Skin Deep

Dr. Alastair Carruthers, named by the Observer as one of the “50 men who really understand women,” is sitting in a room papered with his diplomas, certificates, and publications. He calls it—wryly—the Credibility Room, and credibility is important to him. He explains that he’s had his vertical frown lines removed so as not to look threatening, but the horizontal lines in his forehead are okay for a man, as they suggest curiosity and involvement. Maybe there’s something to this; he certainly looks trustworthy when he says, “There’s no putting the genie back in the bottle.” The genie is Botox, whose wrinkle-busting talents he and his wife, Jean, discovered in 1987. Since then, it’s become a billion-dollar industry, North America’s number one cosmetic procedure, and the inspiration behind a crowded new generation of fillers, intense pulsed light and radio-frequency therapies, and other age-fighting products. This husband-and-wife team, you could argue, has played a major role in reshaping our notion of beauty.

Given all that, one might expect the Carruthers’ Broadway offices to be rather grand, with wide hallways and, perhaps, lashings of granite. They are far from that. They’re located in a stocky, no-nonsense 1970s building between Oak and Laurel. Jean’s, on the seventh floor, is a feminine warren of small rooms, with creamy brocade wing chairs and a framed thank-you note from the Queen in the waiting room. (The Carruthers guard their patients’ confidentiality religiously, and the note refers to congratulations sent on her 80th birthday.) Alastair’s eighth-floor suite is roomier and more masculine, with grey and brown chairs that would suit a boardroom, and a framed note from Katharine Hepburn. (He met her when Jean treated her for an ophthalmological condition and she wrote Jean, “Very handsome husband!”) Everything is immaculate and comfortable, but designed to be reassuring rather than impressive.

Somehow that fits with the whole Botox founding legend, which is low-key, even familial. In 1987, Alastair was a dermatologist who divided his practice between surgery for skin cancer and cosmetic dermatology. He shared his office with Jean, an ophthalmologist who treated pediatric disorders as well as adult conditions such as blepharospasm. An uncontrollable blinking and spasming of the eye and surrounding area, blepharospasm was treated with injections of a dilute solution of botulinum toxin, which temporarily paralyzes the relevant muscles. (Although botulinum, the source of botulism, is the most acutely toxic substance known, its ophthalmological use, in minute quantities, had been established several years before.) One day, in Jean’s account, one of her blepharospasm patients became irate that her forehead was not being injected. But your forehead isn’t spasming, Jean responded, and asked why she cared. Because when you inject my forehead, the patient said, my wrinkles go away.

At dinner that night, Jean mentioned the woman’s reaction to Alastair. He and his dermatology patients were frustrated in their attempt to erase vertical frown lines between the eyebrows, known to doctors as glabellar lines—the fillers available at the time didn’t last long and could be painful. But dinner in those days—their sons were then aged six, eight, and nine—was not conducive to concentration, and Alastair remembers, “The comment went straight over my head.”

Next day, Jean talked their receptionist, Cathy Bickerton, into being the first guinea pig for the cosmetic use of botulinum toxin. Once Alastair saw the frownless Bickerton, he needed no persuasion. “I had the patients,” he says, summing up what would become one of the most successful symbioses in late-20th-century cosmetic medicine, “and Jean had the toxin.”

Both expected the world to embrace their discovery. Instead, says Jean, the typical reaction was “You want to inject what into my wrinkles?” At this point, Jean injected herself, whence her famous boast that she hasn’t frowned since 1987. When they presented their results at the American Society for Dermatologic Surgery meeting in Orlando in 1991, she remembers, medical friends told them it was “a crazy idea that’s going nowhere.” They continued conducting clinical trials, although it was difficult to find willing patients, and presenting their findings at dermatology meetings, watching their audience size grow from small to medium.

The snowball effect started in 1993, when three doctors in the audience at the American Academy of Dermatology had actually used Botox, as it was now called. As Botox swept the world, Jean qualified as a cosmetic surgeon; she now does mostly head and neck procedures, and treats very few ophthalmological patients. Her husband says her transformation has been so complete that, in a group of dermatologists, “they forget she’s not one of us.” He stopped doing cancer surgery, and now does full-body liposuction as well as head and neck cosmetic procedures. Botox was, as Jean says, “a three-year overnight success story.”

WEARING SLIM BLACK pants and a tiered purple vest over a black blouse, Dr. Jean Carruthers has mildly spiky hair and perfect red nails. She leads me into her bright corner office. I study the pictures of her three sons—an architect in New York City, a neurology resident in Boston, and a business student in Toronto—while she calls a restaurant and arranges for “a bottle of Dom” to be delivered to a birthday celebration that weekend that she and Alastair can’t attend. As she dictates warm wishes, I remember the last time I saw her, about 30 years ago.

My daughter, then six, had an optical problem, and we were referred to a young pediatric ophthalmologist in a dowdy office on Commercial Drive. I remember Carruthers as taller and bigger than she is now, English (or so I thought), and not a woman who paid much attention to fashion. I would never have recognized her in this petite, chic woman, although I do recognize the light, rapid voice and the mid-Atlantic accent. I also recall that she had a nice, uncondescending way with my daughter, and that her explanations to me were models of clarity.

No doubt she was already a rather unusual combination, a maternal super-achiever. She traces her “deep desire to nurture,” as she puts it, to her childhood dog, to the family’s horses, to the caring environment her parents produced. Whatever its source, it’s still in evidence: she hugs her staff hello and goodbye daily, sends her patients birthday cards, brings bagels for medical students who shadow her, loves to cook and entertain, hosts a Thanksgiving dinner for “waifs and strays.”

The achiever part is not hard to explain. She was born Jean Elliott in Brandon, Manitoba, to two English doctors who had immigrated after World War Two. When her mother, a GP, decided to do a year’s training in England to become a radiologist, she took her two young daughters with her. Jean found school in England so demanding that when she returned to Canada, she was advanced a year, into Grade 4. The English sojourn, she says, was a turning point, giving her a taste for striving that has stayed with her. At 16 she went into honours chemistry at UBC, and she remained there for medical school.

After graduation in 1971, she wanted to stay at UBC for an ophthalmology residency, but female surgeons were rare and she was given the distinct impression that her application would not be particularly welcome. In any case, by then she had met an English medical student who was doing an internship at Vancouver General. Both Carruthers agree that Jean is the decisive one in the couple; Alastair tends to ruminate. She demonstrated this the night they met at a UBC mixer and spent two hours talking. At the end of the evening, Alastair said they should have dinner sometime. Jean answered immediately, “That would be nice. When?” That was the moment, he says, that captured him.

Born in Cheshire in 1945, Alastair was also the child of a doctor father; his mother was a teacher. He and Jean went to England for their residencies and married in the chapel of Brasenose, Alastair’s Oxford college, in 1973. Jean became one of the first women to work at Moorfields, England’s premier eye hospital, and Alastair had a prestigious appointment at Hammersmith Hospital. They might have stayed in London’s stimulating medical atmosphere permanently, but consultants there worked until 9 or 10 at night. They wanted children, and Vancouver promised a more balanced life. “We gave up the academic excellence of London for the whole family thing,” Alastair says, “and yet I think we’ve managed to do quite a lot.”

An understatement. Before Botox, the Carruthers had each already accumulated a career’s worth of laurels. Since their concentration on cosmetic medicine, their hefty résumés now include more than 100 new articles in peer-reviewed medical journals, 60 book chapters, and five textbooks. Travelling the world, they give about 30 talks a year, to dermatologists, and cosmetic and plastic surgeons. The Carruthers’ kingdom includes a research institute (in the same building as their offices) that coordinates their studies on new products and procedures. (A recent one, funded by the pharmaceutical company Allergan, investigated the eyelash-growing potential of the eyedrops used to treat glaucoma.) All told, they employ about 10 people—nurses, researchers, administrators, patient-care coordinators. People often ask them why they maintain separate offices, and Jean says, “Because we prefer to stay married.” It goes back to their differing styles and speeds, Jean full of drive and Alastair more reflective. “It works out fine at home,” Jean says, “but not in the office.”

Cosmetic medicine demands a personal touch. Sydney, one of Alastair’s few male patients, praises his literal touch: “He’s not fussing—it’s precise and confident and quick and it’s over. As a makeup artist, I know what it feels like when someone is insecure—you can feel it in their hands. You don’t get that from Alastair.”

Making the procedures as painless as possible is another part of the job, and the Carruthers use topical anesthetics, dental blocks or needles inside the mouth to dull the nerves, and a medical massager designed to prevent the brain from feeling pain. Jean plays classical music, and talks nonstop to distract the patient; her nurses, two of whom worked in obstetrics, are available for hand-holding.

It all helps to ensure return visits. If you’ve kept a patient comfortable while fixing one thing, Jean says, “something else starts to bother them.” On the follow-up visit after a procedure, she hears new comments about lips or neck or cheeks that need attention. The doctor-patient bond in the cosmetic world, she says, lasts 30 to 40 years: “We’re talking about family.” It’s such an intimate relationship that getting a locum in is impossible. And when a patient absents herself for a while, the doctor is sympathetic: some patients are struggling with aging parents and have no time for themselves, Jean says, while others are spacing out some of the larger procedures because of the recession. The Carruthers’ staff are crucial to this bond, and each has a coordinator of patient care. Jean’s is Barbara Kelly, Miss Canada of 1967; when workaholic patients have an early-morning procedure, Kelly covers any bruises with professional makeup, and the women are at their desks by the start of the business day.

Jean says admiringly that the staff all look like “after pictures,” a reference to the before-and-after photos they take for their records. Does that mean the young beauties at the clinic, all helpful and efficient—? She answers my question before I finish it: “It’s important that all of us in the office are…I’m going to say ‘users.’ ” When she interviews a job applicant, she’s careful to get a sense of how open the person is to the idea, asking if she’s ever had cosmetic work or considered it. “What message does it give if Christa can say, ‘Oh, I’ve done crow’s-feet and frowns’?” Staff are treated for free, since it’s to the Carruthers’ benefit if everyone in the office not only looks good but is a source of reassurance.

Campsall, a friendly, statuesque brunette, agrees that it’s much easier for her to put a patient at ease now that she’s had Botox and Restylane tissue fillers. When she started managing the clinic seven years ago she was only 32, and the other staff would tease her, reminding Jean, “Christa’s still a Botox virgin.” She hadn’t been there long before she volunteered to be injected, to soften her “really strong frown,” her crow’s-feet, and her smile lines. She’s had her lips puffed up a few times, too. A Botox virgin myself, I’m surprised—outside of Los Angeles, Miami, pockets of Manhattan, and the middle-class suburbs of Latin America, I thought you waited until you were middle-aged before starting these procedures. Campsall shrugs. Her husband was a little disapproving when she began treatments, she says, but he’s gotten used to his unlined wife and now occasionally asks her if it isn’t time for another round. “There is a certain look” about the staff, she admits, adding that free work is a perk—“I’ve had thousands of dollars of treatments.”

Jean Carruthers is too canny not to understand that she herself is the main poster girl for their office. She’s matter-of-fact about the procedures she’s had: a complete face-lift 10 years ago, lid lifts, Botox, fillers (“I lost 30 pounds five years ago”), Thermage, and intense-pulse light treatments. Most cosmetic procedures aren’t permanent: gradually, gravity will relax or undermine (depending on your point of view) a face-lift; Botox and fillers eventually dissolve. So perhaps I saw her at the tail end of some procedures, but I liked her face. True, it has the very slightly masked or veiled effect that cosmetic work can produce, but it has enough subtle creases that it looks appropriately lived-in for an attractive woman of 61.

She’s also matter-of-fact about costs. Botox runs $16 a unit and most people require 30 units, close to $500. Restylane, one of the best-known fillers, used for lip augmentation and for injection into wrinkles and facial folds, costs $600 a syringe (one millilitre); most patients use three or four syringes. Botox and the fillers, as well as the newer thermal treatments, all need to be repeated, sometimes every three or six months. Jean tells her patients, “Think of a nice handbag or several manicures.”

When I ask her if she thinks of Botox as a watershed in her career, or if she sees the last 35 years as a continuum, her answer is typically savvy. It’s a continuum, she says, because it’s all about the patients. In pediatric ophthalmology, she learned how to win the child’s trust and how to explain things to a child’s parents, so that they could make decisions. Now, the mothers and aunts of her pediatric patients come to her for cosmetic work.

Not surprisingly, she has ready answers for the hard questions about her practice. She sees herself as being in the business of restoring self-esteem, and “there’s no higher calling.” Like it or not, she says, we’re hard-wired to be attracted to beauty. Beautiful people earn more money, and people who look after their appearance have better cardiovascular health and live longer. She’s not interested in transcending the wish to look as good as possible: “Freud used to take people with baggy eyelids and send them to therapy. That’s so negative.” Better to use Botox, which she has called “penicillin for self-esteem.”

Asked if she feels part of a climate that makes people unhappy about aging naturally, she answers, “What is aging naturally?” Then she adds, “It’s a choice. In 2005, I sold my car and I ride a hybrid bike and take the bus and walk—that was a choice. There’s always going to be a spectrum.” She likes the story of a young woman who excoriated her aunt, one of Jean’s patients, for having had Botox. The aunt listened to the lengthy scolding, and responded with two words: “Just wait.”

Cassandra, a patient of Jean’s, equates the procedures she’s had with exercising and taking her vitamins: “They are part of my wellness package, and psychological wellness is not to be underestimated.” She agrees there may be too much pressure to look young, but on the other hand it’s better for a woman who’s gotten “kicked to the curb in a divorce” to be able to feel good about herself. When I ask if she thinks cosmetic work could help that woman, she widens her eyes in a “Duh!” look. A “workaholic professional,” Cassandra has a pleasant, unlined face and sunny blond hair cut in a pageboy. Had she not told me that she’s 56, I would have taken her to be in her late 20s.

Sydney, Alastair’s patient, also in his 50s, rattles off the fillers he’s used. Unlike the unblinkingly descriptive Botox—a contraction of “botulinum toxin”—these newer names shimmer with promise: Radiesse, Evolence, Juvéderm, Dermalive. “I’m plastic from the neck up!” he jokes, but adds, “I just want to maintain the way I was at 35, and I started in time to make that believable. These lips aren’t new; they’re what I had in my 30s.” A professional in what he calls a “youth-obsessed industry,” Sydney is a discriminating user, keeping his horizontal forehead lines because he wants to look expressive. He praises Alastair’s conservative approach: “You’ll never leave his office with dolphin lips.” Last year, to mark their 10-year anniversary, Alastair sent him a bottle of wine.

Most people assume that the Carruthers’ discovery of Botox made them rich. Jean was interested in patenting their idea, but Alastair was not. When he trained in the U.K., he says, “we learned that if you have an idea you give it away.” Jean prevailed, and they consulted a Toronto patent lawyer. He advised them, incorrectly, that it wasn’t patentable. Allergan marketed Botox, and today no one holds the patent, as it’s in the public domain.

These days, Alastair has changed his mind about patenting discoveries, but neither Carruthers seems to spend much time regretting a lost fortune. True, their income has risen significantly now that they are concentrating on cosmetic medicine: they live in Shaughnessy and travel widely, to visit their sons, to bicycle in the Basque country, to see the ruins in Turkey. Alastair says that after 30 years of doing what he calls “straight medicine,” he’s paid his dues: “I gave society back what it gave me in education. If I’d started out doing cosmetic medicine right after medical school, I’d feel less proud.”

Are some noncosmetic doctors critical of his career shift? “That I used to save lives, and now I get rid of wrinkles?” He nods. Apparently he’s made his peace with that. He prefers thinking about all the research he and Jean have done to make cosmetic medicine “academically respectable.” When I ask him about being part of a sensibility that pushes people to try to stay young forever, he pauses. Finally, he says, “I think my job is to help people to be themselves.” He tells a story of a psychologist, in the early days of Botox, who accused the Carruthers of giving everyone the same expressionless McLook. “I felt bad for about two weeks until I realized that he was totally wrong—we were allowing people to express themselves.” Patients do come in with pictures of film stars’ lips, he says, but he refuses to turn them into someone else.

Musing about people’s negative attitudes to cosmetic medicine, he says, “Where do you draw the line between wanting to look your best and something that’s too extreme? Right now, for example, I’m looking at Katherine…”

For a split second, I wonder if he’s going to point out the many ways his procedures could improve me. But he’s far too smart—and probably too much a gentleman. “I’m looking at Katherine,” he goes on, “and I notice that she has highlights in her hair. Where do you draw the line between normal grooming and something else?”

It’s a good question. For me, a potent but unstable brew of warmed-over feminism (why are 90 percent of the Carruthers’ patients women, while we admire men’s seamed and furrowed faces?), egalitarianism (why should the well-off be able to buy the semblance of youth when the poor cannot?), nostalgia (can’t we turn the clock back to the days when people believed there was beauty at every age?), and—maybe most of all—needle-phobia has me drawing the line well before anything that involves injections. As for Alastair himself, he’s had his frown lines and underarms Botoxed, and that’s it. Although “it hurts like hell,” having his underarms done means that he doesn’t sweat while speaking in public. He injects the armpits of about 10 percent of his patients, including many teenagers, for that purpose.

Where’s all this leading? “The Holy Grail,” says Alastair, “is skin tightening and in a simple, safe, effective manner.” He expects to see a Botox cream before too long, and is bullish about the long, thick eyelashes produced by the drops for glaucoma. Jean also sees good things on the horizon—new neurotoxins will give Botox a run for its money, she believes, and fillers will be developed that don’t just fill in cracks but encourage skin tightening. Also, Thermage will get better at shrinking skin.

In their 60s, the Carruthers remain awesomely vigorous. They’re up by 5 a.m. to exercise in their home gym, and they’ve taken up golf and bicycling. Alastair is an enophile who relishes his post as the Grand Pilier of the Canadian Confrérie des Chevaliers du Tastevin, a French organization that promotes the wines of Burgundy. But the promise of new developments entices them more than retirement. Jean compares her vantage point on cosmetic medicine to that of Cosimo de’ Medici, the Renaissance founder of a political dynasty. She can’t imagine retiring: “I’m having too much fun.” Her patient Cassandra shakes her head, disbelieving and even alarmed at the thought of the Carruthers closingup shop: “The good work they do for their patients, they should work until they’re 110.”