Shino Bay Aguilera, Autumn Saizan, Sabrina Fabi, Mara Weinstein Velez, JackieYee, Sabrina Ghalili, and Oben Ojong discuss facial ageing and the aesthetic needs among ethnic populations
Within the past 10 years, there has been a significant increase in non-Caucasian patients seeking cosmetic enhancements. This is due to the increased availability and accessibility of non-surgical aesthetic procedures. The rise in cosmetic dermatology may be attributed to several factors, including the massive growth of the industry, lower price points from extenders/mid-level injectors, de-stigmatisation of partaking in cosmetic procedures, and, most notably, the rise of social media and ever-increasing pressure to be filtered to perfection.
The aesthetic population continues to grow and become more racially and ethnically diverse. In 2000, people of colour accounted for 17% of overall cosmetic procedures. This percentage increased to 32% in 20191. Regardless of age, gender, race, sexual orientation, economic status, and culture, this exemplifies the strong desire to look and feel attractive, which is subconsciously hard-wired in our most basic human and survival instincts. Some feel that the desire for cosmetic procedures is a result of vanity, but nothing could be further from the truth — it is far more complex and intrinsically wired than that.
Beauty, traditionally considered subjective, has shown through time to consist of many objective markers that transcend racial and ethnic backgrounds. Symmetry, youthfulness, facial averageness, sexual dysmorphism, and certain ‘golden’ ratios and proportions are such contributors2. In order to best serve all patients, it is imperative to learn and appreciate not only the role of ethnicity and gender when undergoing enhancements but also the critical differences in how their individual ageing process takes place.
Caucasians still comprise the largest section of aesthetic procedure. The literature did not begin to expand its focus on the aesthetic preferences of skin of colour populations until the 1990s; therefore, Caucasian facial features and ageing patterns constitute the current bulk of published articles and educational training3,4. As aesthetic providers, it is our objective to create awareness and education regarding the differences and similarities in ageing patterns between Caucasians, people of colour, and all other ethnicities.
LATINO AND HISPANIC POPULATIONS
Among the Latino/Hispanic populations, interest in cosmetic procedures continues to rise. The terms’ Latino’ and ‘Hispanic’ are often used interchangeably. The term ‘Latino’ refers to inhabitants or descendants of Latin America, which includes Brazilians but not those directly from Spain5. Hispanic refers to people from or with ancestors from Spain, Mexico, Central America, and South America. Brazilians are not considered Hispanic by some censuses because they are of Portuguese descent. Both terms collectively encompass various populations from various geographic locations, including Mexico, Central America, South America, and those of Spanish-Caribbean descent3. The biological ancestry of Hispanics and Latinos may include European, African, Native American, and Central, North, and South American3.
There is great intra-ethnic diversity in skin type and facial structure among the Hispanic and Latino people, potentially rendering this population the most diverse to treat4. The great variability is due to inter-racial mixing in various regions of the world6. In general, Hispanics and Latinos have increased melanisation compared to Caucasians, with a diversity in Fitzpatrick phototypes ranging from III to V7. This provides enhanced photoprotection against UV radiation.
With regards to structure, Hispanics and Latinos have been described in general to have increased bizygomatic distance, a broader nose, and a recessed chin4,8. Those of Mestizo background, a mixture of Spanish and Native American, have a flat forehead, broad face with prominent malar eminences and a broad nose with widened alar base9. Central and South American Hispanic anthropometric measurements are more similar to Caucasians, and depending on the island of origin, some Caribbean Hispanic features share similarities with African Americans10. Through anthropometric analysis, Milgrim et al. found that some Caribbean Hispanics share similar nasal features (length, width, and alar length) with African Americans6.
Ageing in the Hispanic and Latino population affects the lower-upper and mid-facial regions. Eyebrow and eyelid drooping, lower lid fat herniation and infra-orbital hollowing occur most commonly4,8. There is also often thickening and descent of the mid-cheek area, including thickening of the nasolabial folds11.
In general, there has been increasing acceptance of soft tissue filler augmentation in the Hispanic and/or Latino population7. A recent survey of 401 Hispanic and/or Latino women found the tear-trough and crow’s feet line were the most important areas for younger participants3. In contrast, older participants noted a double chin, nasolabial folds, and forehead lines as areas of concern.
BLACK/AFRICAN AMERICAN POPULATIONS
As the patient population considering facial aesthetic treatments in the United States continues to increase and becomes more diverse, African American/Black patients are no exception. As of 2020, patients who identify as Black, African American, African, or persons of African descent make up 10% of persons requiring aesthetic procedures12. African American/Black patients in the USA comprise a diverse group as many patients who identify as Black may have varied ethnic and cultural backgrounds. The term ‘African American or Black’ comprises multiple ethnicities, including but not limited to African, Afro-Caribbean, European, and Native American ancestry12, 13.
Due to this diverse background of Black patients, there are certain similarities and differences that make for unique facial aesthetics. The most significant difference in Black skin from Caucasian skin is the melanin content and the melanosome dispersion pattern, which confers an approximate SPF of 13.44,14. While this provides protection from UV induced photoaging and skin cancers, it also leaves Black skin prone to dyspigmentation, which should be viewed as a sign of ageing in this population.
Structural features often associated with Black patients include broad nasal base, decreased nasal projection, bimaxillary protrusion, orbital proptosis, increased soft tissue of the midface, prominent lips, and increased facial convexity15,16. This leads to more prominent facial ageing in the periorbital region and midface rather than the upper face and brow. Additional ageing features include increased eyelid fullness, infraorbital fat pad volume loss, increased ocular proptosis, pronounced sagging of malar fat pads, jowl formation and increased submental volume11. Due to increased facial convexity and melanin content, patients of African descent demonstrate forehead skin wrinkling in later decades compared to Caucasian age-matched cohorts.
In general, the leading aesthetic concerns among African American/Black patients include uneven skin tone, sagging underneath the chin (double chin), tear trough deformity, and crow’s feet lines16.
EAST ASIAN POPULATIONS
Variability in aesthetic preferences extends to the Asian population as well. The ideal Asian aesthetic can vary immensely due to multiple factors beyond ethnicity and location of residence. The nuances of what is deemed aesthetically pleasing to a Korean woman that resides in Seoul can vastly differ from the Chinese woman that resides in the United States.
Historically, it has been recognised that Asians tend to age at a different rate than their Caucasian counterparts. The combination of increased superficial fat and thickened dermis lessens the incidence of superficial rhytids17. It has been reported that in the Chinese population, wrinkle development follows a biphasic trend, with a slow increase until the age of 40–50 years, followed by a rapid increase thereafter19. Despite facial ageing similarities across all races, differences in skeletal structural support and sagging of facial tissue delays ageing in Asians more than Caucasians17,19. Oftentimes, Asian patients seeking injectables prefer beautification, reshaping, and enhancement, rather than rejuvenation.
Asians tend to have wide and short faces with wider bitemporal, bizygomatic, and bigonial width20. The wide facial width in Asians may provide greater structural support against sagging tissue21. This may account for the lack of ageing, but it also limits the use of injectables in rejuvenating the face as more lateral zygomatic injections may overly widen an already wide midface, thereby distorting proportions or creating an unnatural and undesirable look. The Asian population will often request and improve with more medial midface injections to correct midface retrusion. This structural deficit overlying the medial maxilla also contributes to the early signs of volume loss of the infraorbital area, creating hollowing and dark circles, which may also need to be recognised and addressed21. When attempting to rejuvenate the ageing lower face, jawline injection goals and expected outcomes should be thoroughly discussed. The wider bigonial width is not classically deemed attractive by most Asian standards22,23, and injecting the jawline may result in the patient thinking the result is too masculine or unattractive.
The majority of Asian patients want to maintain their ethnic identity and do not want to lose important features that exhibit racial characteristics20. Being aware of cultural differences involves an understanding of what patients desire and how they want to enhance their natural beauty, which may differ from the aesthetic injector’s own ideals of beauty perceptions22.
SOUTHEAST ASIAN POPULATIONS
To further highlight the differences in both aesthetic preferences and ageing within the Asian population, it is important to highlight the nuances that exist within the Southeast Asian population. Southeast Asia consists of 11 countries, divided between the mainland and the maritime or insular region. The mainland region is comprised of Myanmar, Thailand, Laos, Cambodia, Vietnam, and West Malaysia. The maritime region includes East Malaysia, the Philippines, Indonesia, Singapore, Brunei, and East Timor. Using the Fitzpatrick skin type classification, Southeast Asian individuals are typically types III–VI; however, the majority of individuals strive to maintain a fairer complexion4. It is important to note that preferences for lighter skin types and the use of skin-lightening products may stem from the complex history of colonisation and the persistence of Western beauty standards4.
While the multi-ethnic variability of Southeast Asia makes it difficult to characterise facial structure and cosmetic preferences, there are a few facial features that persist despite the ethnic variation. Common Asian facial morphologies may include a wide and short face, which is often flat, or, at times, concave20. A lack of anterior projection commonly presents as a flat brow, flat nose with a wide base and minimal tip projection, and a recessive chin20. Additional features include increased intercanthal width, epicanthal folds, decreased eye fissure length, hooding of the upper eyelid, decreased oral width, increased mandibular width with a square lower face, and full lips20. In general, typical treatments involve narrowing the lower face (masseter reduction), increasing the vertical height of the face (chin augmentation), and increasing the anterior projection of the brows, cheeks, nose, and chin20. Despite the commonality in some of these features and treatments, clinicians should avoid treating ‘Asians’ as a homogenous group.
A survey study by Corduff et al. highlights the varying preferences amongst different ethnic groups while discussing the use of a ‘simplified visual assessment tool’ (SVAT) to discern between their unique features and ideals24. With respect to Southeast Asians, Corduff et al. found that one-third of males and two-thirds of female Malaysian patients, respectively, preferred shorter faces24. This contrasts with the preferences of their Singaporean and Korean counterparts24 as well as the general assumption that Asian patients prefer an elongated face. Additional variations in preference and treatment priorities between countries were noted24.
With respect to ageing, increased pigmentation, superficial fat, and a thickened dermis among Asians ultimately results in the delayed physiologic and anatomic signs of ageing20. Unlike their Caucasian counterparts, Asian individuals are more likely to have delayed and less severe rhytid development and midfacial sagging. Eventually, however, ageing presents as malar descent with increased nasolabial folds and jowl formation, temple hallowing, supra- and infraorbital hallowing, brow ptosis, and loss of volume and projection of the lower face, particularly the lips and chin20. One study highlights ageing variability in the context of geographic location and culture, with Southeast Asians, specifically Thai individuals, more likely to experience photoaging compared to their Chinese and Japanese counterparts20. This may be attributed to Thailand’s more tropical environment and the associated increased ultraviolet exposure as well as differences in language and facial expression18,20.
It is challenging to classify all Southeast Asians into one group when it comes to their beauty ideals and cosmetic concerns. Clinicians must listen to their concerns, educate, and manage expectations.
It is important to distinguish South Asian individuals from East Asian or Southeast Asian individuals, as there is a paucity of literature highlighting the differences between these groups. Very few studies discussing the beauty standards amongst South Asians, despite them making up roughly one-sixth of the world’s population25 and being the second fastest-growing population in the United States26.
South Asia consists of eight countries, specifically India, Nepal, Pakistan, Bangladesh, Bhutan, Sri Lanka, the Maldives, and Afghanistan. Like many of the other regions discussed, there is great inter-ethnic variability in this region. Geographic and cultural differences ultimately translate to ageing and aesthetic differences. One study noted that North and South Indians differ in both facial height and width, with North Indians having a longer, more narrow face25,27. A study by Ghosh et al. noted that people from West Bengal often have broad faces,30 like their South Indian counterparts.
A study by Husein et al. focusing on Indian Asian women (IAW) found that they often have a larger forehead, smaller midface, smaller lower face, shorter vertical facial height, narrower midface, and wider lower face than Caucasian women27. They also tended to have smaller eyes and less down-slanting ears. Adipose fullness, epicanthal folds, and narrow palpebral fissures help distinguish the Asian upper eyelid from a typical Caucasian eyelid. The IAW nose also tends to be smaller but wider27. South Asians also tend to have fuller lips and high cheekbones with more buccal fat, causing the lower face to have a more rounded contour25. Because they become ‘bottom heavy’ with age, tightening energy-based devices are preferred over injectable fillers for creating definition.
A weaker facial structure among South Asians results in greater gravitational soft-tissue descent of the midface, malar fat pads, ptosis, and tear trough formation25. A study by Shome et al. found that Asian Indians aged earlier than their Caucasian counterparts based on previous studies25. This is unexpected and surprising given the melanin content in the Asian Indian skin. According to this study, dermatochalasis, brow ptosis, and crow’s feet may occur about five years earlier among Asian Indians, with the earliest signs seen amongst West Indian ethnicities. Maximum dermatochalasis, however, was seen in East Indians followed by West, North, and South Indian populations. Additional investigation pertaining to the ageing process in Asian Indian skin is imperative25.
MIDDLE EASTERN POPULATIONS
The Middle East includes over 20 countries within southwest Asia and northern Africa. The most populous of these are Egypt, Iran, Turkey, Iraq, and Saudi Arabia29,30. The region is ethnically, geographically, and culturally diverse, resulting in equally diverse healthcare practices, beauty standards, and cosmetic procedure preferences.
Skin type and skin colour vary depending on the country and sub-region. In general, Middle Eastern skin tends to be thicker and darker than Caucasian skin. There are regions, however, in which light and thin skin are the norm31. Patients typically prefer lighter skin over their natural skin colour. As of 2020, an estimated 43% of Saudi women and 60% of Jordanians use skin lightening products, with demand increasing in the region32. However, this preference is less prevalent in those having lived in the United States33.
Face shape and features in Middle Easterners are highly variable, but there are similarities among them when compared to their Caucasian counterparts. Of all the facial features, the Middle Eastern nose can be highly distinct. In general, they have a similar nose width, but substantially greater nose height34. On profile, the nose has a high arching dorsum with a long nasal contour8. Rhinoplasty to achieve facial balance and correct deformities is one of the most popular cosmetic procedures in this region29. Middle Eastern eyes are also distinct with larger intercanthal and biocular width and smaller eye fissure length, in general34.
Genetic studies trace the Middle Eastern population back to three distinct ancestries; Bedouin, Persian-South Asian, and African35. Iranians, many descended from the Persian-South Asian ancestry, tend to have a longer, flatter face with a smaller forehead and a wider mandible with increased dental protrusion causing greater lip convexity34,35. Egyptians, many from African ancestry, in contrast, have a shorter face and a greater sloping forehead, more prominent lips, and more prominent malar and periocular regions34,35.
Multiple studies show that Middle Eastern women prefer cosmetic procedures that enhance their ethnic identity rather than mask it34,35. The Middle Eastern conception of beauty prioritises the eyes followed by the lips and cheeks, and Middle Easterners generally prefer a round, full face; well-defined and full cheeks; a small, straight nose; fuller lips, and a prominent pointed chin with a defined jawline35. Both surgical and non-surgical cosmetic procedures to achieve these features have become highly popular in this population in the last two decades, even in those countries that tend to be culturally conservative such as Iran and Saudi Arabia. Turkey and Saudi Arabia have been ranked in the top 30 countries by estimated number of plastic surgeons worldwide37.
The features of skin ageing in Middle Eastern skin is unique. Middle Eastern facial skin is heavier and therefore is more likely to sag and form jowls with age. This is pronounced in the midface and lower facial third.33 This is more common in Gulf and Arab populations and less common in Iranians37. Despite the unique facial features of Middle Eastern people, they are technically classified as ‘Caucasoid’ along with those of European and Indian descent, resulting in a paucity of research on Middle Eastern skin specifically and how it ages38.
As more individuals of colour seek cosmetic treatments, aesthetic providers have a responsibility to familiarise themselves with the natural features, ageing patterns, and cosmetic concerns unique to patients of non-Caucasian descent. While there is no single standard of beauty, Eurocentric features have dominated the cosmetic industry for several years and the aesthetic preferences of the ‘ethnic’ patient have often been overlooked, or even concealed in an effort to achieve a more ‘westernised’ appearance4. With European features often considered the standard, the features of skin of colour populations often become ‘pathologised’ and thus, seen as something requiring treatment or correction39.
To conclude, an adequate cosmetic consultation requires adaptability, cultural competency, a celebration of diverse facial features and aesthetic standards, and shared decision making. For a number of skin of colour populations, however, the literature on unique facial characteristics and aesthetic preferences remains scarce, ultimately limiting excellence in patient care.
Declaration of interest All authors contributed to this manuscript. All authors of this manuscript have no conflicts of interest to disclose.
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