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.

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.

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.

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.’”