Last year, Dr Asma Qureshi attended an influential Memon client’s wedding. According to her, almost all the women there had had their lips filled.

“Girls as young as 16 were walking around with visibly plumped up lips,” the Karachi-based dermatologist says.

Shortly after, the Covid-19 pandemic swept the country and the government shuttered all non-essential businesses. But even during the lockdown, Dr Qureshi was getting calls from people wondering if she’d make an exception and see them for their routine Botox appointments.

“I was thinking ‘who is even seeing your face right now?’"

When she was finally given the green light to reopen, Dr Qureshi did her best to be careful. But in June a client failed to mention that he had traveled right before his appointment.

“He was so desperate to get his injections, to look more chiseled, that he basically came straight to my clinic from the airport. Because of that I had to close for another two weeks,” laughs Dr Qureshi.

Every person I spoke to for this article told similar stories: of dedicated patients willing to overlook the pandemic, lockdown restrictions and their fear of needles, all in the name of eternal youth.

All this begs a necessary question: what are injectables and why the hype?

Commonly known as Botox or fillers, injectables are chemical substances that are inserted into the skin with a needle. And while the two words are frequently used interchangeably, Botox and fillers accomplish very different things.

Botox is a neurotoxin that temporarily paralyses a muscle preventing it from contracting. Fillers, on the other hand, help reduce facial wrinkles and folds (such as smile lines), contour the body (such as reducing the appearance of a double chin) and restore facial volume to the areas of the face that, with age, tend to lose volume (like the cheeks and lips).

To better understand this, put down the device you’re reading this on and take a look at yourself in the mirror. Scrunch your eyebrows together. The lines that appear between your brows are a muscle that a Botox injection can help relax and smoothen out. Next, look at yourself in selfie mode on your phone camera using one of Instagram’s filters. The plumped up lips, foxy-looking eyes and lifted cheeks looking back at you? That is the sort of thing that can be achieved with fillers.

Put your best face forward

The physicians I spoke to for this story unanimously agree: social media apps (like Instagram) are behind the uptick in cosmetic procedures, including injectables. And although revolutions are typically driven by the young, this revolution is not confined by age or gender.

“Everyone is doing it now. It’s become normal,” says Dr Qureshi. “I am half Iranian. And with Iranians it was always common [to have work done] at a young age. In their early 20s, girls would get a boob and a nose job. Sometimes they even had liposuction or put in gastric balloons for weight loss purposes. Mothers would bring in their daughters. In Pakistan, it’s a mix. Some mothers are progressive or proactive about it. But the majority of patients hide it from their parents and husbands and generally don’t want people to know.”

The rise of filtered reality has opened up a chasm between our digital and real selves. And savvy and skilled dermatologists, plastic surgeons and nurse injectors have rushed to fill the void.

Many physicians I spoke to say they use digital editing apps like FaceTune to discuss treatment options with their patients.

“People don’t come in wanting to look exactly like a particular celebrity. Instead, they’ll want certain features enhanced like how a celebrity has done,” explains Dr Qureshi.

“For example, many patients ask for Kylie’s lips, Deepika Padukone’s sharp jaw or Kareena Kapoor’s cheekbones.”

While Dr Qureshi personally thinks that seeing so much filtered, edited perfection is bad for the human mind, she sees firsthand how injectables can be a positive boost to a person’s self esteem.

“Many patients ask for Kylie’s lips, Deepika Padukone’s sharp jaw or Kareena Kapoor’s cheekbones.”

“I’ve seen some really pretty girls ruin their face because [injectables] can easily become an obsession. Say, you get lip filler and you like it so you go back before you need to and get more and more.”

Lahore-based dermatologist Dr Amna Ahmar echoes this.

“The media, in general, plays a big role [with self-perception] and now with social media there’s just a lot more awareness of how we look and how we age. I have people bringing in pictures of celebrities or influencers they follow saying ‘I want to look like that’,” she says.

According to Dr Ahmar, cosmetic procedures are Pakistan’s new trend.

“People follow people they want to look like. And we can help create that look. If people get satisfaction and peace with looking a certain way, then there’s nothing wrong with that.”

Most of Dr Ahmar’s patients bring in pictures of the infamous Kardashian-Jenner sisters. She also frequently has patients request Anushka Sharma’s features and Kareena Kapoor’s jawline. She doesn’t see many patients requesting to look like Pakistani celebrities, however.

“A year ago a lot of people were asking for chin filler because it was trending at their tea parties. But not everyone needs their chin elongated. I used apps to show patients how an elongated chin would look on them to confirm that’s what they wanted. If they still wanted it, I had them sign a written consent form saying it was their choice,” explains Dr Ahmar.

Shh, it’s a secret

Along with wanting to look a certain way, Pakistani patients put a premium on the discretion and minimal downtime that come with injectables, especially when compared to more invasive, traditional plastic surgery procedures.

According to Dr Anam Falak, South Asian women are very wary of their husbands and families. “They want minimal downtime, minimal bruising and as less healing [time] as possible. This is why my most popular procedures are lip fillers and under eye fillers,” she says.

Dr Falak, who sees patients both in the UK and in Pakistan, says the biggest difference between her two patient populations is that her Pakistani patients are far more secretive.

“My patients are not going home and telling their families what they have done. They don’t share my name with their friends. Whereas in the UK, one client will bring in five other friends,” she says. “I would love to get rid of the stigma [around injectables]. It’s normal. We all age. And if you treat these procedures as anti-ageing procedures it can be very beneficial. For example, if you take care of your under-eyes at a younger age — say, by getting under eye fillers in your late 30s or early 40s, then that area won’t have thinned out by your 50s and it’s just easier to maintain.”

For Dr Falak, injectables are simply a part of the limited self-care options available to Pakistani women.

“Historically, skincare hasn’t been the most important thing on the minds of Pakistani women,” she points out. “Most women in this country are homemakers. They cook and do housework in the heat. They don’t get time to take care of their skin as much. They assume that getting a blow dry, buying a nice outfit and doing their makeup is enough to look great. What they don’t realise is that things like your lips losing volume with age or deep under eye hollows are actually making them look older and more tired. No amount of makeup can conceal that.”

Trendsetting

Pakistanis may have just started to truly embrace the $8 billion injectables industry, but injectables are not new to Pakistan.

Dr Mabroor Bhatty, who is widely credited for introducing Botox to Pakistan in the early 2000s, spoke to me late last year. According to Dr Bhatty, initially no salon owner wanted injectables offered at their salons because they (falsely) assumed that by smoothing out their clients’ wrinkles, there would be a reduction in the demand for salon services like facials. Dr. Bhatty had to explain that injectables like Botox complement and enhance topical procedures like facials.

“It’s all about trust. If you trust your sabziwala [vegetable seller], you’ll go to Nazimabad for him.”

Today, Dr Bhatty’s black book is no joke. People wait for him to travel to Pakistan and he counts the crème de la crème of Pakistan as his patients.

“People come to me after things go wrong at fancy clinics in the US and UK. I have overseas Pakistanis who will fly to Pakistan from the US just to see me,” says the doctor who, in the last decade, has made over 99 trips to Karachi. “It’s all about trust. If you trust your sabziwala [vegetable seller], you’ll go to Nazimabad for him.”

Despite the increase in demand, injectables are not a pocket-friendly on-the-whim purchase. To start, because the body eventually dissolves both Botox and most fillers, clients who start injectables are looking at a lifetime commitment, unless they decide to go for a more permanent fix like plastic surgery. Second, the price tags on reputable brands of injectables are out-of-control high.

Consider one syringe of Restylane (a popular filler used for lips), which, if done by a reputable injector, will set you back Rs40,000. A syringe is just a millilitre of product, which measures out to be about one-fifth of a teaspoon. That’s not a lot of product — especially if you’re looking to restore volume to a large surface area like your cheeks.

And unlike the US, where the Food and Drug Administration (FDA) heavily regulates the injectables industry, Pakistani injectors have easy, unregulated access to cheaper European, Korean and Chinese injectables. This increases the risk to patients.

Still, the price and the risk has done little to stem demand for injectables.

According to Karachi-based dermatologist Dr Tasneem Nakhoda, because of procedures like injectables, her patients no longer need to go under the knife to look younger or feel prettier.

And, according to actor, dentist and injector Nadia Hussain, injectables are now considered par for the course for Pakistan’s film and TV industry.

“Like everyone else, celebrities have also become more critical of themselves now. They constantly see themselves on TV or have their pictures circulating on social media and become aware more quickly that they are ageing. They’ll notice that they look different than they did just a few years ago,” says Hussain.

“It’s all a race for followers. More brands come to actors with more followers. These actors then get to charge more for their drama serials. There’s just so much more opportunity,” she explains. “This is why celebrities are getting treatments done a whole lot younger. To stay relevant.”

Hussain, who treats many of her celebrity colleagues at her salon, tells me that even her male colleagues are not immune to the gravity-defying effects of injectables.

“Botox and fillers are common for male actors. Most younger female celebrities start out with lip fillers. That’s where it all starts. Usually, these same celebrities will then return to have the under-eye area filled because of the dark, deep circles that are caused by extreme work hours, dehydration and exhaustion. Celebrities in their 30s usually come in wanting fillers or threads for laugh lines or cheeks,” says Hussain.

It’s not just celebrities turning to injectables to ramp up their relevance. Hussain frequently works with housewives who turn to cosmetic procedures like injectables because they feel they have lost their husband’s attention or worry their husbands are being unfaithful.

“A lot of time women will come in who realistically can’t afford the treatment but still want something done because they feel their husbands are losing interest in them. They feel their husbands are moving on because the wives don’t look the same. Of course, this is not a solution. It’s just a fix in their mind,” laments Hussain.

And herein lies the dark lining to the puffy, white cloud that is eternal youth.

Not only do these clients have to be prepared for a long-term commitment, they also have to be able to pay upfront for services. That’s because unlike their Western counterparts, Pakistani practitioners do not offer payment plans or instalment contracts.

“To be honest, my clients are middle to upper class only. There’s less awareness and education in the lower classes,” says Dr Falak. “A lot of my patients are working women. Very few take the money from their husbands.”

Dr Bhatty’s experience is similar.

“Everyone wants to look better but within their means. Since there are no financing plans in Pakistan, patients pay out-of-pocket. Oftentimes, it’s cash — money they’ve taken from their allowance or the money they were given for groceries,” he says, adding, “the cost can get high. I won’t name names, but I know people in Pakistan who are hard sellers. They will inject Rs100,000 worth of fillers in one go. I can’t imagine how much filler that is.”

Slippery slope

The underlying current to my conversations with Pakistan’s injectors is that injectables can achieve only so much.

Indeed, Dr Nakhoda’s magic hands, Dr Falak, Dr Ahmar and Dr Qureshi’s artistic eyes, or Dr Bhatty’s black bag (a la Jason Bourne’s burn bag — except instead of passports it has syringes), can only take us so far.

In other words, Botox and fillers cannot magically translate into self-acceptance and fulfilment.

According to a recent Stanford study, seeing ourselves constantly on video chats has resulted in a new level of fatigue. Dubbed “Zoom fatigue”, this excessive amount of constant, close-up eye contact is both highly intense and highly exhausting for those of us who, because of work or school, find ourselves having to spend even more time staring at our reflections on computer screens.

Add to this the near daily act of smoothing, stretching, blurring and polishing that we all do for our pictures and videos, and what remains is an ego-shattering, massively exhausting crash course in the art of human insecurity.

As a friend recently said to me, “perhaps, on some level, we’ve all absorbed the message that we are measurable and modifiable commodities that are wanting and so can be improved upon. The byproduct of reducing our self-worth as measurable in likes, shares and follows.”

A risky venture

Injectables can be a risky venture in the wrong hands. According to the experts Images spoke to, the Pakistan Medical Association requires that injectors be board-certified doctors. But enforcement is at best shoddy and at worst nonexistent. This means unlicensed, untrained injectors can easily get their hands on product and set up a practice.

According to Dr Ahmar, “it may look very easy to do these things...to just poke a syringe into the face. But it’s one of the most dangerous treatments. No matter how many years I’ve been doing it, how well-versed I am in facial anatomy, I’m still aware of how blind we are to what is under the skin.”

Equally problematic is the flood of bad products in the Pakistani injectable market. According to Dr Bhatty, there is no authorised injectables dealer in Pakistan, which means he has to travel with his own products. And, according to Dr Ahmar, local injectors frequently turn to cheaper alternatives (like cheap, diluted Chinese fillers) so that they can charge their clients less. These cheaper alternatives often come with their own set of risks because around the world injectables are regulated as medical devices not drugs, which means they don’t go through the same rigorous clinical safety trials that normal medicines undergo.

Power players

All of this makes an injector a powerful player in a potentially dangerous game.

“I refuse to see pictures of influencers or celebrities that patients bring in. If I feel something is not right for my patient, I’m not going to do it,” says Dr Bhatty.

Similarly, Dr Falak talks about patients who come in with false hopes or unrealistic expectations of what they think they need versus what they actually need.

“I don’t want to give people completely new faces. I want them to embrace their beauty and use [injectables] only to emphasise it. So, I’ll tell my patients to look at a mirror and tell me what they think is “wrong”. If you have a nice nose with a slight hook, I’m not going to tell you to get a nose job because you already have a beautiful nose. I’ll suggest just a bit of filler to straighten things out. Same thing with patients who already have nice lips. I won’t let them turn it into a duck pout. Instead, I’ll recommend they simply define their lips with a bit of filler,” says Dr Falak.

“It should be about what is least invasive but also offering people an option. And it’s about having the right guidance.”

Art by Momina Yasir