Aesthetic considerations for treating the Middle Eastern patient: Thriving in Diversity international roundtable series

The Middle East has a significant influence on the global aesthetic market. Within the United States and globally, patients with Middle Eastern heritage have a wide range of ethnic and cultural backgrounds that affect their perceptions of beauty and motivations to seek cosmetic treatment.

of cosmetic surgeons in the world, with 47 cosmetic surgeons per 1 million people. [7][8][9] In Lebanon, a country of 6 million people, there are 1.5 million cosmetic procedures performed annually, and the aesthetics market continues to thrive despite economic challenges. 10,11 Dubai and Abu Dhabi have launched official initiatives to increase medical tourism and take advantage of this growing interest in the region; the medical tourism market in the Middle East and Africa is projected to be a $1.35-billion industry by 2027. 4,12 People from the Middle East also make up an important population of patients seeking aesthetic treatment in the United States. There is little content within the medical literature available to guide aesthetic treatment of Middle Eastern patients in the United States. In fact, demographic information about Middle Eastern populations in the US itself is difficult to obtain, as the Census does not include "Middle Eastern" as a race or ethnicity option. 16 Despite this paucity of information, it is clear that people of Middle Eastern descent have unique and varied cultural, anthropometric, and personal priorities and concerns that should be considered as part of their medical care. 15 As with other areas of aesthetics, especially those for which research is minimal, expert guidance plays a centrally important role in bringing to light key ideas that support optimal care and avoidance of incorrect assumptions about treatment approaches. This report, developed with the expertise of both Middle Eastern clinicians and clinicians who treat patients of Middle Eastern heritage in the United States, describes unique features and motivations within Middle Eastern populations regarding beauty standards and aesthetic preferences, in an effort to increase physician awareness and support culturally competent care.
Importantly, clinicians should never forget that each patient is an individual with unique experiences and beliefs which may influence their treatment preferences, and the information within this manuscript only supplements a culturally informed treatment approach. Arabia. 17 People from the Middle East have a high degree of genetic and ethnic diversity, even within individual countries. [18][19][20][21] Ethnic groups include Arabs, Persians, Jews, Turks, Berbers, Kurds, Armenians, Nubians, and Azeris. 22 Three distinct racial clusters reflect primary ancestry within this population:

| ME THODS
Bedouins, Persian-South Asians, and Africans. 18 25 The faces of beauty icons are generally oval-shaped and symmetrical, with thick, arched eyebrows, almond-shaped eyes, full lips, well-defined cheeks and jawlines, and prominent chins; however, little is known about the degree to which these standards reflect beauty standards in the Gulf region. 25 • There is little published on anatomical differences that should be considered when treating these patients, which contributes to a lack of clinical knowledge, including aesthetic preferences and facial anthropometry. In cases where communication and awareness are lacking, this lack of understanding can lead to aesthetic clinicians imposing Western beauty ideas. 34 The small amount of literature describing the anthropometry of people of Middle Eastern descent is focused on specific geographic regions and includes studies describing Iranian, Lebanese, Saudi Arabian, Egyptian, and Emirati anthropometry. [35][36][37][38][39][40][41][42] Understanding these variations is part of a wellrounded baseline knowledge, and personalized assessment for each patient is needed. Facial shape, convexity, and proportions are highly variable among Middle Easterners, and perceptions of these features can be shaped by the high degree of ethnic diversity exhibited by people with Middle Eastern heritage.

• Motivations and Considerations for Treatment May Be Unique.
A variety of factors affect a Middle Eastern woman's perception of her appearance and decision to seek cosmetic treatment.
According to physician consensus, women report heavy influence of the media and their peers. 25 Women under 40 years of age also list social media as a significant influence, and women over 40 years are influenced by husbands, friends, and partners. 25 In a survey of Saudi Arabian women, 42% had had at least 1 elective cosmetic procedure and 33% had considered having one. 43 Motivations for seeking an aesthetic procedure included improving appearance and self-esteem, attracting or maintaining attraction from a husband, and improving interpersonal relationships.
• Religious Considerations May Be Present: Islam is an influential religion in the Middle East that traditionally suggests modest dress for men and women. The decision to wear a head covering is personal and variable among Islamic women; the interpretation of and adoption of modest dress can vary from covering all hair as well as arms and legs to dressing similarly to Western counterparts. 15 There are many different types of hijab that a woman might wear, but regardless of the type of garment worn, wearing a covering does not seem to affect whether women seek cosmetic treatments. 43 However, among women who choose to wear a covering, the type and style of that covering can influence facial shape preference and aesthetic priorities. 25 For patients who wear a full hijab in particular, a rounder face with fuller cheeks may be preferred, as this shape is often perceived as more attractive when framed by a scarf. Among women who wear head coverings, the eye and periorbital area are preferred areas for treatment.

| Patterns of aging and common aesthetic concerns
The current literature does not describe common aging patterns specific to the Middle Eastern demographic. According to the one consensus group, the eyes, lips, and cheeks are the top aesthetic priorities among Middle Eastern women, followed by skin quality/ tone/color, nose, and eyebrows. 25 In the experience of the authors, the most common signs of aging in Middle Eastern patients include darkening under-eye area, sagging in the midface, and jowling, which may be explained in part by somewhat thicker skin. 25,44 The authors note that the most challenging aesthetic issues in Middle Eastern patients include heavy faces, disproportionately large or flat and prominently wide noses, thin lips (Lebanese, Jordanian, and Syrian patients), and jowling. Middle Easterners have a similar nasal base width as Caucasian North Americans, but greater nose height with a high arching dorsum and long nasal contour. 38,45 Demand for surgical nasal alterations is high in the Middle East, and in the experience of the authors, surgical correction as opposed to nonsurgical approaches is most often necessary to achieve satisfactory results both for the patient and the clinician.
Regardless of age, most Middle Eastern women desire a natural appearance without exaggeration of facial features. 25 In general, women over 40 years want to appear younger and lifted, while younger women present with concerns around skin quality and facial shape or proportions. One author noted that it is not uncommon for younger women to report a desire to resemble beauty icons, even if this conflicts with the patient's natural features. An overview of general preferences for commonly addressed features is shown in Table 1; however, it should be noted that this guidance is not a substitute for individualized assessment to determine the most appropriate treatment approach.
During the roundtable, the panelists discussed several minimally invasive treatment approaches for common issues among their patients with Middle Eastern heritage. The following section summarizes this discussion and provides specific guidance for safely and effectively applying these approaches. While these treatment recommendations are by no means exhaustive, they touch on common techniques used to treat this patient population.

| Special considerations for the skin
Though even skin tone and texture and overall skin quality are universal indicators of health and beauty, aesthetic desires surrounding skin characteristics can vary with ethnic background. 46 Skin color is often a primary concern. Compared with Caucasians, people from the Middle East generally have darker, thicker skin that may have pigment alterations. Within this demographic, patients often voice a preference for skin tones that are lighter than their own and also actively seek treatment for pigmentary pathologies. 25 Though regional influences may impact perceptions of ideal skin tone, the authors have noticed that most people from the Middle East seem to prefer Fitzpatrick skin types II-III while Egyptian patients prefer darker skin (skin types II to IV). Skin lightening is quite common among Middle Eastern women despite the negative side effects. [47][48][49] In one recent study, 43.3% of Saudi women and 60% of Jordanians reported use skin lightening products. 47 Patients may not be aware of the risks that accompany some of these treatments, and dermatologists and aesthetic clinicians play an important role in educating patients and promoting treatments and practices that support skin health and vibrancy as well as inclusive views of beauty. 49 One survey within the United States identified uneven skin tone, discoloration (including melasma), dry skin, acne, and facial hair as top concerns for Arab American patients. 50 Treatment for melasma, which is a common skin disorder among people with pigmented skin, is challenging because the pathophysiology of the condition is not just a pigmentary issue from aggregation of melanin and melanosomes, but also includes mast cells, structural issues like solar elastosis, altered basement membrane, and increased vascularization. 51,52 Thus, management requires a multimodal treatment response. 51 A aggressive baseline treatment may involve oral tranexamic acid 250 mg twice daily for 3 months in addition to lightening or other treatment approaches (e.g., topical hydroquinone). 53 For a more advanced approach, adding laser-based treatments can improve outcomes and is recommended to address the multiple components of melasma. Figure 1 shows an example of this type of approach. In the authors' experience, the best approach is to combine a picosecond laser and microneedling with radiofrequency. Emerging data suggest that microneedling with radiofrequency restores the basement membrane, which promotes clearance of melanin. 54,55 Above all, patients with melasma should make lifestyle changes to increase sun protection, including frequent application of anti UV-A + UV-B + VL sunscreen.

| The upper face
During discussion, the authors noted that while there is a wide range of facial shapes in Middle Eastern patients, the convexity of the forehead is a key feature for which patients often seek treatment.
While several studies of areas across the Middle East report that a straight profile is preferred in some regions, forehead contour (often including the upper brow) is a feature many Middle Eastern patients wish to modify (in the experience of the authors). 25 Irrespective of overall facial shape, it is important to ensure that any hollowing in the temple area is managed to ensure youthful facial shape and support the appearance of the eyes. For the patient shown in Figure 2, management of the temples, as well as management of the mid and lower face has supported a more youthful and balanced aesthetic.

| Forehead contour
Forehead injection for improving contour is a highly sought-after procedure for Middle Eastern patients. There are a range of approaches to improve forehead convexity, and the optimal method depends on the needs of the patient. The following are key procedural points: • When managing forehead contour, it is important to assess and treat the temples first, which not only is important for harmonious appearance in the upper face, but also may facilitate repositioning tissue within the midface. 56 When injecting the temple, it is important to inject the portion of the temple within the hairline to take full advantage of indirect lifting infects. and more complexity involved in offering this procedure. Thus, fat tends to not be a first-line option for most injectors. Worth, TX]) can be used to define the jawline. Use of a more structural filler is indicated in those with thicker skin who require a robust product to project and accentuate the jawline or chin.
Management of the chin and jawline to create a more defined appearance is shown in Figure 4.
• To treat the chin, the injector can enter through the midpoint of the mentum and inject either side. For patients with wider chins, the injector may choose to enter laterally and deposit filler in a line along the jawline. A smooth transition between the lip and chin along the labiomandibular sulcus is necessary to prevent the appearance of a pointy chin. For female patients, the chin should be no wider than the distance between both medial canthi, and attention must be paid to both saggital projection and the length of the chin.
• When performing injections in the chin area, avoid the ascending submental artery, which is a branch of the submandibular artery that enters the chin deeply, approximately 6 mm off the midline and then traverses more superficially as it ascends toward the lower lip. A vascular injection can compromise the vessels leading back to the floor of the mouth via the lingual artery and cause ischemic complications in the tongue. 61,68 Injecting carefully with a large-bore cannula (22-gauge) or deep in contact with the bone when using a needle can be effective and reduce the risk for an intravascular injection. When defining the entire mandible from gonial angle to gonial angle, multiple syringes of product may be needed. Importantly, while using sufficient product is an important procedural consideration in this area, too much product in the chin (>4 cc) may lead to soreness, and rarely to discomfort with chewing or sensitivity/soreness. 69 While uncommon, excess superficial injection of filler can lead to hypervascularization and skin discoloration.

| CON CLUS IONS
People from the Middle East represent a growing and influential demographic within aesthetics. Physicians who treat these patients should take into account the extremely wide range of ethnic and cultural features among Middle Eastern patients to ensure appropriate treatment selection, optimal outcomes, and patient satisfaction with treatment. More research is needed to better understand the needs and desires of this important patient population.