It is a common observation that the Asian face

INJECTABLES Ethnic and Gender Considerations in the Use of Facial Injectables: Asian Patients Steven Liew, FRACS Sydney, New South Wales, Australia Background: Asians have distinct facial characteristics due to underlying skeletal and morphological features that differ greatly with those of whites. This together with the higher sun protection factor and the differences in the quality of the skin and soft tissue create a profound effect on their aging process. Understanding of these differences and their effects in the aging process in Asians is crucial in determining effective utilization and placement of injectable products to ensure optimal aesthetic outcomes. Methods: For younger Asian women, the main treatment goal is to address the inherent structural deficits through reshaping and the provision of facial support. Facial injectables are used to provide anterior projection, to reduce facial width, and to lengthen facial height. In the older group, the aim is for rejuvenation and also to address the underlying structural issues that has compounded due to age-related volume loss. Conclusion: Asian women requesting cosmetic procedures do not want to be Westernized but rather seeking to enhance and optimize their Asian ethnic features. (Plast. Reconstr. Surg. 136: 22S, 2015.) It is a common observation that the Asian face retains its youthful appearance for longer due to delayed signs of skin aging and sagging compared with age-matched whites. 1 3 Factors identified to explain the observation include higher sun protection factor of Asian skin against photodamage, 4 6 dense fat and fibrous connection between the superficial muscular aponeurotic system and the deep fascia in reducing midfacial sagging, and the lesser superficial rhytides due to the combination of increased superficial fat and thickened dermis. 7 Asians have distinct facial characteristics due to underlying skeletal and morphological features that differ greatly with those of whites. Understanding of these differences and their effects in the aging process in Asians is crucial in determining effective utilization and placement of injectable products to ensure optimal aesthetic outcomes. CHARACTERISTICS OF ASIAN FACIAL FEATURES Asians tend to have a wide and short face. Structurally, Asians have wider bitemporal, bizygomatic, and bigonial width compared with whites. 8 11 In profile, the face is relatively flat due to retrusion of the central midline skeletal structures (glabella, nasal bone, pyriform margins, medial maxilla, nasal spine, and mental protuberance of the mandible). These structural findings give rise to the common morphological features seen in most Asian faces (Fig. 1). It is the author s opinion that the wide facial width in Asians provides greater structural support against sagging tissue. Interestingly, however, many Asian women consider the extra width of the lower face as masculine. It is this, together with the retrusion of the midline facial skeleton and its associated morphological facial features, which is viewed as undesirable and considered suboptimal within their aesthetic cultural norms, thereby creating an the impetus for some patients to seek aesthetic treatments. ASIAN FACIAL AESTHETICS The concept of facial beauty has become universal. Attractive female faces of different racial background has been shown to share similar facial shape and individual facial structures of optimal From the Dr. Steven Liew Clinic. Received for publication March 24, 2015; accepted June 24, 2015. Copyright 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001728 Disclosure: The author has no financial interest in any of the products, devices, or drugs mentioned in this article. 22S www.prsjournal.com

Volume 136, Number 5S Use of Facial Injectables in Asian Patients Fig. 1. (Left) A young Asian woman with short and square face. (Right) Profile view illustrating the low nasal dorsum, retruded medial maxilla, alar base, and chin resulting in flat midline profile. proportion and sizes while retaining features unique to their ethnicities. 12 14 Oval facial shape is now generally recognized as the ideal female facial shape in both Asian and Western countries. 14,15 For most Asian women, there is a distinct preference for an oval, upside-down egg-like facial shape, with fullness in the upper half of the face and smooth tapering from the cheek to the chin. This is in addition to the pursue of a clear, bright, and lighter skin with optimal skin quality and texture. This aesthetic preference for oval facial shape and the perceived detracting aesthetic features arising from midline structural retrusion form the basis of treatment with injectables practised in Asia as outline below. It is important to note that the majority of Asian women requesting these cosmetic procedures do not want to be Westernized but rather seeking to enhance and optimize their Asian ethnic features. COMMON TREATMENT AREAS FOR FACIAL INJECTABLES The most common indications of treatment in the author s experience for Asian patients are as follows: Neuromodulators for upper third dynamic wrinkles and for masseter muscle hypertrophy to reduce the lower facial width; Nasal augmentation; and Medial maxilla and chin augmentation with dermal fillers. Areas most commonly treated for Asian female patients, classified by age, are listed in Table 1. Hyaluronic gel fillers are used exclusively in all patients. Table 1. Most Common Areas of Facial Injectable Treatment for Asian Women Based on Author s Experience Injectables Priority 18 40 years >40 years Neuromodulators 1 Masseter reduction Upper facial lines 2 Upper facial lines Mentalis muscle hyperactivities 3 Mentalis muscle hyperactivities Platysma muscle for jawline definition 4 Lower eyelid wrinkles Lower eyelid wrinkles Dermal fillers 1 Nasal augmentation Malar volume restoration 2 Medial maxilla augmentation Tear trough and infraorbital margin 3 Chin augmentation Nasolabial (including alar base) 4 Tear trough Oral commissure, prejowl sulcus, and chin augmentation 5 Forehead, glabella, and eyebrow volumization 23S

Plastic and Reconstructive Surgery November Supplement 2015 Fig. 2. (Left) A young Asian woman with wide face and flat midline facial structures secondary to the intrinsic Asian skeletal structures. The aim is to provide three-dimensionality to the midline structures and to reshape the face to that of an oval shape. (Right) The after result showed a conversion from a square short face to that of an ovoid shape with narrower lower face, more taper chin, and better projection to the central midline structures. This is achieved with the use of neuromodulator to reduce the bulk of the masseter and dermal filler to augment the retruded medial maxilla, the alar base, and the chin. 24S

Volume 136, Number 5S Use of Facial Injectables in Asian Patients Fig. 3. ( Left) A 65-year-old Asian woman with wide and square facial shape. The soft tissue of the lower face is very well supported with minimal tissue sagging. (Right) Full-face approach to rejuvenation involved volumization to areas displaying volume loss in the temple, forehead, eyebrows, submalar, lips, and jawline. Volumization was also provided in areas of intrinsic structural deficit compounded by the physiological age associated volume loss in the medial maxilla, perialar recess, glabella, chin, and nose. Neuromodulators were used for the minor dynamic upper third lines and mentalis. PRINCIPLE AND FOCUS OF AESTHETIC TREATMENT IN ASIANS For younger Asian women (<40 years), the main treatment goal with the administration of facial injectables is to address the inherent structural deficits through reshaping and the provision of support, to enhance the face rather than to rejuvenate. This is principally addressed through the 25S

Plastic and Reconstructive Surgery November Supplement 2015 Fig. 4. (Left) Volumization of the midface in a 40-year-old white woman. Note the bulk of dermal filler to be placed in the lateral maxilla and the zygoma. (Right) Volumization of the midface in a 39-year-old Asian woman. Note the bulk of dermal filler to be placed in the medial half of the maxilla to provide central projection. Fig. 5. (Left) A 39-year-old Asian woman with a short square face. The medial maxilla and pyriform margin are retruded (left), creating recession of the infraorbital margin (dark shadow) and perialar shadowing. (Right) An esthetically improved and narrower facial appearance was achieved with neuromodulator to reduce the masseter muscle mass and after dermal fillers were placed in the medial cheek and alar base to create anterior projection of the central third of the face. The volumizing effect of the filler in the medial cheek also reduces the infraorbital and perialar shadows and creates a visual effect of narrowing the midface. 26S

Volume 136, Number 5S Use of Facial Injectables in Asian Patients provision of anterior projection and three-dimensionality to an otherwise centrally flat or retruded facial structure to reduce facial width and to lengthen facial height to the typically short and wide facial features. The endpoint is to achieve an esthetically desirable oval facial shape and threedimensionality while maintaining the patient s ethnic characteristics (Fig. 2). This is commonly achieved by the combined use of neuromodulator injections to reduce the bulk of the masseter and filler injections to project and support the nose, the medial maxilla, and the chin. In the older Asians, neuromodulators are primarily being used for facial wrinkles, and dermal fillers are used to restore volume in areas that show signs of aging due to volume deflation, such as the midface, nasolabial and perioral area, and jawlines. In addition, one also needs to address areas of intrinsic anatomical structural deficiency that become more pronounced with age-related volume loss, such as the glabella, the forehead, the medial malar, the nose, the inferior orbital rim, the perialar recess, and the chin (Fig. 3). In this group, the combination of neuromodulators and dermal fillers is used not only for rejuvenation but also to address the underlying structural issues that have compounded due to age-related volume loss. SPECIAL CONSIDERATION TO THE TREATMENT OF MIDFACE IN ASIANS Midface is the area where dermal fillers are most frequently used. When treating the midface, it is important to appreciate the wide bizygomatic distance in most Asians in distinct contrast to whites. It is crucial not to place excessive volume in the lateral half of the midface as this could create facial disharmony by further widening the midface (Fig. 4). Volume should be preferentially placed in the medial half to provide not only projection in the structural deficient part of the medial maxilla but also volume restoration in older patients. This structural deficit of the medial maxilla also contributes to the early signs of volume loss in the infraorbital area, creating hollowing and excessive dark circles, even among younger patients. It is the author s opinion that the correct volumization of the midface in Asians can provide multiple benefits. It projects the central third of the face, which also serves to create a visual illusion of narrowing the midface and reducing the infraorbital hollow (Fig. 5, right). Treating the midface together with, where appropriate, the nose and chin and reducing the width of the lower face with the use of neuromodulators on the bulk of the masseter both help to convert a short and square face to an oval facial shape with central dimensionality, which is most desired in Asians. 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