Katie Beleznay, MD, FRCPC, FAAD,

Clinical Instructor, Department of Dermatology and Skin Science University of British Columbia, Vancouver, BC, Canada

Asia is the most populous continent with its 4.3 billion residents accounting for 60% of the world's population.1 Immigration trends have made Asians the fastest growing racial group in the United States.2 Vancouver, British Columbia, where I practice, has one of the highest Asian populations outside of Asia at 43%.3 When treating cosmetic patients from an increasingly diverse population it is important to understand the unique cosmetic concerns of those patients and techniques that will deliver best outcomes. In this article I will primarily be referencing female patients from East Asia including China, Korea, and Japan.

Most published studies on cosmetic treatments reference Western populations, but Asian patients often differ in terms of their attitudes toward beauty, structural facial anatomy, and rates of aging.4 Understanding these differences is key to providing a desired cosmetic outcome. Asian patients are increasingly seeking facial aesthetic treatments, and at even younger ages.4 Aesthetic treatments sought by Asians should not be viewed as an attempt to westernize their appearance, but rather as an optimization of Asian ethnic features.4

As societies have evolved there has been more of a blending of facial characteristics making racial anatomical distinction less clear.5 Nevertheless, there are some key differences between Asian and Caucasian facial appearance with respect to anatomy. Asian patients tend to have a wider and shorter face. In profile, the face may appear more flat with less brow, nose and chin projection. Asians tend to have a greater mandibular width contributing to more of a square lower face, and typically more of a retruded chin. The nose is flatter with a wider base and less tip projection. Asians also tend to have greater infraorbital volume and fuller lips with an upper:lower lip ratio of 1:1.2 compared to 1:1.6 for Caucasians.4-7

Skin aging differs between Asians and Caucasians in several aspects, as well. On average, skin in Asian patients has greater dermal thickness, collagen content, and melanin than Caucasians.7 Benign pigmented lesions such as lentigines and seborrheic keratoses are quite common in Asians, but wrinkles tend to manifest one to two decades later than in age-matched Caucasians.1 In the Chinese population it has been shown that there is a slow increase in wrinkle development until the age of 40-50 followed by a more rapid increase thereafter. This difference in facial wrinkling may be due to the increased photoprotection in Asian skin secondary to the increased melanin content, which results in a natural SPF of approximately 7 compared to an SPF of 3 in Caucasian skin.4 Further, differences in the propensity of facial soft tissue to sag results in slower rates of facial aging. Asian patients tend to have denser fat, which reduces midfacial sagging for longer.2 In addition, the combination of increased superficial fat and a thickened dermis lessens the incidence of superficial wrinkles. Though the increased dermal thickness may help with skin aging, it has also been thought to contribute to the higher incidence of hypertrophic scars in Asian patients.5 Other reported reasons for reduced skin aging in Asia include diets high in antioxidants like green tea, reduced smoking rates, and sociocultural factors such as skincare practices and liberal use of sunscreen. Muscle use during language articulation and facial expressions may also contribute to the differential development of dynamic wrinkles between Asians and Caucasians.4,8

Formulating a Cosmetic Treatment Plan

Knowing the differences between Asian and Caucasian skin can help guide physicians on best approaches when formulating a cosmetic treatment plan. Facial shape is a key contributor to facial beauty, with an oval-shaped face considered youthful and attractive by people of all racial backgrounds. Balance and symmetry with a well-projected nose and chin, along with clear, unblemished skin is uniformly considered attractive.4 Asians tend to have a wider face with shorter vertical height and flatter projection. As such, Asian patients often wish to create more of an oval facial shape by narrowing the lower face and increasing the vertical height of the face. A full but not prominent lip is often requested along with a v-shaped jawline. The anterior projection of the brow, medial cheek, nose and chin is increased to improve the three-dimensionality of the face. This midline emphasis is different from Caucasian patients who often seek to enhance the lateral cheek area.4

As treatments to enhance facial shape have increased in popularity, the proportion of younger Asian patients seeking treatment is rising.7 One survey showed that close to 50 percent of those seeking facial aesthetic treatments are 18 to 40 years old.4

Figure 1: A. Before and B. 2 weeks after treatment with 20 units of Botox® in each masseter, 8 units in the mentalis, 0.5 cc Volift® nasal bridge, 1 cc Volift® divided in the melomental folds, 1 cc Voluma® in the chin and 1 cc Voluma® divided in each cheek to create a more oval shape with v-shaped jawline

Based on what we know about trends in Asian beauty it is important to understand treatments available to achieve the desired aesthetic outcomes. With current trends valuing the 3-dimensional profile, augmentation of the T zone—forehead, nose, medial cheeks and chin—with fillers is a fundamental treatment strategy.7 The forehead can be treated with filler to create a smooth convex surface. The nasal bridge is also a common site for augmentation. In this region, filler should be injected cautiously, especially if a prior surgical procedure was done in the area, as there is a greater risk of vascular complications. The nose was identified as the second highest risk site for blindness after filler injection in a review paper we recently published.9 In many Asian populations, lateral augmentation of the cheek is considered a masculine feature and is not necessary or appreciated. A more rounded apple cheek is preferred.7 Volume should be placed in the medial half of the cheek to provide not only projection in the structurally deficient part of the medial maxilla but also volume restoration in older patients. This differs from Caucasian populations where lateral malar cheek augmentation is common. Many Asian women desire an inverted triangle shape to the face with a slender chin and jawline.7 As such, filler for the chin area and neurotoxin for the masseter muscle to slim the face is commonly utilized. Asian patients commonly have a more retruded chin area and this can lead to hypertrophy of the mentalis muscle. Relaxation of the mentalis muscle with neurotoxin can be considered as well.10 An example of facial shaping can be seen in Figure 1.

There are also some differences with botulinum toxin delivery in Asian patients. With regards to the forehead, studies have shown that Europeans have larger facial movements in the frontal region than Asians, resulting in higher wrinkle scores. Smaller doses of botulinum toxin may therefore be needed in Asian patients. The glabella is the most common site of injection. Asian patients have been shown to have a shorter square corrugator muscle compared to Caucasians. As such, more conservative dosing may be sufficient in 3 injection points. A consensus recommendation suggested only 8 units of botulinum toxin in total compared to 20-30 units in the glabella for Caucasian females.11

Figure 2: A. Immediately after electrocautery treatment of syringomata and B. several weeks after treatment showing complete resolution and no postinflammatory hyperpigmentation (for point of reference note the benign nevus of the upper inner eyelid in both images).

Courtesy of Dr. Alastair Carruther

Hypertrophy of a component of the infraorbital muscle (also known as the jelly roll) can give the perception of lower eyelid bags and can narrow the palpebral aperture, especially when smiling. This area may be treated with 1-2 units of neurotoxin placed subdermally in the lower eyelid at the mid-pupillary line to relax and flatten the orbicularis muscle (Figure 2). However, for some Asians, this structure is thought to make women look younger and cute and is known as the “charming roll” so this is often created with filler rather than reduced with neurotoxin. This treatment is known as Aegyo Sal.11 Botulinum toxin treatment of crow's feet, gummy smile, bunny lines, dimpled chin, and enlarged masseters are common in Asian patients. Another unique treatment is calf muscle injection with botulinum toxin in order to make the legs appear long and slim. Calf contouring can be done with 50-60 units of Botulinum toxin A per side divided between six injection points.11

Procedures to address skin tone, texture and pigment are also commonly performed. Lasers that are safe to use in patients of darker skin phototypes should be utilized. Intense pulsed light and non-ablative fractionated lasers with the appropriate energy can be effective with low risk of side effects. Removal of benign lesions on the face including seborrheic keratoses, syringomata and sebaceous hyperplasia can reduce signs of aging and contribute to the sought after blemish-free appearance. A common treatment for these lesions is electrosurgery or electrocautery as the risk of dyspigmentation is lower (Figure 2). A test area can be done first to ensure the lesions resolve with minimal side effects. The importance of sun protection and general skin care strategies should always be emphasized.

A Need and Opportunity

With the growing Asian population and increasing demand for cosmetic procedures, there is both a need and an opportunity for core cosmetic physicians to develop expertise in treating this demographic. Based on current trends, aesthetic procedures that focus on facial shaping and three-dimensional enhancement of the T-zone in a younger population are common. Treatments to improve skin tone, texture and any pigmentary changes are also part of a complete cosmetic treatment plan. While it is important to take an individualized approach with each patient, having an understanding of key differences and trends in the approach to cosmetic treatment in Asian patients is important to achieve optimal results.

Relevant Disclosures: Dr. Beleznay has served as an investigator for Allergan, Revance, Evolus

Dr. Katie Beleznay completed her medical training and dermatology residency at the University of British Columbia and is currently a Clinical Instructor with the UBC Department of Dermatology. Dr. Beleznay is a board certified dermatologist in both Canada and the United States and is fellowship trained in laser and cosmetic dermatology. She currently practices at Seymour Health Centre and Carruthers & Humphrey Cosmetic Clinic in Vancouver BC.

1. https://en.wikipedia.org/wiki/World_population. Accessed August 10, 2016

2. Pew Research Center: http://www.pewsocialtrends.org/2012/06/19/the-rise-of-asian-americans/. Accessed August 10, 2016

3. Todd, D. http://blogs.vancouversun.com/2014/03/28/vancouver-is-most-asian-city-outside-asia-what-are-the-ramifications/. Accessed August 10, 2016

4. Liew S, Wu WTL, Chan HH, et al. Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty. Aesth Plast Surg; 2016;40:193-201

5 Sykes J, Nolen D. Considerations in non-caucasian facial rejuvenation. Facial Plast Surg Clin N Am 2014;22:463-70

6. Liew S. Ethnic and Gender Considerations in the Use of Facial Injectables: Asian Patients. Plast Reconstr Surg. 2015;136:22S-7S.

7. Rho NK, Chang YY, Chao YY et al. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers. Plast Reconstr Surg. 2015;136;940-55.

8. Vashi NA, Maymone M, Kundu RV. Aging Differences in Ethnic Skin. J Clin Aesth Dermatol. 2016;9:31-7.

9. Beleznay K, Carruthers J, Humphrey S, Jones D. Avoiding and Treating Blindness from Fillers: A Review of the World Literature. Dermatol Surg. 2015;41:1097-117

10. Wu W, Liew S, Chan HH et al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesth Plast Surg. Published online 18 Feb 2016.

11. Ahn BK, Kim YS, Kim HJ et al. Consensus Recommendations on the Aesthetic Usage of Botulinum toxin type A in Asians. Dermatol Surg. 1013;39:1843-60.