about having “work” done.

At 23, I moved to New York City and began hearing (and having) more candid conversations with friends about their own cosmetic tweaks. Now, at 28, I know more people who’ve had work done than haven’t — many of them are around my age.

In fact, more millennials than ever are trying injectables. A reported 98 percent of millennials say they’d consider an aesthetic treatment and according to some studies, over a million Americans receive injectable treatments every day.

Increasingly, getting your face injected has become a common occurrence and casual topic of conversation. But with the normalization of these treatments, has the tolerance for what we see as "normal" when we look in the mirror changed too? Is there a risk of developing a kind of facial dysmorphia? And if so, what role does an injector play in the regulation process, from consultation to continued upkeep?

I talked to seasoned experts to find out.

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Can Botox and Filler Cause Facial Dysmorphia?

“I’m not sure that Botox and filler lead to dysmorphia as much as they make people with dysmorphia or those with a propensity for dysmorphia more [pronounced],” says Dana Omari, RDN, founder of the popular plastic surgery-themed Instagram account @IGFamousbyDana. “In that case, it is up to the injector to turn away a patient ... It's not only in the patient's best interest but also to preserve the reputation of the injector.”

Board-certified dermatologist Whitney Bowe, MD, author of The Beauty of Dirty Skin, believes there can be a “slippery slope” when it comes to getting injectables, but that an experienced practitioner can usually spot a potential issue during the initial consultation — and press pause.

“Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived defect that others see as non-existent or very slight,” explains Dr. Bowe. “People with BDD are not good candidates for cosmetic procedures. However, if someone comes in with a healthy mindset and realistic expectations, cosmetic procedures can be very rewarding and enhance confidence and quality of life.”

Though Dr. Bowe says most patients come in hoping for a natural look with an emphasis on minimizing the appearance of aging or looking more rested, some enter the first meeting with unrealistic expectations. “I don’t want to see pictures of other people,” says Dr. Bowe. “Putting Angelina Jolie’s lips on someone else’s face is not going to look natural or healthy.”

“Putting Angelina Jolie’s lips on someone else’s face is not going to look natural or healthy.”

No doubt, some cases of so-called facial dysmorphia have been driven by social media trends. Back in 2019, writer Jia Tolentino noted a propensity for what she called “the Instagram face,” a cyborgian, increasingly ubiquitous look achieved through cosmetic fillers and photo-altering filters.

More recently, some celebs have used the pillow face filter to call out plastic surgery trends, which apparently was the intention of the filter’s creator.

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How Far is Too Far When it Comes to Injectables?

“Anything unsafe or unnatural — like injecting areas of the face that are ‘no-fly zones,’” says Gabrielle Garritano, the founder and CEO of JECT, a growing chain of New York City-based studios offering medical-grade aesthetic treatments

Also, the drive and dedication to see continued change can escalate to a bad place.

“When people start to see differences and feel more empowered, that can improve your self-esteem to a point, but there are those that want to keep going,” says Dr. Bowe. “In those personalities, it’s up to the injector to say, ‘If we keep going, it won’t look natural.’ It’s my job to take a step back.”

"It’s up to the injector to say, 'If we keep going, it won’t look natural.’”

Another piece of information that Dr. Bowe tries to ascertain: How much time a patient is spending in front of a mirror or a magnifying mirror every day. If it’s significant, that might be a reason to pause.

A few more giveaways: “If you’re excited to go to the dermatologist and you feel like learning more about how to take care of your skin and it’s part of a health and wellness journey, that’s a good sign,” says Dr. Bowe. “If you feel panicked at the thought of a doctor cancelling or you’d have a hard time coping at the idea of a cancellation, that’s a bad sign.”

Are There Positive Mental Effects of Injectables?

In many cases, the correlation is clear — and positive. One 2020 study found that patients receiving Botox injections in six different sites experienced less depression than those seeking alternative treatments.

Why? “When you look good, you feel good,” says Garritano. “It’s a source of empowerment. Clients tell me every single day how confident they feel or how good they feel.”

Those feelings come more easily when you don’t feel judged: “I think openness reduces the stigma and shame associated with having procedures done,” says Omari.

Adds Dr Bowe: “For some people, beauty and wellness can mean eating organic but also getting botox … The biggest thing is embracing whatever your journey is and owning it. The old days of feeling like eating clean and getting botox are mutually exclusive — we’re past that.”

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What Should I Expect During a Botox or Filler Consultation?

To combat any unrealistic expectations, Dr. Bowe says, “I want pictures of you, not from 20 years ago, but from a time when you loved the way your face looked. Even if I can’t achieve exactly what that picture shows, I can make you the most natural, most refreshed version of you. The picture gives me a sense of what a patient sees when it comes to beauty— something we can work to get a little closer towards.”

Garritano echoes Dr. Bowe.

“We need to show patients what realistic expectations are, show them before-and-after photos, review their photos and walk through a service step by step,” says Garritano. “We review their medical history and if they write something unrealistic on their intake form (such as wanting treatment for an area we wouldn’t perform on or that they’ve had multiple procedures), we hone in on that.”

Adds Garritano: “Sometimes patients come in and want one thing but I recommend another thing and in the end, they’re happy they listened to our advice. For example, a lot of people come in wanting under-eye filler, but the issue is related to cheek volume.”

Louis Baragona is a Brooklyn-based writer, editor and social manager. He started his career writing for publications such as Allure, INSIDER and Men’s Health. Most recently, Louis was on The Knot’s social team, where he specialized in increasing impressions, running campaigns and making memes.

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