A 20 billion dollar industry, about as big as the NFL, and almost none of it is being policed.
That is the state of medical aesthetics in 2026, according to Kate Dee, MD, a board certified breast radiologist who runs a med spa and wrote Med Spa Mayhem after watching her own field fill up with operators cutting corners.
Here is the mechanism. Botox, fillers, lasers, IV drips, PRP. Demand exploded, the money is enormous, and the enforcement never arrived. So a parallel system grew up next to the legitimate one.
There are weekend courses all over the country that teach an unlicensed person how to inject, then guarantee they will find that person a medical director. The director exists on paper. They might work in a hospital a hundred miles away and never appear at the clinic. With that arrangement, an unlicensed person can order product and practice medicine on your face, on their own, which is illegal in every state.
And the consequences almost never come. Last year people in 11 states were hospitalized from fake product ordered off the internet. When patients are harmed, the response from the enforcement side is often that they chose to walk in, so they got what they got. There is frequently no malpractice case, because there is no license, no insurance, and no money to recover.
Real medicine is heavily regulated, and everyone in it knows it. Walk into an actual medical office and there are rules layered on rules. The trouble is that a cash only storefront offering injections and IV drips can look almost identical to a patient, while operating under none of that oversight. The procedures keep widening too. Botox and filler were just the start. Now it is lasers, IV bars where people order a drip like a cocktail, blood draws, PRP for the face, all of it offered in places with no one qualified in the building.
This is not an argument against med spas. A physician run clinic is a genuinely good thing, and most physicians will not gamble a license they spent a decade earning. The problem is the layer of illegal operators that no regulator is actually watching.
The line from the episode that sticks: if you don't have a license, you don't have one to lose. That is the whole enforcement gap in nine words.
Listen to the full conversation on The Podcast by KevinMD. Link in the replies.
What is the one question you would want every consumer to ask before a cosmetic injection?
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