Integrating Anti-Aging Initiatives: Medical Procedure Recovery
Stephen Holt, MD
From inception, I have witnessed the growth of the premier Anti-Aging Society, (A4M), due to the meritorious efforts of Dr’s, R. Goldman and R. Klatz. It is gratifying to see the emergence of a multi-disciplinary scientific forum with international influence. Recuperative medicine has evolved with advanced preventive medicine and innovative surgery to define the new science of longevity. Anti-aging medicine has attracted many medical disciplines and there has been much recent integration of esthetic medical procedures that can produce youthful appearances.
The philosophy of the anti-aging movement has focused on gentle and more natural ways to engage in recuperative medicine, using lifestyle change, nutrition and remedies of natural origin. Against this background, one sees new advances in the integration of anti-aging initiatives, such as the combined use of cosmetic surgical procedures with gentle remedies of natural origin. Anti-aging medicine has witnessed major expansion in the practice of plastic surgery, aesthetic surgery and topical laser therapy. These common procedures produce many cases of modest iatrogenic trauma which may be managed by remedies of natural origin.
The objective of this article is to review the evidence-base that exists for the application of homeopathic remedies, dietary supplements or natural topical agents in clinical procedure or recovery from modest trauma, iatrogenic or otherwise.
Nutraceutical Management of Trauma
The use of herbs, botanicals, nutrients, topical natural agents or homeopathic remedies to support wound healing or trauma recovery has emerged as a very important medical intervention in integrative medicine. Many nutrients are reported to have specific activity in the healing of soft tissue wounds. Malnutrition has been known to result in major impairment in wound healing and associated tissue changes that result in swelling or bruising1. The correction of nutritional deficiency in individuals with significant degrees of malnutrition is known to accelerate wound healing2, 3 .
It is not cost effective to investigate the nutritional status of patients undergoing aesthetic procedures by using complex, laboratory investigations. It would seem logical and justifiable in the presence of any suspicion of suboptimal nutrition, to recommend a reasonably intensive and balanced nutritional supplement program prior to any form of elective surgery – at least in the short term. Dietary corrections combined with nutrient supplementation prior to elective surgery may assist in expediting the achievement of good nutritional status.
Claims concerning the benefits of some nutritional supplements in improved wound and soft tissue healings are supported by several controlled clinical observations4- 7. A number of specific nutrients have been defined to play a beneficial role in wound healing in both animal and human experimental studies8. Specific nutrients with these properties include vitamins A, C and E, pantothenic acid, thiamine and minerals including zinc, copper, manganese and others8. Various combinations of specific nutrients have been utilized to study wound healing in animals or humans with variable outcome, but it is notable that a deficiency of essential fatty acids may retard wound healing9.
The use of enteric coated fish oil supplements to provide extra nutritional support with essential omega 3 fatty acids prior to elective surgical procedures has become a focus of recent interest Nutritionally orientated physicians are increasingly using fish oil in enteric coated format to prepare individuals for cosmetic surgical intervention, because many such individuals may have Metabolic Syndrome X10. Metabolic Syndrome X is most often associated with an overweight status and insulin resistance10. Fish oil (EPA) contains the active omega 3 fatty acid, eicosapentanoic acid (EPA), which has desirable anti-inflammatory and insulin sensitizing properties.
Common herbs, botanicals or their derivatives with documented, but variable benefits on wound healing include bromelain11, Papain(Carica papaya)12, Centella asiatica (Gotu Kola)13, Aloe Vera (most often used topically)14, Chamomile (Matricaria chamomilla, most often used topically)15, mixed species of Echinacea and Procyanidolic Oligomers (OPCs or PCOs)16,17. The importance of the use of selected enzymes in wound healing is apparent in studies that show accelerated or enhanced healing functions following surgery or reduction in inflammatory responses to trauma or surgical interventions18, 19. It is believed that the enzymes, referred to for use in trauma, have beneficial systemic effects, not merely digestive-enhancing effects 18-24
Cascades of Healing and Nutrition
The complexity of the physiological cascade of events involved in soft tissue healing has led to the proposal that multiple substances can be formulated together to provide a more effective, synergistic way of achieving desired outcomes. Pivotal, well controlled studies of combined nutrients and dietary supplements that have shown benefit in several measured parameters of wound healing are documented in medical literature4, 8.
The variable combination of proteolytic enzymes, calcium and antioxidants have proven quite valuable in soft tissue healing in clinical trials4. Preferred antioxidant incorporations in dietary supplements include vitamin C and vitamin C helpers such as Rutin and OPCs in grape seed or other fruit extracts4, 8. In a randomized, crossover, placebo-controlled trial, such combinations have proven valuable in accelerating soft tissue wound healing 4. In fact, recovery time with these kinds of supplement regimens, compared with placebo, may result in accelerated healing by a factor of approximately 17%, with full healing in about two weeks compared with placebo. (Media@plasticsurgery.org)
Arnica Montana (Leopard’s Bane, Mountain Snuff, Mountain Tobacco, Wolf’s Bane, Wolfbane)
Arnica montana is an endangered flowering herb found in elevated regions of Europe and Asia. In ethno-botanical literature, Arnica has been used most often in tinctures, pills and topical delivery systems to relieve traumatic injuries, pain, bruising, sore muscles and lacerations. Because of known toxicity, Arnica is not recommended to be taken as a dietary supplement in whole or extracted form25.
The toxicity of Arnica montana used in whole or extract form in oral agents has included reports of heart damage, irritation of oral mucous membranes, upper gastrointestinal irritation and sudden increases in blood pressure25-27. These adverse effects have not been found or described or observed with the use of homeopathic Arnica preparations27. The irritation of mucous membranes induced by whole Arnica taken orally may be due to its presence of several sesquiterpeme lactones25.
German Commission E recommendations for the use of Arnica include only topical application or only its use in homeopathic remedies27. While few reported deaths have been related to the use of whole Arnica, one active component of whole or extracted forms of this plant (helenalin) can interact with many body enzyme systems in a manner that creates risks that exceed possible benefits.25
Topical Arnica montana preparations are advised to be used only when less than 15% of Arnica oil or less than 25% of Arnica tincture is present. It is reported that higher concentrations lead to skin irritation, especially when used for prolonged periods of time. Large amounts of Arnica taken by mouth in whole form may cause death and the use of Arnica on “raw skin” or open wounds may cause blistering and scarring, with or without the development of systemic toxicity and allergic dermatitis. There are no described drug interactions between Arnica montana in topical or oral forms. Homeopathic Arnica does not appear to alter various tests of blood coagulation in healthy volunteers (noted at www.herbmed.org). There has been much confusion about the potential toxicity of Arnica Montana and I stress that homeopathic preparations of Arnica montana are considered to be quite safe and variably effective when taken by mouth. Information available about the toxicity of Arnica montana is summarized at www.drugdigest.org.
While ointments, gels and other topical forms of Arnica can be used with variable effectiveness for trauma and soft tissue healing, there may be problems with the use of high concentrations of Arnica in the presence of open wounds or damaged skin. Arnica Montana belongs to the Compositae family of plants, which are notorious for producing allergic skin reactions or eczematous lesions with chronic use.
In one recent placebo-controlled trial evaluating the effects of topical Arnica on the resolution of laser-induced bruising after the treatment of telangiectasias, no real benefits were observed26, but these results may not be generalized to other circumstances where beneficial effects of topical Arnica have been described in postoperative recovery26. There has been much recent interest in the study of homeopathic forms of Arnica that can be used in oral preparations for enhancing wound healing, treatment of bruises or contusions, dislocated bones, hematomas, phlebitis, post traumatic or post surgical edema and benign musculoskeletal disorders 28-32.
Homeopathic Arnica Montana
In the September 15, 2003 edition of The Journal of Plastic and Reconstructive Surgery, two randomized placebo-controlled clinical trials compared Arnica Montana in a homeopathic strength of 30X with placebo and reported overall less bruising and less swelling in the postoperative period following plastic surgery. In one study of homeopathic Arnica montana examining the reduction of bruising after facelift surgery, Seeley and Maas32 reported 24% more bruising following facelift surgery in the placebo group which took 50% longer to recover than the group treated with the homeopathic Arnica. The results were defined from computer-imaging programs to analyze bruising and other parameters in the postoperative period of these patients. Overall, the results were found to be statistically significant with benefits for homeopathic Arnica noted on Day 1 and Day 7 in the postoperative period32.
In studies to examine the reduction of bruising and swelling following liposuction, homeopathic Arnica montana was studied in a randomized, prospective, double-blind, placebo-controlled trial. These studies reported at the American Society of Aesthetic Plastic Surgery, (ASAPS, 2002) shared that homeopathic Arnica Montana reduced bruising and swelling following liposuction surgery in female patients, in the age range of 18-45 years. The results of this study were derived from opinions of independent plastic surgeons who were asked to rank the sets of photos collected following liposuction. In these studies, there was no substantial difference in the volume of fat removed from the 29 patients who were studied33. The beneficial results of homeopathic Arnica in the reduction of bruising and swelling showed statistically significant improvement with the use of homeopathic Arnica when compared with placebo, under the conditions of this study33.
The Data Committee of the ASPAS has been reported to have reviewed the worldwide medical literature regarding the safety and efficacy of homeopathic Arnica. These committee members report the finding of studies with homeopathic Arnica that meet usual and customary standards of medical research. It is notable that the strength of Arnica that appeared to be optimal in the review of some studies by the data committee of the ASPAS was a homeopathic strength of 30X.
Bromelain: A Key Approach to Accelerated Healing
A natural mainstay for assisting in soft tissue healing, bruising and swelling is the use of proteolytic enzymes, such as bromelain and papain4, 8, 11, 12. Taussig and Batkin20 describe the introduction of bromelain as a valuable medicinal treatment of trauma in the mid 1950s. These authors20 comment on the existence of more than 400 scientific papers that describe, variably, the overall benefits of the therapeutic use of this enzyme in reduction of inflammation, rehabilitation of sports injuries and prevention of soft tissue swelling and bruising following trauma or surgery. The aggregate scientific data on bromelain provide strong support for the use of bromelain in any dietary supplement or remedy of natural origin that may be used to provide nutritional support to enhance general healing 11,21- 24.
Bromelain deserves considerable renaissance of interest in medical practice as a very safe and effective way of managing swelling, bruising and inflammation for traumatic or postoperative soft tissue damage. While high dosages of bromelain may inhibit clotting function, few documentations of this theoretical adverse effect exist and high enzymatic activity is preferred to result in bioactivity in bromelain preparations, of the order of about 100mg of bromelain with around 2400 GDU (Gelatin Digestive Units). Pharmaceutical preparations of bromelain were made with special enteric coating many years ago, but these useful “drugs” have not remained very popular. If high enzymatic activity of bromelain is utilized, enteric coating of dietary supplements containing this enzyme may not be necessary.
Natural Protocol for Clinical Procedure and Recovery from Modest Trauma
Practitioners of Anti-Aging medicine play a major role in the expanding areas of medical spa treatments and aesthetic surgical procedures. Women’s health clinics have converted significant amount of clinical practice space and time to medical aesthetics, including popular procedures such as Botox injections, lip puffing and eradication of facial lines by the injection of fillers or stimulants of dermal collagen production (e.g. Restolin®). Overall, the use of modestly invasive surgical or medical practices for cosmetic reasons presents a newfound need, in many clinical contexts, for the natural management of postoperative trauma induced by such procedures.
It appears cost-effective and evidence-based to provide general nutritional support, at least in the short-term, for a person prior to an elective surgical procedure, under the circumstances discussed in this article. Modern nutraceutical technology would support the use of a wide range of whole food nutrients in berries, greens, vegetable, fruit, vitamin and mineral enriched powders. These combinations of whole food powders have multifunctional micronutrients. In addition, it seems logical to consider supplementing the patient with enteric coated fish oil to provide optimal essential fatty acid ratios for good healing and other general health benefits.
The evidence base for the use of homeopathic Arnica montana in assisting soft tissue and wound healing seems to be increasing, with evidence that the dosage of homeopathic Arnica in 30X strength. Further research is required with homeopathic Arnica montana to define the extent of the portability of its benefits. While homeopathic Arnica appears to be valuable, safe and efficacious in certain circumstances, it seems quite logical that homeopathic Arnica can be combined with other specific nutritional, herbal or botanical supplements that have an evidence base for improving post procedure healing.
This review of medical literature implies that a corroborative evidence-base may support combinations of homeopathic Arnica montana with bromelain, grape seed extract (OPCs), vitamin C and vitamin C helpers such as rutin or perhaps other bioflavanoids that are found among the class of OPCs. Of course, dietary supplements or homeopathic treatments cannot be used as a substitute to diligent postoperative care and correct patient instruction on lifestyles issues or other factors that promote healthy healing or recovery from circumstances that occur as a consequence of certain medical procedures.
In summary, the natural protocol proposed in this article to provide nutritional support for wound and soft tissue healing for minor to moderate trauma involves: Stage 1: general nutritional support to avoid the presence of isolated or general deficiency of nutrients that may inhibit healing and Stage 2: the combination of homeopathic Arnica montana with other dietary supplements that have an evidence base to support healthy healing
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