The face of sleepiness: improvement in appearance after treatment of sleep apnea

Abstract

Study objectives: Anecdote but no formal evidence suggests that facial appearance improves after hypersomnolent patients with obstructive sleep apnea are treated. We investigated whether masked volunteer raters can identify post- rather than pre-treatment images as looking more alert, and whether impressions are predicted by any objective changes on highly precise 3-dimensional digital photogrammetry.

Methods: Participants included 20 adults with obstructive sleep apnea on polysomnography and excessive sleepiness on Epworth Sleepiness Scales. Photogrammetry was performed before and after ≥ 2 months of adherent use of positive airway pressure. Twenty-two raters then assessed pre- and post-treatment facial images, paired side-by-side in random order.

Results: Subjects included 14 men and 6 women, with mean age 45 ± 11 (SD) years and mean baseline apnea/hypopnea index of 26 ± 21. The 22 raters twice as often identified post-treatment rather than pre-treatment images to look more alert (p = 0.0053), more youthful (p = 0.026), more attractive (p = 0.0068), and more likely to reflect the treated state (p = 0.015). Photogrammetry documented post-treatment decreases in forehead surface volume and decreased infraorbital and cheek redness, but no narrowing of the interpalpebral fissure. Decreased deep NREM sleep at baseline, and pre- to post-treatment decrements in facial redness showed promise as predictors of improved subjective ratings for alertness.

Conclusions: Patients with obstructive sleep apnea are perceived to appear more alert, more youthful, and more attractive after adherent use of positive airway pressure. Objective changes in facial surface volume and color were identified. Post-treatment decrements in redness may inform subjective impressions of improved alertness.

Keywords: Obstructive sleep apnea; face; photography; sleepiness.

Figures

Figure 1. Regions of the face over which volume (left) and color (right) were assessed

Figure 2. Identification of n = 20 participants for this research

Figure 3. Frontal facial images taken before (left) and after (right) treatment with positive airway pressure for obstructive sleep apnea

For the first subject (A), each of 22 raters (100%) chose the post-treatment image (at right) as the one that showed a more alert appearance; 21 (95%) chose it as more youthful; 22 chose it as more attractive; and 22 chose it as the post-treatment image. For the second subject (B), 18 (82%) of the 22 raters chose the post-treatment image (at right) as the one that showed a more alert appearance; 19 (86%) chose it as more youthful; 20 (91%) chose it as more attractive; and 82% chose it as the post-treatment image. Each of these subjects had a baseline apnea/hypopnea index between 5 and 14 events per hour of sleep, and a minimum oxygen saturation between 75% and 85%.