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Wrinkle Reducers

The surprising science behind the lines on our faces. This episode features audio from:

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Today, we look at some of the ways to naturally reduce wrinkles. And, we start with a look at the safety and efficacy of botox injections and facelift surgery.

Anti-aging medicine is one of the fastest growing medical specialties and often targeted at women who are urged to restore their youthful appearance by “any and all available means.” This includes surgery. Ninety-two percent of cosmetic procedures are performed on women––most commonly Botox, fillers, and laser or chemical peel skin resurfacing. But millions in the U.S. undergo cosmetic surgery every year, including hundreds of thousands of facelifts.

There is no consensus on the best facelift technique. None have been shown to be definitively better than others. A systematic review found that most of the studies on the newest techniques were mere case series, one of the lowest levels on the hierarchy of evidence––basically composed of a string of glorified anecdotes.

According to one of the largest and most up-to-date analyses, facelifts are considered relatively safe when performed by a board-certified plastic surgeon, with surgical complications only happening in about 1 in 20 cases––most often hematomas, where blood collects under the skin flaps, or minor infections. Serious infections, like facial necrotizing fasciitis, caused by flesh-eating bacteria, are rare, as is pyoderma gangrenosum, a disfiguring skin-ulcerating autoimmune disease that can be triggered by facelift surgery. Other uncommon consequences include scarring, hair loss, and injuries too gruesome to show. Nerve injuries occur in at most a few percent of cases, but only about 1 in 1,000 procedures may result in permanent facial nerve injury.

About two-thirds of facelifts are performed under general anesthesia, which is associated with a greater risk of complications. The most important way to mediate risk is to refrain from smoking. Smoking can increase the risk of skin flap necrosis, or tissue death, up to twenty-fold. Patients should refrain from smoking at least a month before and a month after surgery. Tempering expectations is also important. Approximately one in three women experience a period of postoperative depression, but this may just be in reaction to the temporary distortion and discoloration of swelling and bruising after surgery.

The most profitable cosmetic procedure is Botox, in the billions, as well as the most common––performed more than four million times a year in the U.S. alone. It all started when a group of surgeons noticed that patients with Bell’s palsy—facial paralysis—didn’t have as many wrinkles. So, what about injecting minute amounts of the nerve-blocking toxin that causes botulism to paralyze a few facial muscles on purpose? And, a multibillion-dollar industry was born. The effect is temporary, typically lasting three to four months, until the body can grow back new nerve terminals.

In response to cases of respiratory failure and death occurring hours or even weeks after injection, in 2009, the FDA mandated a black box warning regarding the potential spread of the toxin resulting in death from swallowing and breathing difficulties occurring hours, days, or weeks after injection. However, most of these complications were tied not to cosmetic uses, but to treating muscle spasms (for example, in cerebral palsy). For wrinkles, only 30 to 60 units of the toxin may be used, compared to an average of about 180 for severe muscle spasms––though still a far cry from the estimated lethal dose of perhaps 3,000 units. (The dose is given in MU, “mouse units,” with one MU being the amount capable of poisoning half of a group of albino mice to death.)

In studies, less than 1 in 2,000 Botox procedures resulted in complications, which can include droopy eyelids, double vision, an asymmetrical smile, or “the Spock,” a devilish curvature of the outer portion of the brow.

Unfortunately, not all such procedures are performed under such controlled conditions. In many states, there is surprisingly little or no regulation as to who can deliver Botox, leading to a rapid increase in injections by nonmedical personnel. In one fiveish-year period, about 30,000 complications allegedly tied to Botox were reported to the FDA––most commonly pain, swelling, and eyelid or eyebrow drooping. But most adverse effects are transient and self-limited.

In our next story, almonds are put to the test in a ​​randomized, controlled trial for facial wrinkles.

After my video on dates blew my mind, showing that eating just a few dates can significantly reduce the duration of labor during childbirth and improve the progression of labor. when I saw that there were randomized controlled trials showing that peanut balls could decrease the length of labor, I didn’t bat an eye, but no, this is the peanut ball they were talking about. But there are some surprising benefits attributed to nuts in randomized controlled trials, like how about a study on the effects of almond consumption on wrinkles? Where’d they even come up with the idea?

Well, population studies have found that healthy diets are associated with less facial wrinkles, like a meat and junk-predominant eating pattern was associated with more wrinkles, whereas a fruit-predominant pattern was associated with fewer wrinkles. In terms of single foods, yellow vegetables and soy appear protective, but wine may make things worse. Their thinking is that it might be the antioxidants in healthy foods decreasing the oxidative stress load, or the anti-inflammatory benefits, or protection from sun damage, or improved collagen production, or better DNA repair. I have videos on most of those topics. The bottom line is that eating healthier may reduce wrinkling, which could actually save lives if people started eating healthier to maintain a more youthful appearance––and get all the chronic disease benefits as a happy side effect.

Other studies have found the same thing, supporting recommendations for more healthy foods like fruits, vegetables, and nuts. Here’s another study that landed on yellow vegetables and greens as well. In this study, a high intake of vegetables, beans, and olive oil appeared to be protective against spots of precancerous sun damage, whereas a high intake of meat and dairy may make things worse. Prunes, apples, and tea seemed particularly good, but this was a cross-sectional study, meaning just a snapshot in time. Maybe people who eat more meat are out barbequing in the sun, or people who eat more prunes just use more sunblock. You can’t know for sure if foods actually affect wrinkling until you put them to the test. But we had no such studies…until now.

Why study almonds? Because it was paid for by the Almond Board, of course. The researchers didn’t know who was in the nut group, though, and who was in the control group, until they were looking at the results. The nut group were given two ounces of nuts a day, like two palmfuls of nuts, and the control group was instead given nut-free snacks to eat instead, like nut-free granola bars or pretzels. Before and after, they got high‐res facial photographs to quantify facial wrinkle depth and severity using a computer‐based photographic analysis. And…boom, the almond group had significantly decreased wrinkle severity compared with the control group by the end of the 16-week study. The paper concludes: “Our study demonstrates that daily almond consumption may reduce wrinkle severity…”

Now, they used a relatively large dose––of two ounces a day––whereas you can get cardioprotective benefits of nuts from even less than a half an ounce. So, who knows, maybe they could have gotten away with using less. The low-dose nut study they referenced, showing a significant drop in LDL cholesterol within six weeks eating just a few almonds a day—10 grams, which is just like eight almonds a day.

That’s the nice thing about healthy foods, they just have good side effects; so, global disease prevention strategies might benefit from emphasizing that a healthy diet is also linked to less facial wrinkling, and maybe vanity will help us prevent a few heart attacks in the bargain.

Finally today, did you know that the skin folding caused by everyday facial expressions etches once-temporary grooves into permanent wrinkles, but only in the context of underlying structural damage.

How are wrinkles formed? Their origin and nature are said to be “notoriously complex,” but current thinking is that wrinkles occur where fault lines develop in aging skin. The process has been compared to an old leather glove (made out of skin, after all) that develops creases at the joints due to repetitive stress. In the face, the repeated flexion may be due to facial expression. An eight-year longitudinal study found that you can predict the pattern of persistent wrinkles by superimposing upon your resting face the expression lines (temporary wrinkles) that form when you smile. Over time, the skin folding caused by everyday facial expressions etches the temporary grooves into permanent wrinkles. See how the smile lines around the eyes at baseline show up as permanent wrinkles eight years later?

Given that wrinkles develop from forehead furrows, and expression lines from frowns and laughter, one dermatology journal review on aging skin offered the tongue-in-unwrinkled-cheek suggestion of “[l]iving alone to minimize the use of facial expressions…” (And while you’re at it you could live “in space to avoid the effects of gravity.”)

However, there is a way to freeze part of your face into an expressionless mask: Botox. In fact, one contraindication to getting Botox is having a job that “necessitate[s] a wide range of facial expressions.” It’s never been formally put to the test, but there was a case report of a pair of identical twins, one of whom who spent tens of thousands of dollars getting Botox treatments across multiple areas on her face a few times each year for 13 years. Compared to her non-regularly injected twin, she ended up with fewer imprinted facial lines.

A paper entitled “Sleep Wrinkles…” tried to make the case that wrinkles may result from the skin distortion from mechanical compression of sleeping on your side. Of course, the primary author also is a partner in a company selling $160 quote-unquote “wrinkle-fighting” pillows. It turns out there does not appear to be any correlation between sleep position preference and the appearance of wrinkles.

Speaking of questionable products, what about topical adhesive “antiwrinkle” pads you paste to your face at night? Product claims include “look up to 10-15 years younger,” declaring a 70 percent reduction in wrinkles. But, when actually put to the test for a month for crow’s feet, forehead, or between-the-eye wrinkles, no objective benefits were reported at all. There did appear to be a placebo effect in that subjectively, the study participants felt the wrinkles looked better, but independent blinded evaluations by facial plastic surgeons of before-and-after pictures showed no significant change.

So, what can we do to prevent wrinkling? Some of it is genetics. For example, having lighter skin color is a predisposing factor. Among light skin tones, Caucasian skin wrinkles more readily than Asian skin, for which aging is more characterized by pigmentation changes, such as freckles, blotchy patches, and liver spots. Among Asian skin types, Chinese women tend to have more wrinkles around their eyes than Japanese women, whereas Thai women tend to wrinkle more in the lower half of their faces.

There are, however, factors we have control over. For example, drier skin has also been found predictive of more persistent wrinkling, suggesting regular use of skin moisturizers may help.

When it comes to wrinkle formation, it takes two to tango. Wrinkles are formed by repetitive creasing of aged skin. Kids can scrunch their faces all they want, because the architecture of their skin has yet to be irreparably damaged. And the lack of creasing is why you don’t have wrinkles on your forearms, no matter how much sun they’ve soaked up. Rather than immobilizing your face with Botox, you can focus on preventing the underlying structural damage that makes your skin susceptible. This involves tobacco avoidance and regular sun protection. What about safeguarding against other kinds of light?

From the Journal of Biomedical Physics and Engineering: “Can Light Emitted from Smartphone Screens and Taking Selfies Cause Premature Aging and Wrinkles?” Human skin cells bathed in the light of iPhones and iPads experienced an 80 to 90 percent increase in free radicals, compared to shielded control cells, suggesting electronic device-generated light “may be harmful to skin.” Nowm on one hand, they positioned the screens unrealistically close—one centimeter—resulting in about 10 times the irradiance, compared to a reading distance of about a foot. On the other hand, the skin cells were only exposed for an unrealistically short time—only an hour. The researchers called for future studies to evaluate the impact of lower, longer doses on skin outcomes such as collagen deposition.

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