How unnatural beauty standards became a multibillion-dollar medical industry

The New Face

Blame Zoom, AI filters, TikTok. Facial alteration has become one of the fastest-growing segments of the $16-billion medical spa market. Toronto providers have never been busier, and their clients have never been younger

By Christina Frangou| Portrait generated with AI via Midjourney
| November 6, 2023

Bianka Kamber is used to people noticing her good looks. When she was in her early 20s, she dated Raptors power forward Kris Humphries for two years. Humphries went on to marry, and soon divorce, Kim Kardashian. The tabloids compared the two women. One even dubbed Kamber “Kim’s lookalike.” Kamber embraced the ensuing media buzz, landing a spot on the inaugural season of The Bachelor Canada and ultimately winning. In 2011, she put her career as a nurse on hold to further pursue the spotlight. She also started getting regular Botox injections in her forehead and, a few years later, dermal fillers in her cheeks. She liked the effects and kept up the routine. Then, in 2021, she took on a role with Bachelor in Paradise Canada.

Her age—then 37—often came up in the press coverage. She hated the not-too-subtle suggestion that it was miraculous a woman in her mid-30s could be considered a potential love interest. Soon afterward, she made the decision to take more definitive action. She’d always weighed around 130 pounds, but now, two years into the pandemic, the scale sat at 152. Looking at her face, she felt like there was too much skin around her eyes. Her eyelids felt heavy. The Botox was no longer accomplishing what she desired. She wanted to look younger, more like she used to.

In February of 2022, she visited the Weight Doctor, a GTA diet clinic known for its rapid, exercise-free weight-loss programs, to help her get rid of the extra pounds. The clinic put her on a 12-week program built around Ozempic, a drug approved to treat adults with type-two diabetes and increasingly used off-label for its remarkable slimming effect. She paid several hundred dollars for the drug and lost 20 or so pounds. Kamber also visited the Lip Doctor, the Weight Doctor’s sister clinic, for Botox. At a separate medical spa, Kamber paid for a fox eye lift. The non-surgical “tweakment” uses threads, inserted under the skin, to tug the tails of one’s eyebrows upwards, which gives the eyes a slight tilt. One week later, as she was driving, she sneezed and felt a snap near her eye. One of the threads had busted. She looked like Spock—one eyebrow pulled up, the other slumped down.

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After that, Kamber decided to pursue a more durable solution and sought out Babak Maleki, a Toronto oculoplastic surgeon. Kamber splurged on a surgical eyebrow lift; a blepharoplasty, which removes excess skin from the eyelids; and another procedure to remove the crepey skin from under the eyes. They were all performed in a single operation, and because of the swelling, it took Kamber a month to feel comfortable going out in public without sunglasses. She paid around $15,000 for the work and feels that the result is worth the cost. Now, her face is perfectly on trend: wide eyes, pronounced cheeks, cupid’s bow lips and dewy, line-less skin. “I just look like a better version of myself—or like I did 10 years ago,” she says.

Bianka Kamber, who is open about how facial alteration surgeries have helped her achieve the face of her dreams
Bianka Kamber shares details of her cosmetic enhancements with her 37,000 social media followers—often broadcasting them as they happen. Photo by Christian Lapid/CP Images

Today, Kamber makes her living as a content creator on TikTok and Instagram, where she has a combined 37,100 followers and posts about her cosmetic enhancements along with beauty trends, Italian vacations and shopping hauls. In one post, she strikes a ta-da pose outside her plastic surgeon’s office. In another, a nurse injects platelet-rich plasma into her hairline, a treatment that is supposed to reverse hair loss. In a third, Kamber and a fellow influencer lie on massage tables and laugh as their abs and buttocks jiggle from an electric current that is being sent through a mass of wires and tape in order to firm up their muscles. Kamber carries herself with a demeanour that flips between broadcast journalist and cheery girlfriend, both informative and chummy. “Those of you following my post-Covid hair loss—telogen effluvium,” she says, using the clinical term for it, “I have exciting news for you.” She goes on to list the treatments she’s taking for her hair.

Kamber tries to help whenever she can, doling out anecdotes and insights. On one of her Instagram highlight reels, she discusses her facial surgeries—and why she believes she needed them—in granular detail. She also praises her plastic surgeon, affixing his Instagram handle to the bottom of the video’s frame. After she first shared her surgeries on social media, she says, thousands of women of all ages DM’d her. Many expressed their desire to fine-tune their looks with the same facial surgeries. She encourages her followers to ask questions and does her best to answer them all. “Women my age and younger are like, Oh my god, oh my god, that’s the one surgery I want to have,” says Kamber, who just turned 40.

When it comes to her various tweakments, Kamber brands herself as an open book. Other highlight reels take her viewers along for the ride to get “Hollywood’s hottest treatment”—an anti-aging procedure called Morpheus8—and also something called EMsculpt, which promises intense stomach contouring. In each, she tells her viewers what is happening as it happens. Many procedures are #gifted, which denotes that she got them for free in exchange for sharing her experiences online. That fact hasn’t deterred her dedicated followers—or the millions of other social media users who scour their feeds for advice on how they, too, can get a perfect face.

All this trend-chasing has pushed the cosmetic enhancement industry into overdrive. The global medical spa market was valued at $16.4 billion last year. In 2021, more than 5.4 million injectable procedures, including Botox and dermal fillers, were performed in the US and Canada. That’s more than double the number of procedures carried out in 2019. An increasing number of clients are women in their 20s and 30s. Some start even younger, as early as age 14. Many of them want what Kamber wants: to look ageless and symmetrical, with a visage that is plump in the right spots and chiselled in the rest. Such a face can rarely be accomplished by biology alone. But that is not a problem. New tech, and a rapidly vanishing stigma, have created a vast market for cosmetic work that is often more extensive, more visible and far more focused on younger clientele. The new mantra: if you don’t like something about your face, you can change it. And there are people everywhere—some do-gooders, some not—who want to help you figure out how.

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Three decades ago, in a Vancouver medical office, an ophthalmologist named Jean Carruthers began using a drug made from botulinum toxin to treat patients with eye spasms. Once injected above the eyebrows, the neuromodulator, which they called Botox, temporarily paralyzed muscles around the eye. But patients noticed another side effect—the two vertical frown lines between the brows, known in the cosmetic industry as the 11s, disappeared. Patients liked that. No, they loved that. In 1991, Carruthers and her dermatologist husband, Alastair, presented their findings at the American Society for Dermatological Surgery. In 2001, Health Canada approved Botox for cosmetic purposes, and the US followed a year later. Joan Rivers, the OG queen of facial renovations, predicted the future: “They’ll be doing it in malls pretty soon,” she said.

Today, Botox is one of several neuromodulators from botulinum toxin that are used to treat forehead wrinkles, frown lines and crow’s feet. Neuromodulation is the most common non-surgical cosmetic procedure, with more than seven million performed in 2021 alone. Hundreds of places in Toronto offer cosmetic Botox injections, running the gamut from chic Yorkville clinics to mobile operators who post their services on Kijiji. On any day, you’ll find as many as two dozen spas promoting Botox deals on Groupon. The costs range from $40 to $200 for 20 units of Botox—maybe enough for a forehead. A full face of Botox can set a person back more than $1,000.

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Botox’s arrival was followed by the emergence of hyaluronic acid fillers, known more commonly by brand names like Juvéderm. These products are injected into the face, primarily to add volume and reshape. Fillers are used to modify noses, lips, chins and jawlines as well as hands and butts. They can also be dissolved and reversed. People sometimes use them to experiment with their facial structure—like taking a nose job for a test drive. Prices for a single treatment start around $700, although fillers need to be touched up every six to nine months. The International Society of Aesthetic Plastic Surgery reported a more than 30 per cent increase in hyaluronic acid injections worldwide in 2021, some 5.2 million procedures compared with slightly more than 4 million in 2020.

The pandemic kicked the popularity of facial aesthetic treatments into high gear, ushering in what is known as the Zoom Boom. Never before have we spent so much time looking at ourselves, whether we wanted to or not. Aestheticians, doctors and nurses saw a deluge of new clients who, after spending hours each day staring at their own reflections, sought professional help to erase the things they didn’t like—the droopy eyelids, the wrinkles, the blemishes, the crooked noses, the double chins, the frown lines that hung around long after they had finished frowning.


The global medical spa market was valued at $16.4 billion last year

  Meanwhile, younger people were spending more time than ever on social media, where the tendency to compare runs high. Through augmented reality, anyone feeling down on themselves could trial-run amped-up versions of their face. Filters were mostly silly in the beginning, with cat ears and puppy noses. But now the most popular ones, like TikTok’s Bold Glamour filter, which was used to create more than nine million videos in the first few weeks of its debut earlier this year, offer a preview of what a person’s face could look like with a few adjustments. As a result, the door has swung open on an industry that once catered mostly to older, richer women.

Jennifer Pearlman, a physician who has worked in cosmetic medicine for two decades, is the owner and medical director of PearlMD Rejuvenation, near Yonge and St. Clair. When she started, most of her clients were in their late 40s or 50s. They’d sometimes pay in cash so their treatments wouldn’t appear on a credit card. But now there’s a much wider acceptance; everyone’s doing it, not just well-heeled women of a certain age. Millennials and Gen Zers have taken to cosmetic facial enhancements with particular enthusiasm. They’re making adjustments to the things they dislike while also getting ahead in the anti-aging game. Pearlman adds that many of these young women are also very open about what they’re doing: “It’s like a badge of honour,” she says.

Philip Solomon, a facial plastic surgeon, opened his first clinic in Toronto in 1999. He, too, has noticed some upward trends. When he started, most clients wanted procedures that made them look ­natural—little improvements on their faces that couldn’t be detected. They wanted faces that appeared young and symmetrical, without unusually large noses or chins that disappeared into necks. The requests have changed. Older clients—those in their 40s and up—still emphasize their desire for a natural-looking appearance, but younger patients are bolder. Plastic surgeons from around the world share their patients’ before and after images and have pushed the boundaries on what has traditionally been done in Canada. Young people want aggressive, dramatic changes that emulate the faces they see on Instagram or TikTok.

“Younger patients often follow what’s trendy, and that includes a slightly unnatural appearance,” says Solomon. He calls it a more “stylized” look—faces with strikingly high cheeks, wide eyes, strong jawlines and an upper lip that tilts skyward, like a ski-jump. These faces are ultra-­feminine and objectively beautiful, but almost uncomfortably so. That’s because they’re often intentionally robbed of the features that make us recognizably ourselves: the evidence of aging, asymmetries, individual quirks. In their place is a perfect look that is eerily uniform.

 

Faces have always been a way to show off trends and social status. The ­Elizabethan aristocracy coated their faces in white powder to hide the signs of smallpox. Clara Bow inspired the heart-shaped lips of the flapper age. British model Twiggy set off a revolution in eyelashes. What’s different now is the level of structural change that people are making to their faces at relatively young ages. This movement was born with the Kardashians, who turned younger generations on to what surgery and non-invasive therapies could do. In 2015, Kylie Jenner inspired young women worldwide to get lip fillers. She then sold lip kits through her cosmetics company, which promised the same pouty effect without the needles. Today, she’s a billionaire.

Bella Hadid, the 26-year-old American supermodel known for her cat-like eyes and chiselled cheeks, is the current face du jour. Hadid has denied having any work done other than a nose job when she was 14. But, in recent years, her cheekbones magically reached new heights, sparking a boom in buccal fat removal surgeries. To do the procedure, surgeons extract the fat that sits where the cheekbones and jawbones meet. The face becomes shaped like a diamond, widest at the cheekbones and narrowing down to a slender chin. Buccal fat diminishes naturally as we age, and getting it removed early can leave faces looking gaunt later in life, yet that hasn’t decreased the procedure’s popularity.

Topics that have traditionally been reserved for the plastic surgeon’s office are now ubiquitous on social media, where everyone’s an expert. There, face shapes are turned into trends—something is suddenly in, then out, kind of like hemlines. People talk about what they’re doing, what they want to do, what their experience entailed. They trade information like medical students readying for an exam. “This is what one syringe of filler looks like,” a woman explains as she squeezes clear gel out of a syringe and onto a silver spoon. Nurses on TikTok draw lines on faces with marker, demonstrating where Botox should never be injected. They trade safety tips: beware of knock-offs and always ask to see the manufacturer’s box for a product.

Facebook has a whole sector dedicated to facial aesthetics, where people upload their personal photos for public comment. Group members ask questions like “I’m 42 and old and haggard. Should I get my forehead and crow’s feet Botox’d?” Or “I’ll be 29 soon and I’m literally having nightmares about aging! I’m terrified!” The responses are mostly clinical, often ­delivered by non-experts with the precision of a surgeon. “I would do lower face Botox, cheek and chin filler,” says one. And another, “Less invasive treatments seem to be a hit or miss, personally I wouldn’t waste the money.”

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“There was always something that I could change about myself. Then I looked in the mirror and I didn’t know who I was anymore”

  Plastic surgeons on TikTok can have millions of followers, and the hashtag #injectorsontiktok (referring to the nurses who inject filler and Botox) has 56.2 million views. One of the latest facial trends is a strong, pronounced jaw—known as a “snatched” look—with 226 million views and counting for #snatchedjawline. To get the look, TikTok influencers are having surgery, adding fillers, getting Botox or even taping their mouths shut at night, presumably to preserve their jawlines and prevent a double chin. Often, the more forthcoming an influencer is, the greater their following.

Samantha Karounos is a 28-year-old nurse injector at Revel Medical Beauty Club on Bloor Street who has 3,100 followers on TikTok. Usually wearing fitted scrubs or a tailored white lab coat, she talks about trends in facial treatments and sometimes mocks people who deny having things done to their face. She believes that influencers should be honest about their surgeries—and not credit their results to something like green juice. She’s open about getting filler in her cheeks and chin. The former she did because she wanted to be able to speak to her clients about it from first-hand experience; the latter she did because she always lamented her lack of a strong jawline. “Most people have something that bothers them,” she says. “And I like to be really candid and be like, ‘If this is something that bothers you, these are the tools that we can use to fix it.’ ”

Teenagers, whose bodies and brains are still developing, can find those tools too. Aria Sahota had her first cosmetic surgeries—a tummy tuck with liposuction and removal of breast tissue—three years ago, just after she turned 18. Soon after that, she had her buccal fat removed. She has no regrets. She says her cheeks are now more proportionate to the rest of her face. Sahota had her most recent surgery, a Brazilian butt lift, last year. So far, she’s spent $48,000 on her procedures. “I’m very happy with my surgeries,” she says. “They brought me a lot of confidence.”

Sahota grew up in a Sikh Punjabi family where she often felt bullied by relatives about her weight. When she decided to have plastic surgery, some family friends opposed the idea, insisting that she should be saving money for a down payment on a house instead. But others supported her decision. Her father told her he’d always wanted her to look thin and be more comfortable in her skin. Sahota paid for all of her procedures with money she made as a self-taught day trader. She also bought a car and a home, she points out.

Aria Sahota had her first plastic surgery at 18. She’s spent $48,000 and has no regrets
Aria Sahota had her first plastic surgery at 18. She’s spent $48,000 and has no regrets. Photo courtesy of Sahota

Over the past year, she’s shared her experiences on TikTok. She gets some pushback from people who think she was too young, but she also gets questions from teenagers who want plastic surgery themselves. They ask what it was like, who did her surgeries and whether they were worth it. Sahota believes that, in general, people should let their bodies develop until age 18 before they consider surgery, but she also thinks the resulting physical changes can be empowering.

Today’s language of cosmetic procedures is loaded with positivity buzzwords: confidence, self-esteem, enhancement, rejuvenation. With it comes a whole industry of cosmetically altered beauty influencers—attractive women outlining what they’re having done and by whom. Hamna Awan, a 28-year-old communications professional and content creator in Toronto, is one of them. She posted numerous TikToks of herself taping her nose into place at night, which was part of her post-­operative recovery after her rhinoplasty. She told me she wanted people to know what the process was like. Like others on the app, Awan also tapes her mouth closed at night. She’s posted a how-to video of that too. For her, it’s all about honesty. “A big part of my brand is wanting to be the best version of myself,” she says, “and wanting to empower others to be the same.”

For those like Awan, cosmetic enhancements are just a part of life, with no more stigma attached than getting a haircut. Many women put them into the category of self-care. Caleigh Rykiss is a 38-year-old business consultant for gyms. She gets Botox in her forehead and in the crow’s feet area around her eyes. For about seven years, she’s also been getting moderate amounts of filler in her lips. In her friend group, almost everyone is getting something. For her, self-love means doing whatever makes you feel like your most useful, energized, competent self. “Sometimes that looks like drinking a lot of water and taking 10,000 steps a day,” she says. “Sometimes that looks like training for a triathlon. And sometimes that means going for your quarterly Botox.”

 

There is a darker side to the medical spa industry, and it preys on people who are looking for a deal. Many consumers have turned to the internet or unlicensed providers to purchase cheaper products, creating a black market for fraudulent cosmetic procedures. During the early days of the pandemic, when many cosmetic spas were closed, there was a mini-boom in home-­administered procedures: in one month alone, multiple patients came to a Boston dermatology clinic having injured themselves by self-­administering products like hyaluronic acid filler to their cheeks, after purchasing it at discounted rates on the internet.

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In 2021, the FDA urged consumers to work only with licensed providers and to stop buying dermal fillers off the internet, warning that these products may be fake, contaminated or harmful. They’d found several cases of injectors using counterfeit and unapproved dermal fillers. Counterfeit filler can sometimes include silicone, which is permanent, unlike approved dermal fillers. When silicone is implanted into areas rich with blood vessels, like the buttocks, it can travel to the lungs, heart and brain, causing strokes or death. It can also lead to painful, hard, gravel-like balls that stay permanently under the skin.

Health Canada warned about the use of off-market Botox after finding an un­authorized botulinum-toxin drug in two Toronto-area clinics. In Ontario, only doctors and nurse practitioners can prescribe cosmetic injectables, but registered nurses or registered practical nurses can do the injections if they work in collaboration with a prescriber. A physician or nurse practitioner is supposed to maintain responsibility for this act of medical care, ensure informed consent and have a plan to help manage any adverse events. None of this happens on the black market, and many nurses without proper credentials (or people pretending to be nurses) have set up illegal medical shops, with horrific—sometimes fatal—outcomes.

One night in 2017, 23-year-old Chanel Steben and her boyfriend arrived at the Toronto home of Anna Yakubovsky-­Rositsan, a registered nurse who offered dirt-cheap prices. Steben was there to receive injections of what she believed to be a cosmetic filler into her buttocks. Yakubovsky-Rositsan injected silicone and mineral oil into Steben’s body. Nearly three hours later, Steben began bleeding at the injection site and went into convulsions. By the time anyone called 911, she’d been unconscious for more than an hour.

Anna Yakubovsky-Rositsan injected silicone into her clients, with fatal results
Anna Yakubovsky-Rositsan injected silicone into her clients, with fatal results. Photo by York Regional Police

Steben died in hospital that day; the injections had stopped oxygen from reaching her brain. In 2021, Yakubovsky-­Rositsan pleaded guilty to one count of criminal negligence causing death as well as seven counts of aggravated assault and seven counts of criminal negligence causing bodily harm. In a victim impact statement, a woman in her 40s who had received treatments from Yakubovsky-Rositsan said her face had become disfigured after more than 10 injections. She eventually spent $66,000 on two surgeries and other treatments to remove the silicone.

Turning clients down should be a regular part of any cosmetics practice, but even among credentialed providers, there is no standard about how much is too much. Asif Pirani runs the Toronto Plastic Surgery Center and teaches his craft at universities across North America. He told me that when a health professional refuses to set limits with their clients, they may themselves have dysmorphic ideas of beauty—or simply lack the morals to do the right thing. “It takes more time to say no to a patient and to explain to them why you’re not going to do something,” he says. “It would be much easier for me to just do the treatment, and I make money doing it. But I’ve taken an oath as a health care professional.”

Studies suggest that the prevalence of body dysmorphic disorder, a mental illness in which a person has a distorted, negative perception of their physical appearance, has increased over the past decade, mostly in women. Anyone who’s spent time on social media knows that doing so can fuel a person’s sense of inadequacy. In 2021, Instagram’s own research revealed that 40 per cent of teens who felt “un­attractive” reported that the feeling had begun when they started using the app. Social media supplies an endless opportunity to compare against others—and influencers aren’t always honest about the extent to which they’re relying on filters, editing, ­cosmetic enhancements or all three. Even if they are, it may not matter: they’re deliberately selling the means by which a viewer can achieve the same.

Nicole Reyes knows body dysmorphic disorder first-hand, both as a patient and a provider. She started getting filler in her lips and cheeks when she was 24 and working as a nurse injector at a medical spa in Ancaster. At first, she just did small amounts of filler in her face—a syringe here and there. But she worked in a place where more was better, and she didn’t understand when to stop. She was also struggling with depression, and all she could see were imaginary flaws on her face. She describes that period as falling down a dark rabbit hole. “There was always something that I could change about myself,” she says. “Then I looked in the mirror and I didn’t know who I was anymore.”

She says she hit rock bottom with a face she didn’t recognize and a depression she couldn’t bear. She got a therapist. Of her own accord, she dissolved everything in her face to start rebuilding her mental health. She’s since founded her own medical beauty spa, Eleven and Co. She now wears fake eyelashes and gets mini lip plumps, injecting her lips with a small amount of filler, because she likes the way it looks—but not because she needs to look like someone else. She’s decided that it’s okay to do injectables in small amounts and has a policy of going slow with her clients, injecting only a little bit at a time. Recently, she treated a woman who was devastated by a breakup and wanted to dramatically change her appearance. Reyes refused. “She’s like, ‘No, please, I just want to do everything.’ I’m like, ‘No, we’re slow.’ So we took it slow. And she loved the results,” Reyes says.

None of the experts who spoke with me suggested a minimum age for facial plastic surgery or injectables. But several said that fillers and neuromodulators should be reserved for patients 24 years old and up. “I normally don’t encourage it before the age of 25,” says Reyes, who believes she started too young. “I refuse to treat high schoolers. I’ve had a couple of parents bring their young children in and say, ‘Hey, I approve of this. Is this possible?’ And I’ll say no.”

 

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It has always paid to be beautiful, and it always will. Over a lifetime, someone with above-average looks takes home an extra $230,000 just for being good looking. People who are considered attractive are more likely to be perceived as good patients and receive less-severe punishments for some crimes. They’re assumed to possess more socially desirable personalities and considered more likely to have happy and successful lives. In that way, cosmetic facial treatments can be a self-fulfilling prophecy: a person spends money to look more beautiful, and because they look more beautiful, they earn more—and then they can start the cycle again, purchasing even more higher-end treatments.

As these treatments have become ­normalized—and stylized—to not follow suit has become abnormal. Psychologists have identified hallmarks of faces that are viewed as most attractive: symmetry, a healthy appearance and texture to the skin, averageness. Yes, averageness. An attractive face, historically anyway, resembles the majority of other faces within a population. We like faces that look like other faces around us. The outliers become less attractive. Increasingly, however, those outliers are the faces that haven’t had any work done: no Botox, no fillers, no tweakments. The draw of cosmetic enhancements in a world of cosmetic enhancements becomes harder to resist.

There’s little point in denying that looking good does often feel good. Being hot, especially for women, has long been one way to make money. Telling people what you do to become hot is now another. But the reality of facial upgrades is so much more complicated than the “Do whatever makes you feel good” maxim that runs through much of the culture. And while the social media landscape is still relatively new, much of its relentless messaging harkens back to an age-old question: Are women agents of their own beauty standards, or are they victims of an industry hell-bent on selling them solutions to problems it created?


This story appears in the November 2023 issue of Toronto Life magazineTo subscribe for just $39.99 a year, click here. To purchase single issues, click here.

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