Who Gets Botox on a Boat?

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My first experience with the Norwegian Cruise Line Breakaway ship’s Mandara Spa was heavenly. I walked into the spa shortly after boarding in New York for a cruise to Bermuda, and it smelled like just the right level of disinfectant with a top note of essential oils. Basically the sort of scent that would have me wiping away tears of joy if I were, say, a mom of three looking for actual relaxation on a family vacation. A young woman with flawless black eyeliner topped by an expertly drawn gold wing walked me through the spa facility. Display cases filled with Elemis and Bliss products flanked modern couches in the reception area. On the left was the barbershop for men, on the right, the ladies’ salon.

I was on the cruise for vacation, but at the spa for work. As a beauty reporter, I was drawn in by the mind-bogglingly varied offerings of the on-ship spa, and I’d come to Mandara for research purposes (and maybe a few treatments). In addition to the standard massages, facials, and manicures, many cruise ships (including the one I traveled on) are now offering services from teeth-whitening to acupuncture to injectables like Botox and Restylane. The ship pushes handwashing every few paces to prevent norovirus outbreaks, but you can have your wrinkles frozen by botulism in the spa.

My tour guide led me deeper into the facility, passing into the heat treatment area. For $199, 120 adult passengers (out of as many as 4,000 on the ship) during week-long voyages like mine can buy an unlimited Thermal Suite Cruise Pass and enjoy heated stone loungers, a thalassotherapy pool (i.e. a seawater pool), sauna, and salt room during spa business hours. A newer ship features a snow room, but for the most part, the treatments offered in cruise spas resemble those offered on ships over 100 years ago. Except for the Botox and acupuncture.

In the past, people who were chronically ill with diseases such as tuberculosis would travel to warmer, temperate climates and visit spas to drink and bathe in supposedly healthful water. The role once played by resort or spa towns for the purpose of healing the chronically ill away from home is now, in some sense, taken on by vacation — with all the attempts at healing and recuperating frantically crammed into a brief window.

A promotional video for the thermal suite shows a middle-aged, handsome couple bonding over some non-sexual steam. Printed promotional materials scattered throughout the ship — but stacked especially high in the “Haven” first-class section where I stayed — feature young, glowing skin and taut bodies.

But while many treatments are aimed at lifting faces and purging inches, what I saw onboard and discovered when I talked to other spa patrons was that most passengers are interested in relief from pain, just like the travelers of the past. Particularly with an older crowd (due in part to school being in session, and in part to just being a cruise), relief from daily aches and discomfort drove interest in the spa. While I saw the women’s salon used by two passengers receiving hair treatments (and the men’s not at all), I witnessed lots of people pretty damn excited about pain relief. When I contacted Steiner Transocean to ask about this and other questions such as how medi-spa staff are trained, I didn't receive a reply.

In the lead-up to a spa gift certificate raffle at 5:30 p.m. on the first day of the cruise, fellow vacationers kicked off their sandals and quickly walked across a piece of paper placed on what seemed to be a plastic tray of firm ink. A young Ukrainian man with a shaved head then lifted the sheets of paper to show passengers the pressure points linked to their pain elsewhere in the body. A few mornings later, the same young, bald man was giving a presentation on pain and arthritis to a surprisingly large crowd in the (closed for breakfast) Maltings Beer & Whiskey Bar. As I waited for the bus in St. George, the historic capital of Bermuda, I met a woman walking with a cane who said that she was looking forward to getting back on the ship so she could return to the thermal suite, for which she had purchased the week-long pass.

This isn’t to say that younger people looking for some treat yo’ self action don’t avail themselves of the spa. A group of twentysomething friends were sitting together in the pre-treatment relaxation lounge talking about how they’d need to ask for money for Christmas to pay off their cruise-related credit card bills as they waited to be summoned by their massage therapists. Even on port days the spa hummed with activity, receptionists constantly assisting customers and booking sessions.

The relaxation lounge is where I happened to be less than two hours after our boat glided down the Hudson River, slipped under the Verrazano Bridge, and headed for casino-friendly international waters. My winged tour guide had sold me a “10/20/30” spa package. I’d book three signature spa services and the cheapest would be discounted 10 percent, the middle one 20 percent, and the most expensive ended up being 30 percent off. Given that the base prices were comparable to or less than what I’d spend at home in NYC for similar services, I was game. Automatically added to the price of each was an 18 percent service charge.

It’s important to note that I paid for the trip (I was going on vacation anyway) and Racked and I paid for the spa services. As a journalist, I could have requested comped spa treatments for the sake of this story, but we decided against that. This was a strategic decision made by my editor so I’d have a chance to explore the spa as a normal passenger and avoid seeing a glossed-over, PR-friendly version of what Mandara offers. David Foster Wallace wrote memorably about his treatment on a cruise ship when he was suspected of being an investigative reporter; rather than ending up in long conversations with Mandara staff about my story, I wanted to just relax and enjoy some tax-deductible spa treatments.

I decided to start with a massage ($139), which is the spa equivalent of surf and turf: classic ship offering, difficult to screw up, but not the most exciting. As predictable as Thomas Kinkade prints in the ship art gallery, a mess at the free ice cream bar, and towel animals at turndown.

My massage turned very exciting very fast when I realized that — HOLY SHIT — my massage therapist, who must have been a foot shorter than me, could have extracted any secret I keep using her hands alone. I had selected a bamboo massage in hopes of working out an old tennis injury aggravated by carrying home beauty purchases from my office (I shop a lot, do not judge me, Racked readers). Five minutes into the treatment I asked if my masseuse was using the bamboo already and she laughed, saying it was just her hands. It turns out that bamboo massage tends to be pretty hardcore and favored by men, who I suspect are looking to explore masochism while on vacation. I switched to a vastly gentler hot stone massage, which felt much more vacation.

Before the voyage, I had read a number of forums where former spa workers shared their experiences working for Steiner Transocean in cruise ship Mandara Spas, both positive and negative. Even positive reviews mentioned the importance of upselling customers on spa products for job security and perceived performance.

So here’s the problem with knowing too much about the labor system in which your massage therapist works: Oh god, it’s awkward when the upsell happens. Rather than make my no-shopping intentions clear from the outset, as experienced cruise ship spa fans recommend, I decided to experience it. Mega awks.

At the conclusion of my session, my massage therapist handed me a “timetospa” card with three product recommendations, each product ranging between $63 and $65. If I’d have bought all three, the cost of the products would have exceeded the price of the massage. She said that I should buy at least one product that day for the sake of maintaining the gains made by the treatment. I said that I heard my mom calling me to dinner and ran away after handing over a bigger tip. My regret level? Bead braids on straight hair, done in a tourist trap port.

One treatment down, I had two more to go, and it was time to branch out into non-standard ship offerings. But could I risk the medi-spa? Before the cruise, I considered getting Botox or something else involving an injection for the sake of this story. Yet at 33 and relatively unlined, even the most enthusiastic plastic surgery pushers would be hard-pressed to say I need Botox — unless I plan to audition as a K-pop idol, and even then, my micro fine lines aren’t going to be what keeps me from singing about oppa in a school uniform. I thought about getting it anyway, but that seems just as groan-worthy as “my week as” stunt journalism with the rockiness of a moving ship thrown in. I was still open to the idea until I learned more about the training of medi-spa injectors.

According to one of Steiner Transocean’s medi-spa recruitment sites, doctors administering facial injectables undergo a five-day training course that “includes clinical training on the facial injectables and onboard sales and marketing strategies to manage a successful business onboard.” Medi-spa doctors need to hold a medical degree from a university recognized by the International Medical Education Directory (IMED) and a medical license, as well as have at least two years of clinical experience. According to another Steiner recruitment site, “[t]here is no prior experience in facial injectables required.”

I contacted Dr. Neil Sadick of Sadick Dermatology to hear his thoughts on boat Botox. According to Dr. Sadick, “a five-day clinical training in facial injectables cannot be compared with a four/five-year residency program in dermatology.” He explained: “Apart from lacking intimate knowledge of the facial anatomy in order to deliver satisfactory results, study after study has demonstrated that the majority of complications related with injectable fillers are due to injector technique/inadequate clinical training.”

But what about the common claim that injectables like Botox are extremely safe — even if you don’t end up with perfect results, isn’t it still safe and bound to go away after a few months anyway? “Although cosmetic injections are relatively safe,” wrote Dr. Sadick via email, “they are not without potential side effects, such as allergic reactions, vascular reactions, blindness and low-grade chronic infections…[m]y main concern with performing these injections on a cruise ship is the lack of access to comprehensive medical care; if something goes wrong, timely treatment is of essence.”

I checked in with my travel insurance provider to see if treatment in case of onboard Botox emergencies would be covered. My insurance (certainly not the cheapest company or policy on offer) responded that I’d need to make a claim that could be reviewed by a claims analyst, who would rule on whether my (theoretical) accident would be covered, but the email helpfully included a list of limitations and exclusions. Among them, any loss resulting from non-injury-related dental treatment and “any non-emergency treatment or surgery, routine physical examinations, hearing aids, eyeglasses, or contact lenses.” It’s quite possible that most people who receive spa treatments at sea are not actually covered by their travel insurance — I certainly wasn’t.

Moreover, each time I filled out an appointment intake form with information about my health and needs from the treatment, I also signed a liability release, acknowledgement, and waiver that would protect Steiner Transocean Ltd. et al. The wording of the forms varied, but each required me to acknowledge risks associated with the procedure and limited my right to seek damages. The acupuncture form mentioned that I’d need to bring all claims arising from spa or salon treatments before a court in Miami Dade, Florida (standard practice for the cruise industry), so there is a way to sue for damages in the US despite the ship being registered in the Bahamas and the treatments being administered in international waters or in foreign ports.

Getting Botox at sea, in a sense, is like being in open water.

On the first night of the cruise, I woke at 3 a.m. with the sensation that I was being rocked by a Mesopotamian god who’d like nothing more than to drown me in the black Sargasso Sea. Spray from the ocean reached so high it misted the railing of my balcony on the 15th floor with salt water. I opened the door to the balcony to hear the roaring waves and then stumbled to the bathroom to be ill. For the first time in my life, I was seasick.

Later that day, alone in a too-warm room and an hour and 15 minutes into my 50-minute pain relief acupuncture treatment ($150), I began to strategize how I'd maneuver my new wing made of needles over to the sink without jamming them irreparably into my shoulder — all so I could get ill without creating a mess in the sterile room. I experimentally flexed to see if I could get off the table and felt shooting pain. I looked around for a telephone in the room, but found none. I was stuck until the doctor returned to remove my wing, the ship rocking all the while.

After pulling out my needles, my doctor left me to dress and gather my bearings. Rather than face another awkward post-treatment upsell, I tugged on my clothes and ran off to pay my bill, ultimately crying from frustration, pain, and hormones when I returned to my stateroom. I would have been better off actually buying something at the shipboard art auction.

On our final day in port in Bermuda, I returned to the spa for my final treatment, a teeth-whitening session (GO SMiLE Tooth Whitening Treatment, $149). My technician’s nametag said they were a hairdresser, giving me the chance to experience the past, when barbers handled dentistry. I wasn’t given protective goggles while the light processed my gel, but I was offered information: 23 passengers on the cruise whitened their teeth during the week (this was considered a lot). I walked away with some singed gums and brighter teeth, once again dodging the post-treatment upsell in the most awkward way possible. My teeth look much better, but I should probably get someone with dental experience to do my future treatments to avoid, you know, burning my gums off.

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Before I left the ship, I tried to track down the doctor in charge of giving (and selling) anti-aging injections. At 3:55 p.m. on day six, I slid into a cozy chair at Shakers Martini Lounge with a tall glass of Gosling’s Ginger Beer, hoping to observe the four o’clock “Go Home Looking 10 Years Younger” talk that would focus on facial injectables such as Botox. When the doctor arrived, he looked around the crowded bar, full of friends and couples enjoying afternoon drinks, and proceeded to ask people if they were there for the seminar. No, no, no, they said from behind their cocktails. He looked around for a few minutes in case participants showed up and then left. There was no audience for the talk.