Asian Americans are the highest-income, best-educated and fastest-growing ethnic group in the U.S., according to a Pew Research Center report released in 2012, called “The Rise of Asian Americans.” When it comes to cosmetic treatment in this patient population, successful outcomes may depend on understanding physiological and cultural nuances.
Washington, D.C., area dermatologist Hema Sundaram, M.D., has a special interest in Asian aesthetics. She is lead author of a new consensus group publication that will be published this spring in Plastic and Reconstructive Surgery, which includes a discussion of injectables treatments in Asians and other ethnicities. This article, "Global Aesthetics Consensus: Hyaluronic acid fillers and botulinum toxin type A: Recommendations for combined treatment and special considerations to optimize outcomes in diverse patient populations," provides recommendations from a notable group of dermatologists and plastic surgeons from the U.S., Canada, Europe, Asia, Australia and Latin America. Joining Dr. Sundaram, the North American faculty includes Drs. Jean Carruthers, Steven Fagien, Gary Monheit, Rod Rohrich and Arthur Swift.
Dr. Sundaram says that dermatologists and plastic surgeons in the U.S. will likely be treating increasing numbers of Asian patients.
“This reflects ongoing expansion of the Asian population in America, and the steady increase, year by year, in the number of patients of color who seek cosmetic procedures, as revealed by annual procedural surveys from the American Society for Dermatologic Surgery, American Society for Aesthetic Plastic Surgery and other core aesthetic specialty organizations,” she says.
Dr. Sundaram’s first recommendation for cosmetic surgeons treating patients of all ethnicities: Focus on facial harmonization, rather than rejuvenation.
“This entails age-appropriate modification of congenital baseline characteristics, together with correction of acquired disharmonies, which are usually age-related in our patients seeking cosmetic procedures, although they can have other causes, such as injuries,” she says.
In This Article
‘Typical’ Beauty Strategies
Cosmetic clinicians treating Asian patients need to distinguish among ethnic populations, realizing the notable differences between Caucasian and Asian faces and reflecting on cultural disparities, as well as “distinctive treatment goals,” according to consensus recommendations by the multi-specialty Asia-Pacific Consensus Group. Dr. Sundaram was a member of this group, which developed consensus recommendations for Asians based on members’ experiences using cohesive polydensified matrix hyaluronic acid and calcium hydroxylapatite fillers. The group published its findings in November 2015 in Plastic and Reconstructive Surgery.
Taking that a step further, it’s important for cosmetic surgeons to be aware of the typical congenital baseline for Asian patients, but also to understand that Asian patients are not the homogeneous population that some perceive them to be, according to Dr. Sundaram.
“Typical Asian strategies with injectables include injection of filler to the medial midface, forehead and chin. Filler may also be injected to the radix and dorsum of the nose. Botulinum toxin neuromodulator is typically injected to the masseters,” Dr. Sundaram says.
Geographic variations reflect the significant differences in facial canons and morphotypes between Northern-type Asians, such as those from Korea and Japan, and Southern-type Asians, such as those from Indonesia or Singapore, according to Dr. Sundaram.
“For example, augmentation of the medial midface is not required for many Southern Asians, who already have sufficient convexity in this facial region. However, they may have more requirement for augmentation of the nasal bridge and dorsum, to correct concavities and produce a narrowing effect,” she says. “Conversely, high doses of botulinum toxin to the masseters may be more appropriate for Northern Asians, since their congenital baseline tends to include a greater bimandibular width and a squarer jaw.”
Arched eyebrows are not aesthetically appropriate when there is a wider bimaxillary width, making a straighter eyebrow more harmonizing for most Asian faces, according to Dr. Sundaram.
“This is currently a trend for many Caucasian faces too,” she says. Dr. Sundaram has discussed aesthetic and procedural considerations for the eyebrows and upper eyelids in a 2013 chapter for Clinics in Plastic Surgery.
Facial Analysis, Societal Ideals
Dr. Sundaram, who directs educational and training programs focusing on Asian aesthetics and serves on scientific boards of conferences in Asia, says ideals and canons of beauty have been traced thousands of years back, to the Ancient Greeks.
“Originally, the canons were for Caucasian faces, but now we have some publications for African and Afro-Caribbean faces, [as well as] for Asian and for Indian. While an understanding of ethnic facial canons is certainly helpful, we cannot get locked into these principles,” she says.
An example Dr. Sundaram gave in a recent lecture on the topic was to show images of two of her patients — one Caucasian and one Asian. When she asked the audience if they saw similarities between the two, everyone said no.
“I explained that I had actually injected them with hyaluronic acid filler in a very similar way. The reason was that the Caucasian patient inherently had many of the features that we see in Asian faces. That was her congenital baseline, or starting point,” Dr. Sundaram says. “She had a relative deficit of medial midface volume, and a retrusion of the chin. Therefore, an ‘Asian-type’ injection strategy was appropriate to harmonize her face.”
Facial analysis is more than individualization; it’s also an awareness of societal ideals of beauty and cultural overlays. An example of societal ideals is that an Asian growing up in America is likely to have different aesthetic ideals than an Asian patient growing up in Asia. To illustrate the concept, Dr. Sundaram points to the "charming roll," an ideal which started in Korea with a celebrity who had tiny volumes of hyaluronic acid filler injected just below the inferior ciliary margin, to enhance the pre-tarsal orbicularis oculi bulge.
The aim, she says, was to give the celebrity a wider-eyed appearance.
“This procedure has burgeoned in popularity and is now very popular with Asian patients who have a relatively narrow palpebral fissure and absence of the supratarsal crease,” she says. “If we inject botulinum toxin too close to the inferior ciliary margin and obliterate the pre-tarsal bulge, this can make patients who desire it and consider it a hallmark of beauty very unhappy.”
On the other hand, second generation Asians in the U.S. and other countries may be more influenced by the ideals of the society in which they live — even preferring to reduce the prominence of the pre-tarsal bulge. Similar variations in preferences exist for contour and projection of the chin and forehead. Dr. Sundaram shares the example of a half-Japanese, half-American female patient at her Washington, D.C., practice.
“She didn't like her pre-tarsal bulge as she felt it made her look tired. She wanted her eyes opened up a bit with botulinum toxin,” Dr. Sundaram says. “When we inject botulinum toxin to open the eyes, it lowers the inferior ciliary margin by a fraction of a millimeter. But it takes away the charming roll. So, that’s an example of the societal influence on cosmetic preferences, and why we need to be well-informed about the nuances of Asian aesthetics and having frank dialogues with our patients.”
Societal ideals have far-reaching cosmetic effects. Another obvious example of societal influences is the longstanding tendency for Asian women and some men to want to whiten or lighten their skin.
“They apply topicals for this purpose, and may also sit in ‘whitening baths’ and take oral medications for that reason. In contrast, Asian-Americans in the US and other Western countries don’t mind having a tan, and may even seek to enhance their naturally tanned appearance, like the rest of the population,” she says.
A Fundamental Treatment Principle
As precise as Dr. Sundaram’s approaches for treating Asian faces appear to be, she reiterates that individual considerations must override generalizations.
“Migration patterns in Asia over millennia have resulted in a great diversity of facial morphotypes in many Asian countries,” she says. “The fundamental principle that I emphasize when lecturing on and demonstrating injectables treatments for Asian patients is that individualized treatment planning and implementation transcend ethnic boundaries.”