Over 9.4 million botulinum toxin procedures were performed in the United States in 2024, and dermal fillers add millions more. The vast majority are done outside a hospital. Most happen at one of two types of facilities: a medical spa (med spa) or a physician's office — typically dermatology or plastic surgery.
Both settings can legally administer injectables. Both can produce excellent results. But the training path of the person holding the syringe, the level of physician oversight, the availability of emergency protocols, and the regulatory structure governing the practice can be very different — and those differences are not always visible to patients.
This article explains how med spas and dermatology practices differ in credentials, supervision, scope of services, emergency readiness, and cost; what the ASPS, AAD, and ASDS recommend patients look for; and what to ask before booking an appointment at either type of facility.
The credentialing difference
What a dermatologist brings
A board-certified dermatologist completes four years of medical school, a one-year internship, and a three-year dermatology residency accredited by the Accreditation Council for Graduate Medical Education (ACGME). During residency, they receive structured training in cosmetic dermatology, including injectables, laser physics, and management of complications like vascular occlusion.
The American Board of Dermatology examines and certifies these physicians. Board certification is verifiable through the ABMS or the American Board of Dermatology directly.
What a plastic surgeon brings
A board-certified plastic surgeon completes four years of medical school, a three- to six-year surgical residency, and often a fellowship. The ACGME requires aesthetic surgery training as part of plastic surgery residency. Board certification is through the American Board of Plastic Surgery.
What a facial plastic surgeon brings
Facial plastic surgeons are typically board-certified in otolaryngology (ENT) with a fellowship in facial plastic and reconstructive surgery. Their training focuses exclusively on the head, face, and neck.
The American Society of Plastic Surgeons (ASPS) identifies these three specialties — plastic surgery, facial plastic surgery, and dermatology — as the only medical specialties that require comprehensive training in the treatments typically offered at med spas.
What a med spa injector brings
At a med spa, the person injecting is often a registered nurse (RN), nurse practitioner (NP), or physician assistant (PA). These providers are licensed healthcare professionals, and in most states they are legally permitted to perform injections under physician supervision.
The key variables:
- Training depth. An RN completes a nursing program (2 to 4 years) and passes the NCLEX. Aesthetic injection technique is typically learned through continuing education courses — sometimes a weekend certification — not through a standardized residency.
- Supervision structure. State laws determine whether a supervising physician must be on-site, available by phone, or merely listed on a protocol. The American Med Spa Association (AmSpa) notes that regulations vary state by state. In some states, the medical director may be off-site and may not have training in the procedures being supervised.
- Experience level. Many nurse injectors are highly experienced — some perform injections all day, every day. But the minimum threshold for legal practice can be very low. A 2024 investigation in Women's Health noted that some regions allow nurses and PAs to begin administering aesthetic injections after just a weekend course.
Supervision: what the law requires vs what patients assume
The FDA classifies botulinum toxins and dermal fillers as prescription medical devices. That establishes a baseline requirement for medical oversight nationwide. But "medical oversight" is defined at the state level, and it means very different things depending on where you are treated.
Direct vs indirect supervision
- Direct supervision requires a physician to be physically present in the facility during treatment.
- Indirect supervision allows remote oversight through protocols, standing orders, and periodic chart reviews.
- General supervision may only require that a physician is available by telephone.
The Illinois Department of Financial and Professional Regulation issued a 2024 memo clarifying that in Illinois, all delegated medical procedures in a med spa must occur within a physician-patient relationship, and the delegating physician must ensure proper training. But not all states have issued equivalent guidance, and enforcement is inconsistent.
The Medical Spa Safety Act
The American Society for Dermatologic Surgery Association (ASDSA) has developed model legislation called the Medical Spa Safety Act. It calls on states to:
- Regulate medical spas and keep medical procedures under physician oversight
- Require medical directors to have training in the procedures being performed
- Require notification to the public if a physician is not on-site
- Establish mandatory adverse event reporting
As of early 2026, adoption varies by state. Patients should not assume the Act applies where they live.
Ownership rules
In many states, non-physicians can own med spas. Some states restrict ownership through corporate practice of medicine laws, requiring physicians to own the clinical entity. Others allow business structures where a non-physician owner hires a physician as medical director. The supervisory relationship in these arrangements may be attenuated — the physician may visit infrequently and may not have specialty training in dermatology or aesthetic medicine.
Scope of services: what each setting offers
| Factor | Dermatology or Plastic Surgery Practice | Medical Spa |
|---|---|---|
| Injector credentials | Board-certified physician, or NP/PA/RN under physician's direct supervision | NP, PA, or RN under physician supervision (direct, indirect, or general, depending on state) |
| Physician on-site | Typically yes | Varies; in many states, not required |
| Medical records and continuity | Full medical record system; can prescribe, diagnose, bill insurance for medical conditions | Usually cash-based cosmetic records; may not maintain comprehensive medical records |
| Complication management | Physician on-site or immediately available; can diagnose and treat adverse events directly | May need to refer to an outside physician for complications beyond hyaluronidase injection |
| Medical dermatology | Can diagnose and treat skin cancer, acne, rosacea, eczema, and other medical skin conditions alongside cosmetic services | Typically limited to cosmetic services |
| Services beyond injectables | Often includes laser procedures, surgical options, skin biopsies, pathology | May include lasers, chemical peels, body contouring, IV therapy; typically no surgery or pathology |
A dermatology practice can identify a basal cell carcinoma during a cosmetic consultation. A med spa without a dermatologist on-site typically cannot. This distinction matters because cosmetic patients sometimes have undiagnosed skin conditions that a purely cosmetic provider may not recognize.
Cost differences
Med spa pricing for injectables is often lower than dermatology or plastic surgery practice pricing. This is not inherently good or bad — it reflects different cost structures, training investment, and sometimes different product sourcing.
| Factor | Med Spa | Dermatology/Plastic Surgery Practice |
|---|---|---|
| Botox per unit | $8 to $15 | $12 to $25 |
| Filler per syringe | $500 to $800 | $700 to $1,200 |
| Consultation fee | Often free | $50 to $200 (may be applied to treatment) |
Lower prices at a med spa are not automatically a red flag. A high-volume med spa with an experienced nurse injector and strong physician oversight may deliver excellent value. But patients should understand what the price includes — and what it may not.
What low prices can leave out
- Product authentication. The FDA has sent warning letters to 18 websites for illegally marketing counterfeit or unapproved botulinum toxin products. Some med spas have been found using gray-market or diluted product. If the price is dramatically below market rate, ask whether the product is purchased directly from the manufacturer.
- Emergency readiness. Does the facility stock hyaluronidase, epinephrine, and an automated external defibrillator (AED)? Can the on-site provider recognize and initiate treatment for vascular occlusion, anaphylaxis, or syncope? These are baseline safety standards that not all med spas maintain.
- Follow-up care. Is there a clear protocol for post-treatment concerns? Can you reach the injector or a covering physician after hours?
- Medical-grade product. The ASDSA has documented cases where med spa patients were injected with unknown or counterfeit substances. In one Texas case, a patient suffered serious complications after injection with an unidentified substance. In a Minnesota case, a med spa owner was charged with posing as a registered nurse and injecting patients with "black market" botulinum toxin.
When to choose which setting
A well-run med spa may be appropriate when
- You are a healthy patient with straightforward cosmetic goals (forehead lines, lip augmentation, cheek volume)
- You have been treated before without complications and want maintenance
- The med spa has an experienced injector who works under appropriate physician supervision
- The facility stocks emergency supplies and has a clear complication protocol
- You have verified the injector's license and the medical director's credentials
A dermatology or plastic surgery practice is the better choice when
- You have a history of complications from prior injectable treatment
- You have medical skin conditions (rosacea, eczema, psoriasis, history of skin cancer) that should be managed alongside cosmetic treatment
- You are considering treatment in a high-risk anatomical zone (nose, periorbital area, glabella) where vascular occlusion risk is elevated
- You are on anticoagulants, have autoimmune disease, or have other complex medical considerations
- You want a physician who can offer both non-surgical and surgical options as part of a long-term plan
- You want injectable treatment plus a full skin examination
Red flags at either type of facility
Regardless of setting, the following should prompt caution:
- The provider cannot name the specific product being injected or the manufacturer
- No consultation or medical history is taken before treatment
- The injector cannot explain their emergency protocol for vascular occlusion
- The facility cannot confirm that hyaluronidase is stocked on-site
- The price is dramatically below market average with no clear explanation
- The medical director's name and specialty are not disclosed
- The injector is unwilling to discuss their training and experience
- Pressure to purchase packages or proceed immediately
The ASPS recommends that patients verify that their med spa is overseen by a licensed physician with specialized training in the procedures offered — ideally a board-certified plastic surgeon, facial plastic surgeon, or dermatologist.
What to ask before booking
- Who will perform my treatment, and what is their license? (MD, DO, NP, PA, RN)
- Who is the medical director, and what is their specialty? Is it dermatology, plastic surgery, or another field?
- Is a physician on-site during my treatment? If not, what is the supervision arrangement?
- What is the injector's training and experience with this specific product and anatomical area?
- Does the facility stock hyaluronidase, epinephrine, and an AED? What is the protocol for vascular occlusion?
- Is the product purchased directly from the manufacturer? Can I see the packaging?
- What happens if I have a complication after hours? Who do I call?
- Can I see before-and-after photos of this injector's actual patients?
- Is there a consultation before treatment? Will my medical history and medications be reviewed?
- What is the total cost, including follow-up visits and any necessary touch-ups?
Bottom line
The setting — med spa or dermatology practice — is less important than the specifics of who is injecting, what training they have, what oversight exists, and what happens when something goes wrong. A well-supervised med spa with an experienced injector and strong emergency protocols can deliver safe, effective cosmetic treatment. A poorly supervised one can put patients at risk.
The three specialties with standardized, ACGME-accredited training in cosmetic procedures are dermatology, plastic surgery, and facial plastic surgery. Patients who choose a med spa should verify that the medical director holds one of these credentials, that the injector's license is current, and that the facility maintains emergency readiness — not because all med spas are dangerous, but because the regulatory floor varies too widely across states to assume safety.
Sources
- American Society of Plastic Surgeons. "How to Choose the Right Medical Spa for You." https://www.plasticsurgery.org/patient-safety/how-to-choose-the-right-medical-spa-for-you
- American Society for Dermatologic Surgery Association. "Medical Spa Safety Resources." https://www.asds.net/asdsa-advocacy/practice-affairs/medical-spa-safety-resources-a-comprehensive-overview
- American Med Spa Association. "Patient Guide." https://www.americanmedspa.org/patient-guide
- Illinois Department of Financial and Professional Regulation. "IDFPR, IDPH Issue Memo Regarding Medical Spa Services." https://idfpr.illinois.gov/content/dam/soi/en/web/idfpr/forms/dpr/idfpr-medspa-memo.pdf
- Nextech. "Who Can Open a Med Spa — Laws by State." https://www.nextech.com/blog/who-can-open-a-med-spa
- World Population Review. "Botox Laws by State 2026." https://worldpopulationreview.com/state-rankings/botox-laws-by-state
- Women's Health. "All About Medical Spas: Cost, Treatments, Risks, Are They Worth It?" https://www.womenshealthmag.com/beauty/a64341988/medspa-trend-safety-regulation
- Revival Dermatology. "MedSpa vs. Cosmetic Dermatologist." https://revivalderm.com/medspa-vs-cosmetic-dermatologist
- ScienceDirect. "Medical spa facilities and nonphysician operators in aesthetics." Journal of Cosmetic Dermatology, 2021. https://www.sciencedirect.com/science/article/abs/pii/S0738081X21002492
