Kara Montgomery*, a petite, blond, 45-year-old mother of two, is a regular at Cascade Eye & Skin Centers, a dermatology and ophthalmology practice with several locations. A few times a year, she spends $300–$500 for Botox injections, something she views as a beauty treatment that’s less expensive and invasive than surgery and no more expensive than hair extensions.

“Is it really any different than coloring my hair? It’s something I do for myself, to look more refreshed,” says the resident of a Seattle-area suburb.  

And Montgomery certainly isn’t alone. Based on local search data, Seattle ranks sixth among the nation’s top cities for interest in the injectable toxin Botox (botulinum toxin), ahead of cities such as San Francisco, Miami and Phoenix, and 10th for interest in line-smoothing injectable hyaluronic acid fillers such as Juvederm and Restylane.

That’s according to Seattle-based RealSelf, an online community and search engine for information on cosmetic procedures. “There’s a perception that Seattleites aren’t interested in these procedures,” says company spokesperson Jennifer Moses. “The thing is, we are.”

With 77 million unique users last year, RealSelf can map out geographic interest in cosmetic procedures based on user search patterns. Its data shows that overall, Seattleites’ interest in both surgical and nonsurgical cosmetic procedures is about 20 percent higher than the national average.  

And what do locals want? A natural, conservative look with normal, expressive facial movement, says Moses. That conclusion is based on search queries and posts by Seattleites.

This “natural look” is something an expert Botox injector can achieve by using less toxin and treading lightly around the eyebrow region to avoid the frozen, arched-brow look, says Evelyn Spieker, ARNP, and medical director at Green Lake’s Skinlogic Med Spa. Cost for Botox is about $15 per unit, or $200–$500 per treatment, which lasts about three months.

Pioneered for cosmetic use use in the late 1980s by a Vancouver, British Columbia ophthalmologist, Botox is still far and away the most popular treatment for crow’s feet, forehead creases and other fine lines. It’s the most researched injectable in the Seattle metro area, generating twice as many RealSelf searches as collagen filler Juvederm, the next most popular treatment, according to Moses.

After all these years, “Botox is still king,” affirms Spieker, who has been injecting Botox for a decade. Botox was approved by the FDA to treat chronic migraines in 2010 and it has long been used to treat muscle spasms, lending it an aura of medical legitimacy that’s helped erase any remaining stigma about using it cosmetically, Moses notes. Indeed, in Washington, Botox injectors must be physicians, nurses or dentists.

“These days, it’s almost a status symbol. People go out for drinks and talk about where they get their Botox done,” Moses says. However, despite its popularity, not everyone—including Kara Montgomery, who asked that her name be changed for this article—is comfortable broadcasting their use of a cosmetic beauty procedure.  

Spieker says that over the past decade, she’s seen the average Botox user start getting injections at younger ages; indeed, the American Society of Plastic Surgeons reports that half a million women ages 19–34 have had cosmetic Botox injections. “It’s seen as a preventative that keeps lines from getting permanently etched into the skin,” she says.

While Botox still reigns supreme, Seattle residents who want to maintain a facial complexion as smooth and pristine as a mountain lake have additional injectable options. Older collagen-based fillers—which required users to undergo an allergy test prior to use and lasted only a couple of months—have been replaced by other options such as Juvederm and Restylane. These injectables last six–12 months and don’t require allergy testing. Cost per syringe varies (and more than one may be needed),
but averages between $500–$600 in Seattle, according to information on the RealSelf site.

These treatments are great for smile creases around the mouth. But “chasing wrinkles”—which is the point of this type of procedure—is giving way to something different. “We’re seeing a trend toward facial contouring, with fillers being used in the cheeks, to add volume for a youthful, fresher look,” says Moses.  

The biggest industry buzz revolves around Kybella (deoxycholic acid), a new FDA-approved injection that permanently dissolves subcutaneous fat under the jawline—aka the dreaded double chin. Until now, one of the only options for this area has been liposuction surgery.

“It’s a huge breakthrough,” says Spieker. She’s injected Kybella numerous times since its FDA approval last year, she says, and clients are happy with it—but they should be advised that the product’s slimming effect isn’t evident until a few weeks after the treatment, because the injection can cause some swelling at first.

Also understandable: People want to use this innovation to dissolve fat elsewhere on the body. There’s some industry chatter about practitioners using Kybella for other body parts, such as the thighs or upper arms, says Moses.

“It’s like the early days of Botox, with doctors still learning about what they can do and what works best.” In the coming months, look for new FDA-approved injectable treatments that treat stubborn fat bulges on the body—like Kybella, but approved for other body parts—as well as an injectable treatment for the “tear trough,” horizontal lines under the eyes that create shadows and dark circles under the eyes, says Moses. Those interested should keep their eyes peeled—and if those eyes happen to look incredibly fresh and rested, don’t worry. Your secret is safe with us.