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    Before treating ethnic patients with fillers, know cultural definitions of beauty

    The population of people with pigmented skin is growing in the United States, and, not surprisingly, cosmetic surgeons are interested in satisfying the anti-aging demands of this burgeoning market. Soft-tissue dermal fillers are the top guns in the quest for rejuvenation in these darker-skinned individuals, say cosmetic surgeons whose patients represent a diverse mix of ethnic backgrounds.

    "If you look at a 70-year-old Caucasian woman and her 70-year-old black counterpart, they are strikingly different," says Washington cosmetic surgeon Cheryl Burgess, M.D. These differences dictate the tools Dr. Burgess chooses to restore a more youthful countenance.


    A Hispanic patient in her 30s before (left) and after filler treatment that consisted of two syringes of Restylane (Medicis), one under each eye, and two syringes of Perlane (Medicis), one into each cheek and the chin. — (Photos credit: Sam Lam, M.D.)
    "In people who have Fitzpatrick skin type IV through VI, you'll see more intrinsic changes as they age, in comparison to light-skinned people with Fitzpatrick skin types I through III, in whom you'll see a combination of intrinsic and extrinsic changes. What this means is more sinking and sagging in darker-skinned individuals and more visible rhytids and photodamage in lighter-skinned people. So to fight the signs of aging in our darker-skinned patients, we use fillers to restore volume," Dr. Burgess says.


    Dr. Burgess
    CLINICAL FINDINGS Dr. Burgess' experience using injectable fillers to restore facial volume loss in dark-skinned patients has led to a noteworthy clinical observation. She says that when she uses stimulatory fillers such as like poly-L-lactic acid or calcium hydroxylapatite, she finds that 25 percent of the time they tend to stimulate more quickly in her dark-skinned patients than they do in her Caucasian patients.

    "I usually tell patients that they'll need three sessions, but I started noticing that when my black patients who are a skin type V or VI would return for their second session, there would be more thickening of the dermis in perhaps one out of four of them," Dr. Burgess says. Normally, she paces injectable filler sessions at about every four to six weeks, but in these patients she has modified the schedule to every six to eight weeks. "Histologically, the collagen bundles tend to be thicker in darker-skinned patients, and I think this is why the collagen is stimulated at probably a faster rate in some patients," Dr. Burgess says.

    Dr. Burgess uses the same amount of filler in patients of color and in Caucasian patients and does not vary her injection technique or filler choice, but she is more conservative as far as the treatment schedule because of her anecdotal observation of ramped-up collagen stimulation. She recommends paying particular attention to the response of skin type V and VI patients after the first session, and then tailoring follow-up sessions based on their response.

    "The most common cosmetic concern among my Asian patients is the fattening and widening of the face. Most patients are very satisfied with the use of fillers to restore the convexity of the cheeks and neuromodulators for narrowing and reshaping a widened jaw line," Dr. Burgess says.

    'WOW' EFFECT Sam Lam, M.D., of Lam Facial Plastics in Dallas, likes to use injectables to subtly shape the face for a reinvigorating 'Wow' effect in his ethnic patients and patients of color. Dr. Lam points out that people of darker races sometimes have a wider faces, and in cases like this he will use injectable fillers "to sculpt the face into a narrower shape by focusing more toward the anterior cheek and anterior chin."


    Dr. Lam
    Often, he points out, these patients come in complaining of the fine lines around their mouth, and he usually advises them that repairing those lines will do little to rejuvenate their face, whereas careful placement of subdermal fillers can provide the improvement for which they are hoping.

    One of the most important facets of using fillers in patients of color, specifically, and in ethnic patients, in general, is to be familiar with the physical distinctions in these groups, Dr. Lam says. For instance, Asian people tend to have rounder, wider faces, so they need a lot less product.

    "You need to be very selective to avoid making them look too full," he says. "I think what's really important is that you understand culturally where a person comes from, because, for instance, if you don't do a lot of Asian patients and you assume that you should treat them the same way as a Caucasian patient, you might blow up their face when what they really need is just a drop here and there."

    SENSITIVITY COUNTS Dr. Lam stresses that it's critical to be sensitive to cultural connotations in order to use fillers for a positive outcome. "For example, if an African American person requests fuller lips and they already have full lips, you may create an accentuated stereotypical lip," he points out. "In Polynesian and African patients, I tend to discourage lip augmentation, because it can result in an ethnic look without necessarily making them look more attractive." Dr. Lam says this is not a frequent request, but that it does occur. (Trends suggest that older black patients are requesting lip plumping in an effort to recapture their youthful look now that fuller lips are a fashionable choice.)

    Another example of when cultural sensitivity is crucial, Dr. Lam says, is in the case of Korean female patients. "If you don't know that large malar bones in Koreans are considered a masculine and unfavorable feature, you might inadvertently enlarge this feature and make a patient very unhappy," he says.

    An example of a common use for injectable fillers in ethnic patients in Dr. Lam's practice is reshaping the nose in Asian patients. "I will inject the bridge of the nose in Asian patients to make it higher and to create a bit more of a dorsum, but I avoid the tip, which is very resistant to injectable rhinoplasty," he says, adding that it's important not to oversimplify this procedure by simply thinking the goal is basically a larger nose. "If you are not careful, you could overly westernize the patient's face, or you could raise their bridge to the level that either their tip looks too small or their nose looks artificial. The bridge starts much lower on an Asian, and you have to be sensitive to that," he says.

    Another noteworthy factor in using injectable fillers in patients of color is that there is a greater margin of error in patients who have thicker skin, and this tends to be the case in darker-skinned patients. "The thicker the skin, the easier to inject because you can inject a little less deeply and feel like you're not going to have as much risk profile compared to very, very thinned-skinned patients," Dr. Lam says.

    DISCLOSURES:
    Dr. Burgess is a trainer for Sculptra and is on the Sculptra advisory board. Dr. Lam reports no relevant financial interests.