#355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance | Tanuj Nakra, M.D. & Suzan Obagi, M.D.
Drs. Tanuj Nakra and Susan Obagi, leading aesthetic medicine experts, explore facial aging biology, beauty standards, and ethical cosmetic procedures. They provide an evidence-based guide to skin health, covering mineral sunscreens, retinoids, vitamin C, and personalized routines, culminating in a candid facial assessment.
Deep Dive Analysis
15 Topic Outline
Introduction to Aesthetic Medicine Experts
Biological Drivers of Facial Aging: Bone and Fat Loss
Hormonal and Stress Impacts on Facial Appearance
Evolutionary Basis of Beauty and Modern Distortions
Ethical Dilemmas and Teen Cosmetic Procedures
Protecting Skin: Mineral Sunscreens and UV Damage
Core Skincare: Retinoids and Vitamin C Explained
Establishing a Daily Skincare Routine
Comprehensive Approach to Managing Acne
The Aesthetic Consultation: Analyzing Aging Changes
Peter's Facial Analysis and Rejuvenation Strategy
Fat Grafting vs. Dermal Fillers for Volume
Addressing Under-Eye Bags and Eyelid Drooping
Risks, Complications, and Choosing a Cosmetic Surgeon
Skin Resurfacing: Ablative vs. Non-Ablative Options
9 Key Concepts
Facial Fat Compartments
These are unique metabolically compared to body fat and tend to atrophy with age, contributing to a more skeletal appearance. This atrophy occurs even as body fat might accumulate, and can be influenced by factors like weight fluctuations and stress.
Osteocutaneous Ligamentous Network
This refers to the ligaments that attach the skin directly to the underlying bone structure of the face. As facial bone and fat volume diminish with age, these ligaments tug on the skin, leading to the formation of deep lines and wrinkles.
Averageness in Beauty
Research suggests that a composite face created by averaging many individual faces across cultures is often perceived as universally beautiful. This 'averageness' subconsciously connotes healthy genetics from an evolutionary standpoint.
Social Media Dysmorphism
This phenomenon describes individuals seeking cosmetic procedures to achieve an appearance that mimics their filtered or edited images on social media. These images often present unrealistic and exaggerated beauty ideals, leading to potential body image issues and inappropriate requests.
Mineral Sunscreens
These sunscreens utilize zinc oxide and titanium dioxide to create a physical barrier that reflects UV rays. They are generally considered safer and more stable than chemical sunscreens, which absorb UV light but can degrade quickly and potentially cause reactive oxygen species or hormone disruption.
Retinoids
Derived from Vitamin A, retinoids (like retinol, retinaldehyde, and retinoic acid) are crucial for skin health. They work by boosting collagen and elastin production, normalizing melanocyte function for even skin tone, and accelerating skin cell turnover, which helps reduce wrinkles and sun damage.
Topical Vitamin C
Applied to the skin, Vitamin C acts as a potent antioxidant, neutralizing free radicals and repairing oxidative damage. It also plays a vital role in collagen synthesis and helps regulate the tyrosine kinase pathway, leading to a more even and improved skin complexion.
Ablative Skin Resurfacing
These are skin treatments, such as certain lasers or deep chemical peels, that intentionally create a controlled injury to the skin's surface. This deep injury stimulates a significant healing response, leading to substantial collagen production and skin rejuvenation, but requires longer downtime.
Non-Ablative Skin Resurfacing
Unlike ablative treatments, non-ablative procedures (e.g., certain fractional lasers, IPL, BBL) improve skin texture and tone without breaking the skin's surface. They offer milder results and require less downtime, making them suitable for gradual improvements and maintenance.
11 Questions Answered
Facial fat pads are metabolically unique and tend to atrophy with age, unlike body fat. Bone loss in the face is often hormonally driven, especially in women, and is comparable to bone density loss elsewhere in the body.
Chronic stress, often peaking in the 30s and 40s, can accelerate facial volume loss and skin aging, potentially due to its catabolic effect on facial fat and impact on collagen and elastin.
Universal beauty is rooted in facial symmetry, proportion (averageness), and sexual dimorphism (features connoting fertility), which are genetically hardwired.
Social media influencers often promote exaggerated and filtered beauty ideals, leading to a rise in requests for overdone features like larger lips and arched brows, even among teenagers.
Mineral sunscreens (zinc oxide, titanium dioxide) provide a physical barrier against UV rays and are considered safer, as chemical sunscreens may degrade quickly, cause reactive oxygen species, and have potential hormone-disrupting effects.
Retinoids boost collagen and elastin production, normalize melanocyte function for even skin tone, and improve keratinocyte turnover, helping to reduce wrinkles and sun damage.
A recommended routine includes using a gentle, glycerin-based cleanser, applying a high-quality vitamin C or antioxidant serum, and then a retinoid (at night), followed by a moisturizer if needed. Sunscreen is essential in the morning.
The number one rule is to treat acne before it scars, as scars can cause lifelong trauma. Cystic acne, which can scar even without picking, is considered a dermatologic medical emergency and often requires systemic treatment like Accutane or photodynamic therapy.
The five R's are: Relax (overactive muscles), Refill (lost volume), Resurface (skin texture), Re-drape (tighten loose skin), and Renew (ongoing maintenance).
Dark circles are caused by visibility of the orbicularis muscle, shadowing from volume loss, hemosiderin deposition, and hyperpigmentation.
Patients should seek a surgeon with appropriate board certification, extensive experience (e.g., 25+ procedures/year for complex surgeries), a creative and evolving approach to medicine, and a strong ethical compass. They should also feel a good rapport and trust with the physician.
47 Actionable Insights
1. Commit to Daily Skin Routine
Commit to a consistent daily skin routine as a fundamental step towards improving skin health and appearance, even if more advanced procedures are not pursued.
2. Use Mineral Sunscreen Daily
Use mineral sunscreens (zinc oxide or titanium dioxide) daily for superior UV protection, as chemical sunscreens may degrade quickly and cause reactive oxygen species.
3. Incorporate Nightly Retinoid
Incorporate a retinoid (retinol, retinaldehyde, or prescription retinoic acid) into your nightly skincare routine to boost collagen, normalize melanocyte function, and improve skin cell turnover.
4. Apply Antioxidant Serum Twice Daily
Apply an antioxidant serum (like Vitamin C) both in the morning (before sunscreen) and at night (before retinoid) to combat daily environmental damage and aid skin repair.
5. Use Gentle Glycerin Cleanser
Use a gentle, glycerin-based cleanser that doesn’t overly strip the skin’s natural oils, as harsh cleansers can cause inflammation and disrupt the skin’s microbiome.
6. Use Separate Facial Cleanser
Do not use body soap on your face; instead, use a separate facial cleanser to avoid stripping essential oils and causing irritation.
7. Apply Skincare Thinnest to Thickest
When applying skincare products, always go from the thinnest consistency to the thickest (e.g., serum first, then retinoid, then moisturizer) for optimal absorption.
8. Measure Retinoid with Fingertip
Apply a ‘fingertip unit’ (from the tip of your index finger to your DIP joint) of retinoid every night to ensure you’re using the correct amount for efficacy.
9. Apply Retinoid to Eyes/Neck
Apply retinoid to the entire face, including the under-eye area (avoiding direct contact with eyes), once a week on upper eyelids, and 1-2 times a week on the neck to boost collagen and elastin in these thin-skinned areas.
10. Persist with Daily Retinoid Use
If starting retinoic acid, persist with daily use, even through initial irritation, as the skin acclimates within 6-8 weeks, allowing you to reap full benefits.
11. Gradually Introduce Retinoids
If sensitive, start with a milder retinoid (like retinaldehyde) 5 days a week and a stronger one (retinoic acid) 2 days a week, gradually increasing the stronger retinoid as skin acclimates.
12. Mitigate Retinoid Irritation
To avoid retinoid irritation, start 2-3 times a week and gradually increase to nightly use, or mix it with 1% hydrocortisone cream during the initial weeks.
13. Deeply Moisturize Skin Nightly
Apply a deep moisturizer, like Aquaphor (petroleum jelly), nightly to thicken the skin, improve barrier function, and reduce fine lines by increasing hydration.
14. Prioritize Topical Skin Antioxidants
Prioritize topical application of antioxidants for skin health, as the skin’s ability to absorb them directly far exceeds what can be achieved through dietary intake.
15. Invest in Quality Vitamin C
When purchasing Vitamin C serum, be prepared to spend more for higher quality, stable formulations that ensure bioavailability and efficacy, unlike cheaper options that degrade quickly.
16. Treat Acne Early to Prevent Scars
Address acne, especially inflammatory or cystic acne, early and aggressively to prevent permanent scarring, which can cause long-term psychological distress.
17. Avoid Picking At Acne
Avoid picking at acne, as this can worsen inflammation and lead to scarring, especially with inflammatory or pustular lesions.
18. Accutane for Cystic Acne
For cystic acne, consider systemic treatments like Accutane (isotretinoin) or photodynamic therapy, as topical treatments are often ineffective for this severe form of acne.
19. Manage Oily Skin with Accutane
If you have very oily skin, consider a short course (e.g., one month per year) of Accutane (isotretinoin) to reduce oil production, tighten pores, and improve skin texture, as oil can be inflammatory.
20. Manage Stress for Facial Volume
Manage cortisol levels through sleep and stress-reducing lifestyles, as chronic stress can contribute to rapid facial volume loss and skin aging.
21. HRT for Facial Bone Health
Women, especially in their early 40s, should consider hormone replacement therapy (HRT) to help maintain facial bone structure and prevent accelerated aging, particularly in the lower face.
22. Invest in Aesthetic Self-Care Now
Seriously consider investing in aesthetic self-care now, rather than waiting, as proactive measures can prevent more drastic interventions later and align with a healthy longevity lifestyle.
23. Research Aesthetic Procedures Thoroughly
Take ownership of your aesthetic journey by thoroughly researching your anatomy and all available techniques, consulting multiple sources (especially reputable society websites), and avoiding secondhand information.
24. Understand 5 R’s Rejuvenation
Understand the ‘5 R’s of rejuvenation’ (relax muscles, refill volume, resurface skin, redrape tissue, renew/maintain) as a comprehensive framework for addressing facial aging, prioritizing skin health first.
25. Prioritize Home Skincare
Emphasize consistent at-home skincare regimens to maximize results and reduce the need for frequent or extensive in-office aesthetic procedures.
26. Ensure Board-Certified Practitioner
When choosing an aesthetic practitioner, ensure they have proper training and board certification in the specific area of the procedure you are considering.
27. Verify Aesthetic Provider Qualifications
Always verify the qualifications of aesthetic providers and ensure a physician oversees all treatments to mitigate risks and ensure proper management of complications.
28. Choose Experienced Surgeons
For complex procedures like rhinoplasty or facelifts, choose a surgeon who performs at least 25 of those specific procedures per year to ensure adequate experience.
29. Seek Facial Aesthetic Specialists
For facial aesthetic procedures, prioritize specialists who focus primarily on the face and do not perform body cosmetic surgery, as facial surgery requires a distinct skill set.
30. Choose Evolving Aesthetic Practitioners
Select an aesthetic practitioner who is actively involved in advancing the field (e.g., publishing, lecturing, teaching) to ensure they are using the most current and effective techniques.
31. Ask About Complication Rates
Ask potential surgeons about their complication rates and how they manage them, as a willingness to discuss this can indicate skill and experience.
32. Trust Ethical Aesthetic Physicians
Seek physicians who prioritize ethical practice and patient well-being over simply fulfilling every patient request, especially when it involves drastic or unnatural transformations.
33. Beware Aesthetic Financial Incentives
Be cautious when seeking aesthetic treatments, understanding that many providers have substantial financial incentives that can influence their recommendations; research thoroughly.
34. Disregard Social Media Filters
Recognize that social media images are often filtered and posed, and do not use them as realistic beauty standards or goals for aesthetic procedures.
35. Avoid Injectable Overfilling
Be cautious of overfilling with injectables like lip or cheek fillers, as they can last much longer than advertised, distort natural anatomy, and complicate future surgical procedures.
36. Avoid Premature Tissue Tightening
Younger patients (under 40-45) should generally avoid ultrasound or radiofrequency tissue tightening procedures, as they can cause fat atrophy and prematurely age the face.
37. Ensure Correct Procedure & Execution
To minimize the risk of bad cosmetic outcomes, ensure the chosen procedure is appropriate for your specific needs and that the surgeon has the technical skill to perform it correctly.
38. Balance Treatment Aggression/Downtime
When considering skin resurfacing, understand the trade-off between treatment aggression (more aggressive = better results) and downtime (more aggressive = longer recovery), and choose based on your personal tolerance.
39. Stack Light Ablative Treatments
For less downtime, commit to lighter ablative treatments (e.g., erbium laser) once a quarter, as the cumulative effect over time can mimic a single, more aggressive CO2 laser.
40. Combine Non-Ablative Skin Therapies
Consider combining non-ablative therapies, such as a clear and brilliant laser with a light chemical peel, for synergistic effects and cumulative skin improvement with minimal downtime.
41. Choose Peels for Darker Skin
Individuals with darker skin tones (higher Fitzpatrick types) should generally opt for chemical peels over ablative laser resurfacing, as peels offer better depth control and lower risk of permanent pigment problems.
42. Prepare Skin for Laser
If considering ablative laser resurfacing with a darker skin tone, prepare your skin with a regimen to control pigment cells, such as hydroquinone, to reduce the risk of pigment problems.
43. Protect Scars From Sun
Be diligent about staying out of the sun, especially after a skin injury or procedure, to aid healing and minimize scar visibility.
44. Avoid Conflicted Longevity Doctors
Be very careful with longevity doctors who sell both diagnostic tests and proprietary treatments or supplements for the results of those tests, as this creates a conflict of interest.
45. Support Ad-Free Health Content
Become a member of Peter Attia’s podcast/website to support ad-free health and wellness content and gain access to exclusive member-only benefits.
46. Retinoid Next to Toothbrush
Keep your retinoid tube right next to your toothbrush as a visual cue to remember to apply it nightly, especially if you tend to forget.
47. Follow a Daily Skincare Regimen
Commit to a basic daily skincare regimen: AM includes cleanser, antioxidant serum, and mineral sunscreen; PM includes cleanser, antioxidant serum, and retinoid.
9 Key Quotes
Evolutionarily, Mother Nature is not helping us with our appearance. Our appearance was supposed to carry us through until about 20 or 25.
Tanuj Nakra
The apparent genetic pool of faces that we're looking at has exponentially blown up into this very strange world that we're living in in 2025 compared to where our evolutionary biology has taken us.
Tanuj Nakra
The biggest one that I can talk about is basically that very well-known family in California that has monetized their appearance and set a lot of trends, for better or for worse.
Suzan Obagi
I always look at it akin to managing hypertension or diabetes. We never let the patients determine how much insulin to use or how much antihypertensive medication to take. And I don't think we should let the patients say that they want to transform themselves to some completely different person.
Suzan Obagi
The aesthetic industry is a very, very lucrative industry worldwide, especially in the United States. There's a lot of forces where those that are delivering the science have a vested interest in receiving monetary benefit from what they're pushing out. And that makes things murky.
Tanuj Nakra
If you look at an 18 year old skin under the microscope, it's this thick, beautiful blanket layer of volume because you've got this collagen elastin structure that's holding this whole thing up and is filled with water molecules, have lots of space to move around in and signals going back and forth.
Tanuj Nakra
Melanin is our own antioxidant. It's a very good antioxidant and that's how it works.
Suzan Obagi
The best diet is the one that allows you to maintain energy balance that requires the fewest amounts of neurons to stay on.
Peter Attia
Nobody on the planet has actually ever seen themselves. You've only seen yourself in the mirror or you've seen a photograph of yourself. You actually don't really know what you look like in the flesh.
Tanuj Nakra
4 Protocols
Daily PM Skincare Regimen
Suzan Obagi, Tanuj Nakra- Cleanse face with a gentle, glycerin-based facial cleanser (avoiding harsh body soaps).
- Apply an antioxidant serum (e.g., Vitamin C) to the face.
- Apply a fingertip unit of prescription-strength retinoic acid to the face, including the under-eye area and neck (avoiding direct contact with eyes).
- Optionally, apply a moisturizer, especially for more mature skin or if experiencing dryness.
Daily AM Skincare Regimen
Suzan Obagi, Tanuj Nakra- Cleanse face with a gentle, glycerin-based facial cleanser.
- Apply an antioxidant serum (e.g., Vitamin C) to the face.
- Optionally, apply an alpha hydroxy acid or polyhydroxy acid if pores are clogged or skin is oily.
- Apply a mineral sunscreen with at least SPF 50 to the face and neck.
The Five R's of Rejuvenation
Suzan Obagi- Relax overactive muscles (e.g., with neuromodulators like Botox).
- Refill lost volume (e.g., with fat grafting or dermal fillers).
- Resurface the skin (e.g., with chemical peels or lasers) to improve texture and tone.
- Re-drape loose skin (e.g., with skin tightening devices or surgical facelifts).
- Renew with ongoing maintenance treatments and consistent at-home skincare to preserve results.
Lower Blepharoplasty with Fat Transposition (for Under-Eye Bags)
Tanuj Nakra- Under anesthesia, make a hidden incision behind the eyelid.
- Transpose the bulging eyelid fat pads into a pocket created in front of the cheekbone.
- Improve the skin texture in the region with laser resurfacing or a chemical peel.
- Optionally, inject tetracycline into malar mounds to flatten swelling.