ALLURE
BEHIND THE SCENES WITH A STAR SKIN DOCTOR
Everyone from supermodels to Streisand swears by maverick Patricia Wexler.
October 1994
By Kathy H. Merrell
Photo Editor: Judith White


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Face-saving measures.

In matters of appearance everyone needs a confessor. Manhattan dermatologist Patricia Wexler has made that role her specialty. Women come to see her with complaints about laugh and frown lines, about thinning lips and sunken cheeks.
They come after they've had face-lifts, for help with the lines that just didn't go away, and they come before they need face-lifts, with grievances that many skin doctors would consider frivolous-some might even say obsessive. But Wexler (universally known as Pat) listens, looks with a critical woman's eye, sympathizes, and generally finds a solution.

Wexler has been a dermatologist a relatively short time, only since 1985, and yet her client roster reads like the invitation list everyone would kill to be on. Like a good doctor, Wexler won't say who her patients are, but no less than Barbra Streisand, Donna Karan, and a score of supermodels have been whisked through her waiting room. Says EMI Music Publishing president Charles Koppelman's wife, Bunny -one of Wexler's best pals, who started out as a patient - "She's doing all of Hollywood." And then some.

It is not unusual for people to fly into town just to see the redheaded doctor with a Kewpie doll face and porcelain skin.

Her complexion belies her 43 years, a fact that she attributes largely to a chemical peel she had at a young age as treatment for bad acne. This was 20 years ago, and none of the treatments we have for acne today were around at the time, so Wexler found herself in the office of an Egyptian cosmetologist she'd read about in a women's magazine. After that, she says, she avoided the sun.

Most agree that she has a cultlike following. One believer from Chicago goes from O'Hare to La Guardia to Wexler's office for a treatment and straight back the same day. On a recent Tuesday, the doctor saw two friends from Los Angeles who come together to New York once a month for fat injections. Then a record-company executive dropped what she was doing in midaftemoon to get a quick touch-up on her frown lines with a botulism injection (no, it's not the same as the killer bacteria in bad canned soup).

She is very much like a lot of her patients. She admits to being a clotheshorse, which is how she met Donna Karan, with whom she recently collaborated on producing a skincare line. Wexler went religiously to Karan's trunk shows and implored the designer to come see her as a patient. "Finally, I saw myself on the Charlie Rose show," says Karan. "The lighting was terrible, and I said, 'This ain't gonna happen again. " And so she turned to Wexler for sprucing up.


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Lip plumping Patricia Wexler injects collagen directly into a patient’s lip line. Although she also uses fat to fill flaws, she’s found collagen works best on thin lips. The major drawback: It’s temporary. Clients have to come back about every three month for a refill, at $425 per. And a high pain threshold is a must.

The doctor is not shy about her own vanity. She brags that she wears only Donna and Calvin to the office -never a white coat. Once or twice a week her hairdresser comes to the office in the morning to blow out her do. And she proudly tells a patient that she's working in Manolo Blahnik pumps. She carries a huge Barry Kieselstein-Cord bag. Her makeup bag contains Chanel, M.A.C., and T. Leclerc Paris. Koppelman says that all the salespeople at Bergdorf's know Wexler by name.

Wexler was born in the Bronx (a hint of an accent still remains) and eventually moved to Greenwich Village, where her father owned a bookstore. She attended New York University as an undergraduate, then went to Brussels for medical school, where she studied in French. She's got the classic Manhattanite's neurotic personality, which gives her an affinity for celebrity angst as well. She says she loves cosmetic dermatology because it fulfills her need for immediate gratification. "I like perfection," she observes. And she claims that her office is the only place where it's possible for her to achieve that. "It's the only place in my life where I don't have insecurities," she notes. This is a doctor without a God complex but with a whole lot of others.

She sits at her desk in an antique Chippendale chair, not the standard-issue polyester office upholstery. The walls display a collection of black-and-white photos by Diane Arbus's daughter, Amy, including one that features a bald model draped in fur -very fashionable. Like a good socialite, Wexler has spent her summer vacation for the past three years at Cap d'Antibes with her two daughters, the Koppelmans, and the other Dr. Wexler, her husband, Eugene, who is a urologist.

All the fuss, of course, is not just about her personality; it is about what she does for the flesh. About 85 percent of her practice is cosmetic, and the majority of that is injections -of fat, collagen, and botulism toxin (which has been used in medicine for more than a decade). These substances are deposited under the skin to smooth the tiny lines, deep wrinkles, furrows, and indentations caused by years of sun exposure, facial expressions, and the natural deterioration of elasticity and superficial fat.

To the uninitiated, Wexler's injections sound positively frightening, but such procedures -though less widely used than, say, Retin-A- are an accepted part of cosmetic dermatology. According to Richard Glogau, clinical professor of dermatology at the University of California at San Francisco, most dermatologists who are active in soft-tissue augmentation (which means filling out the flaws with a substance, most commonly collagen) are working with fat. "The downsides," he says, "have all been identified, and now it's a matter of tweaking it to improve the results." Wexler is considered to be at the forefront of "tweaking." In fact, doctors from as far away as Los Angeles recommend Wexler as the best bet for their patients who would benefit from fat injections.

But the idea of botulism toxin is enough to make even the bravest beauty addict balk. Wexler is one of a growing number of doctors who use bo-tox (as it's called) to eliminate unsightly furrows between the eyes. The injections haven't been approved by the FDA as a wrinkle treatment (neither has Retin-A), but they are the standard therapy used by neurologists and ophthalmologists for facial muscle spasms. "The activity of the drug is extremely well understood," says Glogau. "It gets the muscles to relax." (The botulism bacterium, which produces the toxin in large enough quantities to kill a person when ingested, has been removed from the injectable toxin.) Doctors are allowed to use an FDA-approved drug in any way they wish. Since only commercial promotion of a drug for a nonapproved use (known as an "off-label use") violates federal regulations, Wexler is adhering to the letter of the law.

A minute amount of the toxin injected into the corrugator muscle (responsible for frowning) just above the brow deactivates the muscle for anywhere from three to six months. Thus squinters cannot frown and create wrinkles, though they retain the ability to raise their brows. Muscle paralysis for beauty sounds a bit drastic, but, says Glogau, it certainly beats the most commonly used alternative for smoothing the brow, major cosmetic surgery that entails making an incision from ear to ear just behind the hairline. Any hint of a worry line that remains after the muscle has been relaxed can be injected with collagen. Says one of Wexler's bo-tox clients (a 60-year-old who came into the office in a miniskirt, black tights, and pixie boots), "It's made a tremendous difference in my countenance. I look more rested even though I am never rested."

The only danger, says Wexler, is that the toxin could seep downward and cause a temporary droop in the eyelids, which she says can be corrected with prescription eyedrops. Many patients, after watching the signs of their worries melt away with bo-tox, ask for the same to be done to their crow's-feet. While one or two doctors in the country will oblige, Wexler won't. According to neurologist Mitchell Brin, a pioneer in botulism toxin injections, its use below the eyes could have an impact on facial expressiveness, and even on the ability to blink, speak, and eat. Wexler says there's a slight danger of damaging the eyesight. As she told one woman, "I think you're more attractive as a sighted person, crow's-feet and all."

Compared with botulism toxin, fat injections are relatively tame. The worst side effects are bruising and swelling, which are rare, according to Wexler. She harvests the fat with a hypodermic needle from plump buttocks or hips, where its absence won't be noticed. (The thinner the person, the more painful the removal.) She draws out enough fat from the patient for ten treatments at a time and stores it in a freezer (hooked to an emergency generator). She anesthetizes the area of the face to be injected and uses a rather monstrous needle (fat cells are big) to place the substance, which has been cleaned of blood and other fluids, into the fatty layer of the face between skin and muscle. The fat-about the same color as that of a chicken-is then deposited in strands, which Wexler distributes evenly (she calls it sculpting) by kneading the area. Patients say that this is the most uncomfortable part of the process. Wexler says it's the most important step, and the one that requires the most finesse. If poorly distributed, injected fat can leave a face looking distorted.

Directly after the fat transfer, laugh lines (also called nasolabial folds) are plumped, sunken chins are filled, and hollow cheeks are cushiony. It is, however, a long-term process. Within three weeks of the treatment, about 90 percent of the new fat has been metabolized; the remainder is likely to stay put. Wexler continues the program every month for as long as it takes (usually about a year) for the patient to realize permanent improvement, or "perfection," as she says.

Glogau points out that monthly injections in the face are not for everyone. But Wexler's patients, some of whom have faces that are insured by Lloyd's of London, are a special breed. She knows her patients will suffer for vanity. Says one 51-year-old fat devotee (who could easily pass for 35 in good lighting), "This is vanity, so I won't let myself bitch and moan about the pain. And I'm never going to age."

Despite the wonders of fat, Wexler prefers collagen in the lips. She injects it superficially into pucker lines (the tiny rivulets that make lipstick bleed) and directly into the lip line (called the vermilion border) to plump the kisser itself. The problem is, that the collagen (to which about 3 percent of the population has a detectable allergy) lasts for only about five months at the most. Wexler is, of course, trying to figure out a way to use the more permanent fat in those areas. Fine lines, however, are superficial, and fat injections go too deep.

As a testament to collagen's success and Wexler's empathy with her patients, she injects her own lips when she has time. "Last time I did it was just before the Streisand concert," she says. "I wanted to look fabulous." She also gives herself the botulism treatment.

Probably the biggest challenge is in not overdoing injections, particularly when patients are begging for more. Wexler has even less room for overdoing it than most doctors, says Glogau, because her patients are so social. He says, "I can overinject fat because so many of my patients will take a week at their vacation house afterward. But Pat's patients all have something to do every night of the week."

Not that her patients don't want more. It is common for an injectee to hold a mirror, watching and commenting on Wexler's every move as she injects, and constantly asking for more filler. One patient who becomes unusually swollen for a day after the fat injections said, "I know it's sick, but I love it when I look like a chipmunk because that means in a few days I'll be gorgeous." The same woman asked Wexler for more fat to be placed around her eyes-she felt they looked too sunken-but Wexler refused. She quips, "It's like a methadone clinic around here. I have to tell patients, 'No, you've filled your quota."

The doctor has other cosmetic tricks up her sleeve, in addition to dealing with the usual rashes and bumps. She eradicates varicose veins, performs liposuction, and administers chemical peels. Much like any other dermatologist, she treats acne with Accutane and Retin-A.

She recommends alpha hydroxy acids when they're called for but deplores their widespread use in cosmetics. She believes that women have been victims of marketing in the AHA craze.


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Liposuction Wexler shows “before” and “after” photos of a liposuction patient who lost a few ounces of fat in her neck and gained a chin in the process. Liposuction is performed under local anesthesia; a patient can stand while fat is being removed from the thighs so that Wexler can see the effects of gravity on her work.

The public perceives alpha hydroxy acids to be a nonsurgical face-lift, and it's just not true," Wexler says. "A 30-year-old may see a difference with it, but a 50-year-old will see very little change." She concedes that AHAs with Retin-A are one way to counter sun damage. But she's concerned that about a third of her patients using AHAs get red and scaly and find their faces break out. "I think this is the beginning of the evolution of these products," she says. "We'll come out with better things in the future."

Wexler says she tries to wean her patients off the magnifying glass, though it seems to be a losing battle. "When they're harping on their dots, spots, and fine lines, they are competing with airbrushed images, and you can't live like that," she says. In fact, Wexler has noticed that her celebrity clients are often more willing to accept a bit of imperfection. "They know they'll be airbrushed or made up to hide it all," she says.

Being an ugly child, says Wexler, taught her early on the importance of working at appearance. "My mother was always dressing me up in nice clothes to distract from my appearance." Perhaps such looks-conscious mothering made Wexler more sensitive to the nuances of self-esteem. "If someone comes in with a huge wart on her nose, I say, 'Why are you here?' I never assume anything, because I don't want someone to feel horrible about herself." But in the end, Wexler is the arbiter of her clients' wishes and desires, as is evident in her response to a woman who, after getting fat injections, saw a defect in the mirror that Wexler and other bystanders simply could not see. The patient wanted the phantom flaw fixed. Said Wexler, "The only thing I can suggest for that is Prozac."

SPARE SKIN CARE

Most people who enter Wexler's office find their daily routine pared down. "Usually we eliminate half of what they're using," she says. She takes acne patients off astringent because she says it strips the top layer of moisture and creates a rebound phenomenon of too much oil. And she often takes the fortyish set off “too heavy" moisturizers. She says, "Too much moisture causes acne, clogged pores, and heavy-looking skin.” She’s against a different cream for each body part. "You don't need eye cream. Regular moisturizer will do." Recently she went commercial with her message as a consultant to Donna Karan's beauty company. The result is Karan's new hue of skin-care products, which Wexler helped develop. It consists of one cleanser for all skin types, a moisturizer with SPF 20, and a weekly exfoliator mask (with no alpha hydroxy acid). According to Wexler, that’s all most of us need.

END