#355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance | Tanuj Nakra, M.D. & Suzan Obagi, M.D.

Peter Attia discusses the visible signs of facial aging that he has personally experienced over the last decade. He's joined by experts Suzan Obagi and Tanuj Nakra who explore the underlying factors contributing to these changes.

Facial Aging Involves Skin, Volume, and Structural Changes

Facial Fat and Bone Loss Leads To Aging Signs

Suzan Obagi explains that aging causes atrophy in the facial fat compartments, leading to a loss of volume. This means there’s less padding between the skin and the muscles and bones beneath, which can lead to the skin hanging more loosely. She also discusses how the bone structure changes with age, noting how the openings around the eyes can become wider and the cheekbones and jawline less defined.

Tanuj Nakra adds that as people lose facial volume due to fat atrophy and receding bone structures, ligaments such as the osteocutaneous ligamentous network of the face pull on the skin, causing deep lines and a more skeletal appearance. He points out that there are three basic changes that occur with aging: skin changes, volume changes, gravitational changes, and bone structural foundational changes. These all contribute to the visible signs of aging, with de-volumization of the fat pockets and increasingly visible bone structure.

Hormonal Changes Accelerate Structural Changes in Women

Obagi elaborates on how hormonal factors, particularly in women, lead to accelerated bone loss and facial aging. This is often noticeable by the early 40s, with women typically experiencing rapid aging in terms of facial structure from 50 to 70 years old. She points out that there is significant atrophy in the mandible, which contributes to complaints about loose neck skin. Attia and Obagi delve into how estrogen levels in women affect bone health and discuss the potential benefits of hormone replacement therapy in maintaining facial bone structure.

Sun Exposure and Stress Worsen Skin Aging

Nakra and Obagi mention that lifestyle factors, including stress and sun exposure, clearly affect the aging process. Nakra compares two patients, highlighting that one who has led a more stressful life with significant sun exposure looks older than her age. Obagi also discusses the increased rates of skin cancer, including melanoma, and points out that while many people claim to use sunscreen, chemical sunscreens can degrade quickly. These sunscreens, while blocking ...

Experts discuss the complexities of beauty standards and the influence of social media on aesthetic perceptions, specifically focusing on the impact on youth and the psychological implications of seeking invasive treatments.

Social Media Warps Cultural Beauty Standards and "Ideal" Facial Perceptions

Tanuj Nakra and Suzan Obagi outline the shift in beauty standards over time, with Nakra noting the historical limitation to the local gene pool compared to the broad array mediated through social media. Obagi contrasts today's social media landscape with the limited exposure of beauty trends 25 years ago, citing the influence of a well-known California family on current beauty trends.

Filtered Images Create Unrealistic Expectations, Especially For Youth

Social media's prevalence of filtered images and "subconscious posing" creates unrealistic expectations for symmetry and proportion. Nakra explains that influencers often promote exaggerated beauty standards, such as larger lips and eyes, which are becoming normalized. In Northeast Asia, surgeries to widen eyes and the use of lip fillers are attributed to the influence of social media. Obagi refers to a phenomenon termed "social media dysmorphism," where patients wish to resemble the filtered versions of themselves, further amplified by teenagers requesting enhancements such as fillers and neuromodulators.

Peer and Beauty Pressures May Drive Teens to Seek Invasive Procedures

There is an implicit concern that young individuals are under pressure to conform to social media-influenced beauty standards. Attia and Nakra highlight the trend of teenagers being exposed to exaggerated forms of beauty which may drive them to seek invasive procedures. Obagi acknowledges the potential harm and regret that can result from drastic body modifications. Nakra posits that societal influences, or "beauty pressures," begin affec ...

Experts Peter Attia, Suzan Obagi, and Tanuj Nakra explore the realm of skincare and aesthetic procedures, emphasizing the significance of sunscreen, the role of retinoids in anti-aging, and the various non-invasive and surgical options available.

Sunscreen Is the Foundation of Skincare, With Mineral-Based Preferred Over Chemical Varieties

Both Attia and Obagi agree that sunscreen is essential for protecting against skin damage, with Obagi advocating for mineral sunscreens over chemical ones. She cites concerns about chemical sunscreens containing hormone disruptors, while studies have shown chemicals like avobenzone and oxybenzone can spike after sunscreen application and have potential links to infertility. Mineral sunscreens are recommended due to their ability to protect against a wider spectrum of light, and their importance is underlined with morning routines that should begin with their application after facial cleansing and serum.

Sunscreen Guards Against Uv Damage to Skin, Collagen, Elastin

Sunscreen's effectiveness is critical in guarding against UV damage which contributes to the degeneration of vital proteins like collagen and elastin. Consistent use can slow the signs of facial aging. Obagi further explains that including the under-eye and neck area in sunscreen application is crucial due to the skin's tendency to wrinkle and age faster in these regions.

Sunscreen Slows Facial Aging Signs

The podcast references a four-year Australian study showing regular sunscreen users exhibited fewer signs of aging. The application should be frequent enough to avert damage from strong sunlight, as some high SPF sunscreens can become deactivated within an hour in intense sun.

Retinoids: Essential for Anti-Aging in Various Skin Types and Sensitivities

The evening skincare regimen mentioned in the podcast includes retinoid acid for its anti-inflammatory properties and its ability to build collagen and elastin. Retinoids are championed by Obagi as the next level of prevention after sunscreen and are highlighted for their role in skin health, enhancing collagen production, normalizing cell turnover, and improving skin texture and appearance.

Retinoids Enhance Collagen and Normalize Cell Turnover to Improve Skin Texture and Appearance

Retinoids come in various forms, from retinol to retinoic acid, and their role in signaling fibroblasts to produce collagen is discussed. Their ability to promote uniform cell turnover and repair some DNA damage caused by sun exposure is also noted.

Introduce Retinoid Carefully to Minimize Irritation

To minimize irritation, experts suggest introducing retinoids slowly, starting with less-irritating forms such as retinaldehyde and potentially combining them with over-the-counter hydrocortisone cream. Adjustments in concentration and frequency of use ca ...

When pursuing aesthetic treatments, patients must consider various ethical and practical factors to ensure they receive safe, effective, and appropriate care. The guidance of qualified and ethically motivated providers is essential.

Choosing the Right Provider: Evaluate Qualifications, Experience, and Ethics

Suzan Obagi emphasizes the importance of selecting qualified medical providers for injectables and laser treatments. She includes dermatologists, plastic surgeons, RNs, physician assistants, and well-trained dentists among those capable of performing such procedures.

Board Certification in Specialty, E.G., Oculoplastic Surgery for Eyelids, Is Key Criterion

Tanuj Nakra insists on the importance of a provider having the correct training and board certification in the area relevant to the procedure. Peter Attia discusses the significance of oculoplastic training for procedures like eyelid lifts, indicating a preference for providers who focus solely on facial cosmetic surgery. Additionally, the importance of specialization is highlighted, with a recommendation to choose practitioners who perform a significant number of the desired surgeries, such as at least 25 rhinoplasties or facelifts annually, to ensure proficiency.

Providers Should Demonstrate Excellent Outcomes and Adeptly Manage Complications

Providers must be able to manage complications effectively, a lesson underscored by Nakra’s experiences with corrective surgeries post-complications. Both Nakra and Suzan Obagi highlight the responsibility providers have to show before and after photos, discuss their complication rates, and explain how often they perform specific procedures. Suzan Obagi stresses the importance of physicians overseeing treatments and being prepared to manage any complications that may arise, while Nakra warns against disfiguring situations resulting from improperly selected procedures or execution.

Providers Should Adopt a Comprehensive, Patient-Specific Approach, Addressing all Concerns, Not Just a Narrow Focus

Suzan Obagi speaks to the need for practitioners to adopt a comprehensive approach to aesthetic evaluation and to tailor expectations to individual features. Tanuj Nakra advises against a one-size-fits-all method, instead advocating for treatments suited to each person’s unique anatomical features. He discusses detailed anatomical evaluations that guide his recommendations for procedures, highlighting his consideration of individual anatomy and desired outcomes in devising treatment plans.

Anatomy and Desired Outcomes Guide Provider Recommendations

In assessments, providers such as Obagi and Nakra consider factors beyon ...

Suzan Obagi and Tanuj Nakra analyze the host's facial features, focusing on volume loss, texture changes, and muscle hyperactivity.

Host's Face Shows Volume Loss, Texture Changes, and Muscle Hyperactivity

The experts note common concerns in the host's appearance and suggest non-invasive treatments as solutions.

Under-Eye Hollows, Cheek Volume Loss, Forehead Wrinkles Concerns

Suzan Obagi discusses the host's facial muscle activity, including the onset of platysmal banding, suggesting the use of a neuromodulator or [restricted term] to relax muscles that pull the lower face down. She also suggests adding volume in the malar (cheek) area using a biostimulatory filler to build collagen and improve dermis thickness due to visible buccal fat pad atrophy.

Tanuj Nakra points out the host's volume loss in the mid-face and temporal areas, suggesting that restoring some fullness would be beneficial. He notes that the host's right cheek has experienced an injury, resulting in asymmetry, while volume loss has become apparent in other facial regions, leading to visible changes in the host's facial features.

The team also examines the host's under-eye bags and lines in the eyelids and cheek area, which Nakra states result from the skin's ligaments attaching to the bone, facial volume loss due to fat atrophy, and bones moving backward.

Obagi recommends addressing under-eye hollows and cheek volume loss by refilling lost volume, which could involve procedures that transfer fat from areas such as the abdomen and flanks. She notes the importance of including connective and stromal tissues in these transfers for effectiveness. The addition of PRP (platelet-rich plasma) and nanofat, which contains extra stem cells, to the fat transfer is mentioned as a technique to supplement the fat and ensure more of the tissue effectively takes hold.

The host's bulging fat in the under-eye area is highlighted, a contour unveiled due to volume loss and cheek descent. Nakra and Obagi mention a procedure that could reduce bulk, add volume beneath the eye, and eliminate the visibility of the malar ligament.

As for the host's thinness around his eyes, which makes him look tired, Obagi notes that the host's facial fat pads have atrophied, exposing the orbital rim.

Minimally Invasive Treatment Combos Improve Skin

Obagi references her "five R's of rejuvenation," which emphasize the need to refill lost volume. She notices the host raises his eyebrows frequently, resulting in many forehead wrinkles. This is due in part to hooding on the upper eyelids; as the eyelids touch the eyelashes, signals are sent to the forehead to lift for better vision.

Considering minimally invasive procedures, Obagi suggests using blunt-tipped cannulas for filler injections, leading to significantly less bruising than needles. Comprehensive treatments may include volumizing with fillers or fat grafting to the areas of volume loss.

The Host Expressed Hesitation About Recovery and Co ...