Ashley Karges is the first to admit that the cycle she’s stuck in is exhausting. “I do it whenever I'm sitting at my desk at work, or in the car at a stoplight, or sitting in bed, or sitting on the couch watching TV,” the art gallery assistant and part-time art therapy student says. “Basically, all the things that I do in my daily life, I'm checking Instagram, too… It's almost like I feel like a robot sometimes.”

Like many millennials, the 26-year-old spends time every day carefully curating her own images and keeping a close eye on what her peers are posting. If this urge to frequently check social media feels familiar, you’re not alone. It’s estimated that Americans check their phones 46 times per day, and that number almost doubles if you’re under 24. While this data isn’t particularly shocking for those of us who feel anxious without our devices, how it’s shaping how we perceive ourselves might be.

Karges says she feels pressure to make sure each picture is just right before sharing it with her 841 followers — and she has no qualms admitting that she filters, smooths, and sometimes reshapes her face with a few taps on a photo editing app to make each one perfect. For her, it’s nothing to be ashamed of — it’s just something she and her peers do in 2018 to, quite literally, put their best face forward. It’s also here on social media where she learned how she could correct the thing she hated most about her photos. But this time, in real life.

“I kept seeing people on Instagram getting their lips done, and how, for a lot of girls, it looked really cute… more pouty,” she says. She turned to a beauty group on Facebook for advice on where to go to get injections and was immediately met with a message from a popular chain of clinics in Southern California. “The owner of the medi spa was in the Facebook group and offering discounts on lip injections, so a bunch of us started going,” she says, but that initial boost of confidence was short-lived. “A month later I decided that I needed to do it again,” she says, noting that it fades quickly, so she still continued to edit her photos to make her lips look bigger. So far she’s spent a little over $1,000 on three lip injection appointments.

Her story isn’t unique. Last year, over 55% of surgeons reported that their patients sought aesthetic surgery to improve their appearance on social media. Meanwhile, the use of botulinum toxin, like Botox or Dysport, by those under 34 has jumped 31% since 2015, while over 2 million dermal filler treatments were done in the U.S. last year alone.

Undergoing cosmetic procedures, whether it’s plastic surgery or minimally invasive treatments, isn’t anything to be ashamed of, but it’s important to understand that social media is impacting these decisions for many of us, whether we recognize it or not. For medical professionals in 2018, it’s becoming just as important to have an Instagram as it is to have a website, but because there is little regulation of the accuracy of information, like risks and qualifications, everything has become a little murky. In fact, experts say that having a large social media following can bring in more business than qualifications, like being board certified or having a degree in your field. So how are you supposed to know what’s what and stay safe? And better yet, how can we unpack our own motivations when we’re deeply tapped into the world of social media?

“Social media is the new brochure,” Pamela Rutledge, media psychologist at Fielding Graduate University and director of the Media Psychology Research Center says. “There are doctors all over the place who are posting all kinds of pictures on Instagram of procedures because they're targeting a younger audience. Communicating visually is so much more powerful than communicating in text. It's a way of reaching people to sell your wares.”

The point is simple: The more you see someone online, the more you trust them, so when a celebrity or influencer you admire posts something, you’re more obliged to trust the information than if it came from a stranger. This goes for medical professionals you frequently see on social, too. “Somehow we're presuming, because they're well-known, that they're qualified,” Rutledge says. “The other problem with all of this is that frequency increases liking and liking increases trust.”

Doctors we spoke to, like Alexander Rivkin, MD, a Los Angeles-based facial cosmetic surgeon who says he pioneered the non-surgical nose job, reports that offering free treatments to individuals to post about the service is commonplace in aesthetic medicine. He says that some doctors even pay the celebrity to come in for a treatment if they post on their social. “That’s where I draw the line,” he says. “I don’t pay anyone to get things done, I think that’s weird.”

Simon Ourian, MD — who reportedly treats celebrities like the Kardashians and Jenners, Jenna Tatum, and Cara Delevingne — says that at his practice, Epione Beverly Hills, he charges celebs and influencers “unless there's a collaboration,” he says. “You market for me and then you pay, and then I pay you back — that's a collaboration that's done.” Who, exactly, he has collaborations with, he can’t say.

For celebrities with Hollywood salaries, saving a couple thousand bucks on a treatment might not actually influence if you do it or not, but it might influence who you do it with. Leading your followers to the doctor’s Instagram account with a simple post is a lot easier than opening your wallet. “We have a bad habit these days of equating ‘important’ or ‘celebrity’ with skills and authority, which is why so many actors end up in politics,” Rutledge muses.

Understanding a medical practitioner’s qualifications is nearly impossible on social media alone, no matter how much information they pack into their posts. For example, Dr. Ourian often sports white lab coats that read “cosmetic dermatology” or “cosmetic surgery,” but he didn’t actually study these disciplines in residency. To be clear, any medical doctor can open a dermatology clinic without violating the law, but the American Academy of Dermatologists does not recognize any MD who hasn’t studied the field in school or residency, which are called non-core practitioners. (Core practitioners, on the other hand, are doctors that studied the field they practice.)

Because of this, you won’t find Dr. Ourian in the AAD’s database. “Some practitioners in spas and beauty clinics call themselves dermatologists, but they do not have the correct accreditation,” the group reports. To be a board-certified dermatologist, a doctor must finish medical school, three years of residency, and a one year internship, in addition to passing the board certification exam administered by the American Board Of Dermatology. Ourian studied molecular biology in undergrad, attended medical school at Wayne State University in Michigan, then started a residency at UCLA in anesthesiology, but dropped out before finishing. He can still legally practice, but it’s uncommon to skip this step.

“It was a big decision,” he says about not finishing residency. “It was kind of one of those life altering moments where you think, ‘maybe...all the decisions that I've made were on the wrong path. I want to go a different path.’ I feel I'm going to find out what else is out there before I make another decision.” He didn’t return to school to practice dermatology or plastic surgery, and instead started working in a laser clinic.

Dr. Ourian isn’t shy about his unconventional past, going as far as to tell us that he has no interest in being board certified, a benchmark for most doctors. “I think it's unique because I don't follow what other organizations tell me to follow,” he says. “You can't just say, ‘go only to our members because they're better.’ That's a little bit archaic.”

One agency he couldn’t avoid, however, is the California Medical Board, and in 2009 he was accused of a laundry list of things, ranging from incompetence to gross negligence, so he was put under probation for five years. He successfully completed the requirements of his probation and it was lifted early. “After all these things, I have an attorney in the office making sure all the T's are crossed and all the I's are dotted and we have somebody to make sure that all the paperwork are done correctly,” he says. “It still doesn't mean I'm doing everything right. I'm doing everything as much as I can to make sure that I make fewer mistakes. That's the best I can do.”

Non-core doctors entering the cosmetic world is becoming less unconventional every day. In fact, there’s another phenomenon happening in the world of aesthetics, one that’s outside of the doctors and medical professionals we interviewed for this story and mention here. For example, those that studied things like dentistry or gynecology in school might find the money in aesthetics appealing: It’s all cash, since there’s no insurance to deal with (for the record, things like filler when used in elective procedures are not commonly covered by insurance) and it’s easy to make an elective appointment ring in at thousands of dollars.

“There are literally people who will take a weekend course and then call themselves the equivalent of somebody who's been doing it for years, and has the proper training and credentials,” Anita Patel, MD, a board certified plastic surgeon says. “I guess the next question, especially from young patients, is, ‘Does it really matter?’ Even in the best of hands, complications could happen, but with someone who is not trained, they don't know to even avoid those complications and you can end up losing [skin] or you can end up with blindness, and this happens from fillers.”

Thankfully, Kargas didn’t have a negative reaction or suffer side effects when she got filler for the first time at a medi spa — and not from a core cosmetic derm — and for the majority of people, complications are not common. Still, it’s increasingly important to get off social media to do your research if this is something you’re considering. That is, if you can.