How did being injected with poison come to seem a necessity for the luxury class? Trace it back to Pat Wexler, the beauty doctor who has made herself an addiction to the aging wealthy.
May 5, 2002
By Susan Dominus
Photographs by MARY ELLEN MARK
On any given workday, the waiting room of Pat Wexler, New York's best‑known cosmetic dermatologist, is filled with well‑preserved women flipping through magazines and eyeing one another discreetly. Wexler is known for her high‑caliber clientele ‑ among them Barbra Streisand, Stephanie Seymour and Candace Bushnell ‑ and on one memorable day, three different bodyguards arrived with three different charges. ("I thought, My mother would be really proud," Wexler recalls.). But the patients aren't checking one another out in hopes of celebrity sightings. They're looking for ideas: is she trying something I should know about?
Wexler, a petite woman with an impeccable manicure and neatly lined lips, is meanwhile speeding in and out of rooms like a character in a stage play, slamming the door on one story, opening the door onto another, and another, before circling back to the first to finish up, keeping track of the personal drama each contains. Today she leaves the room where she has just lasered one young woman's acne‑damaged skin and heads into another where a tall, willowy beauty in her 40's ‑ a socialite whose divorce made news a few years back ‑ waits a bit anxiously for collagen shots to fill out the faint lines around her chin.
"People feel it differently," Wexler warns, as she starts the injections. Her patient's face grows red, and her brown suede loafer starts wagging up and down. Making her way across the woman's face, injecting, smoothing, injecting, Wexler begins the highly skilled procedure she calls "talkesthesia. " She kibitzes about her husband, then moves on to the Olympics, while interjecting some coaching: "Try to relax ‑ do you do Yoga?" The effect is jarring: her patient is clearly in some distress, and yet with every shot, she looks less haggard, more relaxed ‑younger. After a few minutes, Wexler wipes away a pinprick of blood, and the patient sits up a little straighter, breathing a sigh of relief.
"What about my lips?" she asks.
"Do you think you need it?" Wexler asks intently. The question sounds loaded.
"Do you think I need it?" she asks in reply. Wexler says she thinks the lips look fine and switches the agenda: "Let's talk about Botox for a minute." A look of panic registers on the woman's face: more shots, with another wrinkle‑removing technique. Again, she asks if she needs it, but this time, it's clear that she's hoping the answer is no.
"It's been seven months," Wexler says, gently. "Technically, and by looking at you, you do need it."
To say that anyone actually "needs" Botox is obviously an overstatement, which is part of what Wexler likes about her job: nobody's life hangs in the balance. She has treated terminal illness, but at some point she realized she didn't have the temperament for it, and switched to dermatology.
Wexler zips out of the room to check in on the laser patient, leaving me alone with the Botox candidate. I tell her, truthfully, that she looks great. "Apparently, I've got wrinkles here," she says nervously, pointing to the spot between her brows. Does she think she has wrinkles? "No," she says, "but I trust her judgment." I wonder aloud if, by that logic, I might need Botox, too. 'Well, try to wrinkle your forehead," she says. "See, you've got wrinkles!" she says, pointing excitedly, and then she laughs, as if suddenly remembering the obvious. "Which is normal."
When Wexler returns, the two agree on a "baby dose" of Botox, which Wexler administers, warning her patient not to bend over for a couple of hours. (The procedure involves some risk, including the very rare case of temporary vocal-cord or eyeball paralysis.) As she zips off, she reminds her patient they'll see each other in a few days, at a black‑tie benefit at the Rainbow Room.
Wexler's medical practice and her social life frequently overlap, with Wexler serving as a kind of court physician to the royal circles of fashion and celebrity. For models, actresses and trophy wives, she's not just a health‑care provider but also an investment counselor in the twin currencies of beauty and youth. As an early adopter of new cosmetic treatments, she has managed to change not just the way many influential beauties look but also the way influential people think about beauty.
Botulinum toxin is "the most poisonous substance known," according to The Journal of the American Medical Association. A single gram, evenly dispersed, could kill more than one million people, causing "symmetric, descending, flaccid paralysis" and eventually cutting off its victims' power to breathe, swallow, communicate or see, while leaving their cognition all too intact.
One day about 12 years ago, Pat Wexler propped up a hand mirror, filled a syringe with a highly diluted form of the stuff and injected it in her forehead. As she expected, her forehead smoothed out like a sheet pulled taut. The shot paralyzed the muscles that draw the brow, into a furrow, leaving the opposing muscles free to lift the skin and brows up toward the hairline.
Botox had already been approved for treatment of eye spasms. But Wexler, following the lead of dermatological innovators on the West Coast, started administering it off label, a common medical practice. She noted that Botox made such commonplace facial expressions as scowling and squinting a challenge (though Wexler says the urge to squint can be so strong, patients recruit muscles from elsewhere on the skull to persist in the habit).
She also noted that Botox made her very popular. Wexler became the New York doctor best known for the procedure, which she dispenses starting at about $500 per treatment area, with boosters recommended every three to five months. If her first patients had any trepidations about filling their face with an off‑label toxin, she didn't hear too much about it. "I have to be honest with you," she says. "Most of my patients are pretty trusting. Sometimes it concerns a doctor. You want them to be a little more aware." Last month, the F.D.A. approved Botox for cosmetic applications.
Botox is Wexler's killer app, but she also offers low‑tech "acid peels" cotton balls soaked in glycolic acid that burn the surface of the skin, which cracks and peels off a few days later ‑ as well as laser treatments that vaporize the top layer of skin. (Until it regenerates, she says, "you look like Chernobyl.") In the newer Cool Touch process, she uses cryogen to chill the top layers of skin while lasers heat the layers below to stimulate new collagen growth. As do many dermatologists, Wexler also plumps wrinkles and sags, injecting various forms of what's known as filler: fat from her patients' own thighs, tissue from roosters' combs, collagen compiled from cattle skin.
To most women outside New York and Los Angeles, Wexler's aggressive approach to skin care may amount to extreme vanity, the morally suspect purview of the idle rich. But just as outlandish runway fashions trickle down to mall stores ‑ in modified, economized ways ‑ the techniques propagated by Wexler and her upscale colleagues reach the masses pretty quickly. Already, mainstream magazines take their readers' interest in these procedures for granted: "Doctors Reveal How to Avoid Plastic Surgery," reads one recent cover line from Elle, as if without this secret loophole, its entire readership would find itself heading for the knife. Botox is, in fact, already being mainstreamed: it's now administered not just by doctors but by nurses (and even, it is rumored, dentists), not just in offices but in spas, strip‑mall storefronts and at "Botox parties," where friends get together for cocktails and injections. Critics may bluster about the corrupting influence of such pursuits, but to Wexler, configuring the body according to one's wishes just makes sense. "It's fun," as she often says, sometimes while administering a shot. Over time, the rest of us may come to see rearrangeable beauty as just as logical, as inevitable, as harmless, as she does.
At one point in "Gulliver's Travels," Gulliver finds himself in a land inhabited by giants. Up close, he says, "Their skins appeared so coarse and uneven, so variously colored when I saw them near, with a Mole here and there as broad as a Trencher." For Wexler, her celebrity clientele are like those giants; where the rest of us see unattainable perfection, Wexler sees a squint wrinkle here, loose flesh there, sometimes even before the celebrity has seen it. At the movies, she tends to fixate on tiny flaws. "If I see bad cosmetic work, it's very distracting," she says. "I can't watch the movie."
Shortly after Wexler met Donna Karan, she let the designer know ‑ nicely ‑ that she would benefit from some liposuction under her chin. "I hadn't even noticed it," says Karan, who not only took Wexler's advice but asked her to consult on the skin‑care and cosmetics line she was starting.
Wexler's aesthetic perfectionism is not limited to clients' faces. While redecorating her Murray Hill office space, she had one wall painted nine different times, with nine different shades of off‑white, before she felt satisfied she'd picked the shade most flattering to her patients' skin. The waiting room's Japanese‑inspired minimalist chairs are bolted to one another because, Wexler says, she "couldn't stand it" when patients moved them here or there a few inches. If a patient who is a model mentions that she doesn't have an outfit for some big event, Wexler has been known to call Bergdorf's and have them set aside a few pieces she remembers from her last visit.
In addition, she offers Botox or collagen shots as a perk for her staff, as well as friends "or nice people who don't have money." Noticing a facial scar on a woman who helped cater a party at Wexler's apartment, she offered Cool Touch; she often dispenses acne medicine to her housekeepers. "Their skin clears up, they get married and they quit," she says mournfully.
Sometimes Wexler can't help herself. One evening, as we were exchanging girlish pleasantries, Wexler told me she'd lost weight with a low‑fat diet (and, she said later, breast‑reduction surgery).
"I need to start running again," I said, batting my hips.
"You don't need to lose weight," Wexler told me flat out. "You need liposuction."
There. I had received a diagnosis. I might have found her candor refreshing, except I was having trouble breathing. I whined about her comment to everyone I knew. A few weeks later, I ask Wexler if I can sit in on a liposuction. "Yours, perhaps?" she quips.
Having started performing liposuction in 1988, Wexler now does it so often that she has what she calls a liposuction arm. "Feel it," she encourages me, pulling up her sleeve and revealing a serious bicep. "It's hard work!" Hard but worth it: procedures start at $2,500 and can go up to $11,000.
The day I'm there to observe, her patient, a woman in her early 40's with a medium build, came to have her waist and hips whittled down ‑ follow‑ups to the stomach liposuction she had a few years earlier. Wexler uses a light sedative and local anesthesia, as opposed to the general anesthesia most plastic surgeons use. "I like my patients to stand up for the contouring," she says. "It's like a seamstress draping fabric ‑ you can't do it on someone lying down." It occurs to me that fashions once conformed to women's bodies, with ample skirts for female curves; now, doctors design women's bodies to conform to fashion's straight lines, its unyielding sizing. When I told her I had trouble finding pants that fit, she responded, "Why should you have to shop for one body part?" She meant, Why should you have to do all your shopping to accommodate one difficult body part? Literally shopping for body parts ‑ newer, slimmer models of whatever nature gave you ‑ is precisely what she encourages people to do.
For the first part of the liposuction, the patient lies on the surgical table. Wexler marks off topographical highlights of the patient's body, injects anesthetic, makes some incisions and inserts a slim plastic tube. She vigorously pokes it through the layer of fat beneath the skin, sometimes angling it in such a way that it is visible from the outside, poking up against the skin, appearing halfway across her waist and lower torso. That this does not induce a level of pain requiring more than local anesthesia suggests some serious flaw in the design of the human body. To keep her patients from fainting at the sight of it, Wexler blindfolds them and keeps her office cool.
As she works, the instrument's clear canister is slowly filling up with a peachy pink liquid, the color of mechanically extruded femininity. In an hour or so, Wexler would wrap it up; a few days later, her client would be at work, a size or so smaller. At the close of the procedure, Wexler gives her patients hot chocolate, but she warns them not to put on any weight. The fat won't grow back where it's been surgically removed, but that just means it'll end up bulging out someplace else ‑ maybe someplace worse.
Even as I'm wincing my way through the procedure, I have to admit that there's something liberating about her advocacy of liposuction. It's so forgiving. There's nothing outside surgery you can do to achieve size 6 hips, she says with all the authority her degree bestows on her, and that's both the bad news and the good news: it's out of your hands; leave it to the professionals. "People think that exercise will give them the body they want," she says. "Exercise won't give you the body you want. It will give you a firm body you still don't want." Despite all the evidence about the benefits of exercise and the popularity of gym culture, Wexler boldly argues that it might be healthier to spend an hour getting liposuction than to spend many, many hours obsessively working out to change some intractable body part. "I talked to a psychiatrist about it; she agreed with me," says Wexler. "And all that yo‑yo dieting isn't good for you; it changes your metabolism."
It's suggested that there's a third possibility: self‑acceptance. "You see, I never got that," she says flatly. "No one ever told me about that." It's the first time she seems anything less than lighthearted about the frivolous fun of a little smoothing and erasing. 'When I was little I had this really curly, really curly red hair, and when I was 5, my mother was taking me to Kenneth, where Jackie 0. went, to all these beauty salons all over the city," she says. "I think she thought I was going to come out with straight blond hair. I still think I'm going to come out with straight blond hair."
Now 50, Wexler gives herself Botox shots every four or five months, facial peels "when the whim strikes" and collagen injections on "special occasions" like a birthday party or a presentation at a medical conference. She had her nose done at 16, and in addition to the recent breast reduction, had liposuction on her abdomen about 14 years back. She still has a "wish list" of cosmetic procedures she'd try if only her medical practice let up long enough. (She also gives one of her daughters Botox shots ‑ for migraines, though her daughter quite likes the smoothing effects.)
Wexler thinks her own body is far from perfect, but says her dysmorphia ‑ the term for misperceptions about one's own body ‑ lies first and foremost with her once uncontrollable curls. That longstanding obsession has given her empathy for other women's selective self‑loathing, however harsh or deluded their judgment. "I think I've taken something dysfunctional," she says, "and made it functional."
The instruments of beauty: Botox (upper left), ice packs (upper right) and various syringes for introducing Botox, collagen and fat.
She has not only made it functional; she's also made it profitable. After consulting on Donna Karan's skin‑care and makeup line, Wexler negotiated a deal with Revlon to develop Almay's Kinetin skin‑care line in exchange for a percentage of the profits. The business relationship eventually devolved into dueling lawsuits, with Revlon suing Wexler, claiming she hadn't done enough to help promote the product, and Wexler countersuing Revlon for the $20 million she had expected to earn. Revlon and Wexler settled in early April. Wexler still maintains another "very generous" six‑figure annual consulting fee for her work on Calvin Klein's cosmetics line, and has discussed the possibility of promoting another skin‑care line on television shopping networks. Meanwhile, her practice continues to grow (her husband, Gene, formerly a urologist, has recently joined), as does the number of different technologies available for in‑office procedures.
As those technologies change, so, eventually, does the aesthetic. Wexler once used filler to plump lines between the nose and the corners of the mouth; now she plumps the hollows of the cheeks, lifting the skin and pulling the lines smooth. Once she favored Greta Van Susteren‑style eye tucks; now she tightens the skin with lasers and injects fat above the cheekbones.
Over an egg‑white omelet at Fred's, the restaurant at Barneys, Wexler details a few of the newest possibilities emerging from the beauty industry's research‑and‑development wing. She has high hopes for hair cloning, which is being studied in labs in the Netherlands, Toronto and North Carolina as a treatment for baldness. Recently, she started prescribing T.N.S., a lotion once used to facilitate the healing of wounds. It needs no F.D.A. approval, falling into the category of "cosmeceutical," one of those hybrid terms that automatically seems suspect by virtue of its failure to commit.
Wexler knows her procedures have their critics ‑ usually men, in her opinion, hypocrites who "think it's draconian for women to be doing these things, but leave their wives when they hit 50 for a woman who's younger and has breast implants. Half of them do," she adds authoritatively. Does Wexler regret the part she plays in that dynamic, the raising of the bar, at great cost and often physical pain? Well, no: she's not going for youthful, she explains, she's going for attractive. "If your skin looks unhealthy and draggy, it makes one think that your mind is sluggish as well," she says, her fork hovering in midair. "It's a presence. It's like wearing a wrinkled suit to an interview. It is!" No longer a fun indulgence, Botox starts to seem like a simple nicety, like combing your hair or making sure your bra strap isn't hanging out. It's one of the more menacing outgrowths of cosmetic innovation, this equation of youthful appearance with social rectitude.
"If your life expectancy has changed from the 40's to the 70's to now probably the 90's, you're going to have to change the way you look," says Wexler, going for the big picture. "As we enter our 90's, we don't want to walk around looking like the Dannon yogurt lady."
Pat Wexler hanging out at Barneys on a Saturday afternoon is a bit like the queen dropping in on Harrods ‑ grateful patrons stop her regularly to pay homage. The jewelry designer Judith Ripka swings by her table to say hello and promises to send a few pieces. Salespeople greet Wexler by name. Two exquisitely dressed women, one in her 40's, the other her mother, pause to chat, getting in a quick cosmetic question or two before they all part.
Wexler and one of her daughters, who has joined her for some shopping, finally extricate themselves from the fourth floor and head down to the sunny Madison Avenue sidewalk. "Bergdorf's?" she says to her daughter, who nods, at which point Wexler hails a cab to take them there ‑ three blocks away. If Wexler feels like springing for the cab instead of putting one mule-clad foot in front of the other and walking there like the rest of the world, she clearly sees no point in depriving herself. The technology is available, so why not take advantage? After all, she can afford it.
Susan Dominus, a contributing editor at Glamour and New York, last wrote for The New York Times Magazine about Eve Ensler.