by Michael Schroeder

Looking through a glass wall, Cyndee Angulo drank in the deep azure of the Mediterranean Sea and the distant horizon from a cruise ship spa. The setting was so beautiful she says she could have written a poem right there. Instead, she reclined in her chair and a doctor injected Botox in her forehead and around her eyes to smooth away her wrinkles.

Vacationers like Angulo, wanting to look and feel better, are finding their fix on cruise ships — getting cosmetic injections, whitening their teeth and undergoing acupuncture to relieve pain or stress. They're also resisting the urge to gain weight, joining fitness-themed cruises.

The most popular nonsurgical cosmetic procedure on land, Botox, was rolled out last year on several ships in the Norwegian Cruise Line, the first cruise line to offer the injections. Celebrity, Royal Caribbean and Princess Cruise Lines followed Norwegian's lead.

The wrinkle-reducing injections, which also include dermal fillers, will be done on at least 21 ships by the end of the month, according to Steiner Leisure Limited, which operates the medical spa program for the four cruise lines. This has many scratching their heads, wondering why anyone would want to get Botox on a cruise.

But Glenn Fusfield, executive vice president and chief operating officer for Steiner's maritime division, says all of Steiner's spa services are demand-driven: "If it wasn't something our guests wanted, we wouldn't offer it."

'More adventurous on vacation'

Angulo, for one, found the idea of getting a cosmetic procedure on a cruise appealing.

"Quite frankly, I wanted to come back from my holiday looking refreshed. ... I think [a cruise is] the perfect opportunity to do that," says the Miami resident who traveled on the Celebrity Solstice.

Angulo gets Botox a couple times a year on land, and is one of more than 5,000 cruise ship passengers who has received injections used to reduce the appearance of wrinkles. The cost starts at $300 for Botox and $700 for a filler injection, comparable to what people pay in markets like Miami.

Unlike Angulo, some are getting the injections for the first time.

"People tend to be a little more adventurous on vacation," says Howard Moses, president of The Cruise Authority, a highly rated travel agency in Marietta, Ga. He says cruise lines are devoting more space to spa and fitness centers, some exceeding 20,000 square feet.

Spa services increase revenue, awareness

Spa services are heavily marketed through demonstrations, classes and freebies.

"People are striving to come up with different angles to increase onboard revenue," says Ryan Wahlstrom, the founder and publisher of Cruise Market Watch, which tracks industry trends. He estimates onboard cruise spas generate up to $520 million annually worldwide.

Although only a fraction of that is for procedures such as Botox or acupuncture, the number of medical spa procedures performed is growing. In the first three quarters of 2009, 70,000 people got acupuncture on more than 70 cruise ships with Steiner-operated spas, Fusfield says.

Annmarie Miller, a retired registered nurse from Augusta, Ga., won her first acupuncture treatment in a raffle after attending a class on the therapy on a Royal Caribbean cruise. She'd been in pain from arthritis in her left ankle.

At her appointment, Miller discussed her problems, including frequent heartburn, with a licensed acupuncturist before lying down on the table.

"My first reaction was the needles didn't really hurt," Miller recalls.

Miller felt better after the procedure and her heartburn went away immediately. "It just totally disappeared," she says.

Miller decided to get more treatments when she got home. They cost $60 each — compared to $150 normally charged on the cruise.

"I would not have gotten it on the ship had I not won it in the raffle because it's very expensive," Miller says.

While cost deters some, safety is a concern for others. A poll of Angie's List members found about 90 percent wouldn't consider facial injections, teeth whitening or acupuncture on a cruise ship, many citing safety, others lack of interest.

"I think medical and dental elective procedures should be done on land," says one member, echoing others who wonder what would happen if something went wrong on the high seas. "It's too risky," another member says. "Creepy!" says a third.

Losing weight and getting fit

Pam Pfeffer takes a different approach to looking and feeling better on vacation. Next September, she'll set sail with Richard Simmons, one of about 275 fans expected to join his 29th Cruise to Lose.

"Most people put weight on during a cruise," Simmons says. "This is not that kind of cruise."

Shedding pounds means passing on the midnight buffet, but Pfeffer of Oshkosh, Wis., doesn't mind. Since 1995, she's been on at least 20 cruises with Simmons, dropped 80 pounds and kept it off. Her goal is to lose 40 more.

"This is my time to reconnect with my friends and to just take care of me," Pfeffer says.

Participants develop tools to help them lose weight and stay healthy when they go home, says Simmons, who leads motivational seminars and his signature exercise classes, Sweatin' to the Oldies.

"It's a solid week of humor, love and motivation," says Susan Bohl of Lambertville, Mich., another cruise veteran. Bohl wants to drop 5 pounds to get to her goal weight of 130 pounds.

Danny Roberson, of Winston-Salem, N.C., is an avid runner and enjoys breaking a sweat on cruises, too. He's been on three running-themed cruises, one in New England and Canada, two in Alaska. Each included on- and off-ship running opportunities, on a track on a Holland America ship's deck, a trail in Ketchikan, Alaska, and through the streets and parks of Quebec City.

"The cool thing is you get to run where the locals run," Roberson says.

But running doesn't mean neglecting age-old cruise traditions. "Runners like to eat," he says. "For a lot of us, that's why we run — so we can eat just a little bit more than those who don't."

Who's doing the procedures?

Going a little overboard is, many say, what cruises are all about. "You're in a splurge environment," says Terry Ribb of Redondo Beach, Calif. She's gotten Botox on land and says she can see why someone would consider getting a cosmetic procedure on a cruise ship.

Her father, Chuck Lee, got his teeth whitened on a Carnival cruise. "I was happy with it," says Lee, a retiree who lives in Phoenix. "And my son saw my teeth so he decided to get his done."

Steiner prices teeth whitening on cruise ships at about $200; dentists generally charge more. But it's not dentists or dental hygienists who do the whitening on cruise ships and that's exactly who should be doing the procedures, says Dr. Leslie Seldin, American Dental Association consumer advisor. If done improperly, the peroxide used in the procedure can cause painful burning and damage the gums and teeth, he says.

Steiner uses GO SMiLE, which is more efficient than over-the-counter whitening strips, but not as strong as what's used by dentists, Fusfield says, so it doesn't carry the same risks. He says Steiner doesn't employ any dentists. Steiner's "smile specialists" wear white coats, but Fusfield says they don't position themselves as dentists.

Lee assumed a dentist did his procedure, but based on his overall cruise experience, he still believes he was in good hands.

Steiner officials say protocols are in place for performing all procedures and treatments, and that the company is responsive when issues arise. But legal experts say it would be hard to sue a doctor — many who aren't U.S. residents — or hold a cruise ship legally liable for a spa medical procedure gone awry because of the way laws are structured.

Jim Walker, a cruise law attorney who represents passengers and crew members based in Miami, says of 300 passengers he's represented in medical negligence cases, "We've probably obtained 25 settlements in 10 years. That's not very many."

Relatively few complications are reported from acupuncture, considering millions get it each year (most on land), according to the National Center for Complementary and Alternative Medicine, a component of the National Institutes of Health.

And the FDA says Botox, which carries a black box label, the most severe safety warning, appears safe for cosmetic purposes.

Be sure to check credentials

But at least some doctors caution against doing cosmetic procedures on vacation — land or sea — where there isn't ample opportunity for follow-up to address complications or answer questions in the following weeks or months.

If you plan on having a procedure on a cruise, experts say to always check credentials.

Dan Brown, director of Steiner's Oriental medicine program, says its acupuncturists are all licensed or certified. About 80 percent are recruited from the U.S., with the rest recruited from places, such as the United Kingdom, with similar educational requirements. In treatment rooms, acupuncturists use standard sterilization techniques.

"All the needles we use are one-time disposable," Brown says.

For Botox or other cosmetic injections, it should be a board certified plastic surgeon or dermatologist or another doctor or physician's assistant trained to administer the anti-wrinkle drugs doing the injections, says Dr. Michael Salzhauer, a highly-rated plastic surgeon based in Miami. Also, make sure clinicians only use FDA-approved products.

Serious complications are extremely rare, but Dr. Paul Wigoda, a highly rated plastic surgeon in Fort Lauderdale, Fla., cautions that a bruise from the procedure, which can take days to weeks to heal, could dampen anyone's vacation. "I've had patients [look] like someone punched them in the eye," he says.

Wigoda estimates that 10 to 20 percent bruise from Botox and recommends those patients stay out of the sun or cover the bruise with heavy amounts of sunscreen.

Dr. Brad Herman, medical director for Steiner's maritime division, says bruising is "incredibly unusual and rare." Maybe three or four patients of thousands who've gotten Botox on cruise ships since last year bruised bad enough that they raised concerns, adds the Miami plastic surgeon.

"We follow the same protocols that I use here in my office," says Herman, noting the doctors wear gloves, use only FDA-approved products and practice other standard sterilization techniques.

Physicians from all over the world hired by Steiner go through background checks to verify their training and credentials and get three days of additional training in Miami. The result: "Patients are absolutely thrilled with the immediate improvement," Herman says.

Angulo was certainly pleased. She is friends with Dr. Herman's Miami-based practice partner, which made her more comfortable getting the procedure done on a cruise ship.

She also researched the physician who did the procedure, finding out she's Johns Hopkins University educated, and asked to see Botox in its original package, so she knew the doctor was injecting her with a safe product.

Angulo says she'd have Botox done again on a cruise, even if Herman wasn't presiding over the program. She believes cruise ships have ample motivation to do it right.

"They wouldn't want to have a public relations disaster," she says.