Aesthetic considerations for treating the Asian patient: Thriving in diversity international roundtable series

The unique anatomy of the Asian face, along with the influence of cultural forces and regional preferences, has led to the development of specialized approaches to rejuvenation and beautification that are applicable to the aesthetic practice within Asia as well as those who serve these patients internationally.


| INTRODUC TI ON
Though ethnic differences in facial anatomy and skin physiology and their influence on signs of aging determine the aesthetic issues for which patients most commonly seek treatment, attitudes surrounding beauty are also influenced by cultural factors. When treating patients of any ethnicity, the goal is not to treat a single aesthetic standard, but rather to optimize patients' unique features while retaining ethnic characteristics and honoring the desires of the individual patient. For the Asian patient, general treatment recommendations developed primarily for Western populations may not be applied without an elevated risk of obtaining unnatural-looking results. 1 Instead, treatment plans should be designed and tailored with the unique anatomy and skin biology of the Asian face in mind.
While global and regional differences give rise to unique aesthetic needs, they also lead to the development of unique expertise on the part of treating clinicians, which in turn drives innovation on a global level. [1][2][3] For example, the use of botulinum toxin type A (BoNT-A) in the United States has centered primarily on resolution of dynamic lines, while in Asia, BoNT-A has also been further developed to address facial and body shape (e.g., jawline, calf, and shoulder contouring) as well as skin quality. 2 These techniques not only serve patients within Asia, but also influence aesthetic clinical standards the world over. This single example highlights the need for the ongoing international exchange of ideas and treatment techniques in support of both optimal and culturally sensitive care for a diverse range of patients within a given practice, as well as the evolution of aesthetic medicine as a field.
Of note, the US Asian population is not evenly distributed: 30% of US Asians live in California and 55% inhabit 1 of 5 states: California, New York, Texas, New Jersey, or Washington. 5 The Asian population in the United is also growing, and Asian Americans are expected to become the largest immigrant group in the United States by 2055. 6 In both the United States and Asia, there is growing interest in injectables and minimally invasive procedures, and increasingly younger patients are seeking aesthetic interventions. However, in South Korea, the market penetration for injectable procedures is far greater than in the US. These patterns have led to an expansion of aesthetic approaches aimed at rejuvenation and at beautification. This manuscript, which is based on the expertise of the authors, details unique features and aesthetic needs of the Asian patient and discusses the most commonly used advanced injection techniques for this patient population. It is the hope of the authors that the discussion detailed here, in combination with diligent patient communication, can support a culturally aware approach to aesthetic management and beautification for the Asian patient. Importantly, while the authors acknowledge that the unique needs of Asians across the continent are important to consider, the discussion is focused upon East Asian (e.g., China, Korea, Japan, Hong Kong, Taiwan) and Southeast Asian (e.g., Thailand, Singapore, Indonesia, Philippines) ethnic groups.

| ME THODS
A continuing medical education (CME) event series of 6 international roundtable discussions focused on diversity in aesthetics was conducted from August 24, 2021  Of note, many of the injection techniques described here are advanced and are best performed by experienced injectors with a firm understanding of anatomy and its variations. There are opportunities to serve the Asian patient with approaches outside of those detailed here, and it is the responsibility of the injector to be aware of the limits of their knowledge/skill and to be well prepared to manage any adverse events that occur. For all patient images shown, consent for photography was obtained.

| RE SULTS
During the roundtable, several key ideas were identified and developed into general themes that support optimal care for the Asian patient:

| Characteristics of the Asian face
Though there is substantial diversity in Asian populations, distinguishing features largely resulting from unique skeletal morphology and skin physiology characterize the Asian face. Compared to Caucasian counterparts, Asian patients have increased bizygomatic, bitemporal, and bigonial widths. The forehead and medial maxilla are often retruded (flat or concave), and the orbit is often smaller and relatively shallow with wide intercanthal distance.
Overall, there is a shallowing of brow, nasal, and chin projection.
Bimaxillary protrusion of a hypoplastic mandible is often present.
The nose generally has a low nasal bridge with a bulbous nasal tip and oily nasal skin.
Importantly, the ideal facial proportions of the Asian face are distinct from those of other ethnic groups, and application of ethnocentric principles developed for the Caucasian face (e.g., the "golden ratios" 7 ) leads to a remarkably disharmonious appearance and a loss of ethnicity and personality. When assessing the most beautiful Asian faces, a lack of these golden proportions in no way detracts from attractiveness. Furthermore, it is important to recognize the remarkable cultural and ethnic diversity within Asia. Thus, aesthetic treatments are best tailored to individual patient needs and preferences. 8

| Skin quality is a key priority
Various skin phototypes, ranging from Fitzpatrick Skin Type II-IV, are present in the Asian population. In general, Asian patients have thicker skin with larger, dispersed melanosomes that is less prone to photoaging and the development of fine lines and wrinkles as compared to Caucasian skin. 9 However, Asian skin is also more prone to post-inflammatory hyperpigmentation (PIH), melasma, lentigines, freckles, and other dyschromias, occurring earlier than in Caucasian counterparts. 10 This propensity is relevant when managing the Asian face with energy-based devices; it is important to be aware of the potential for PIH and to ensure appropriate energy settings are used and pre/post procedure measures are taken. 11,12 Importantly, skin quality concerns change over time, and predominating concerns differ depending on patient age. 13  A recent consensus manuscript by Park and colleagues provides detailed information on approaching these issues using multiple modalities aimed at addressing aging in multiple tissue layers. 13 For melasma in particular, a q-switched or picosecond laser may be used on the same day as a 1927-nm diode or thulium laser. For Asian patients, followed immediately with a topical class 2 steroid to reduce the risk of PIH. 14 One example of how patient prioritization of skin quality has spurred innovation is the microtoxin technique, which comprises injection of diluted BoNT-A (~5-7 cc/100 U of onabotulinum toxin A or incobotulinum toxin A) microdroplets into the skin and immediate subdermal plane. 15,16 When injected in this way, BoNT-A can act as a neuromodulator, reducing dynamic lines or the action of the most superficial fibers of the depressor muscles. In this tissue layer, BoNT-A may also act on cholinergic pathways that control the activity of glandular tissues within the skin as well as non-cholinergic pathways. [17][18][19][20][21] Microtoxin is a versatile technique and has been used to improve skin quality through reducing pore size and sebum production as well as to treat medical skin conditions such as rosacea and acne. Strategically placed BoNTA along the pre-mandibular platysma, may also reduce laxity of the lower face and improve definition of the jawline. 16,22,23

| Key aesthetic concerns and the role of facial shape and projection
Whether the goal of treatment is beautification or rejuvenation, the management of facial shape, 3-dimensionality, and proportions are important parts of any treatment plan. For males, the ideal facial shape is angular and rectangular, while an oval shape is a universal beauty standard for females. 24 In a survey of 596 female patients conducted in China, when presented with 8 facial shapes, respondents most often preferred a narrow lower face with either a pointy (51.93%) or round chin (36.52%); a square lower face was least preferred (0.17%). 25 Of note, the third most preferred facial shape was selected by only 1.84% of patients, reflecting a strong preference. For facial profile, a convex forehead in the Asian patient is an important part of creating a balanced aesthetic. In one recent consensus statement, authors prioritized management of masseter hypertrophy, followed by increased temporal width and angles of the chin, with attention to excess soft tissue and the need for additional bony support. 8 An example of facial shaping with neuromodulators is shown in Figure 1.
In the experience of the authors, proportion will naturally follow if facial shape and projection are adequately managed in the Asian patient. Broader aesthetic concerns may change over time, but the desire for an oval facial shape and improved projection of facial features, including the medial cheek, nose, brow, and chin, are nearly universal. 1 In addition, with age, the outline of the face becomes less oval and more segmented and irregular, and an approach that seeks to smooth these transitions is recommended. For younger patients (18-30 years of age), the most common aesthetic concerns focus on a combination of early aging events and beauty concerns, including facial shape (masseter volume in particular), shallow nasal shape, and hollowed tear trough. 1,26 As patients age (31-40 years), these shape-based concerns shift, and predominant concerns include more pronounced nasolabial folds, tear trough, and malar volume. Upper facial lines are an emerging concern, predominantly for patients 41-55 years of age, along with tear trough/malar volume loss, and nasolabial folds. For patients >55 years of age, leading concerns include the upper eyelids, malar volume loss, and jowling. 1

| Attention to the eyes
Due to the combination of thicker skin, retruded orbital rims, and shallow orbits, hooding or heaviness in the upper eyelids is a commonly encountered concern. 1,27 For the Asian patient, opening the eye and creating a rounder shape creates a more youthful and attractive appearance. The positive impact of aesthetic interventions on first impressions is known, 28,29 and ensuring an open and inviting expression for the eyes in particular is central to positive interpersonal interactions. While filler injections are discussed in detail below, it is important to note that BoNT-A can be used to adjust the position of the brow and infraorbital openings, and 0.1% oxymetazoline hydrochloride (Upneeq, Bridgewater) may be used to address asymmetry due to acquired ptosis. Hooded lids may also be managed using microfocused ultrasound with visualization (MFU-V) in the forehead to non-surgically lift the brow by ~1.9 mm and externally applied monopolar radiofrequency to tighten the skin within the orbit. Published treatment algorithms describe the use of MFU-V, hyaluronic acid (HA) filler, and BoNT-A in combination to rejuvenate the eye. 30 Importantly, a fully ablative erbium laser may be used for patients with significant lid skin crepiness, but patients should be advised that they can expect post-inflammatory hyperpigmentation for ~3 months following treatment. This risk is present for all Asian patients, including those with lighter skin types and those who are half Asian.

| Advanced techniques for treating the Asian patient
During the roundtable, the panelists discussed several advanced filler injections to improve patient facial shape. The following sections summarize this discussion and provide guidance for safer and effective application of these approaches. The patterns of aging as well as the inherit facial morphology of the Asian face often result in a need for medial or central face augmentation, which has a higher risk of vascular compromise. 31 Vascular compromise for the forehead can be particularly devastating: not only are fillerinduced blindness and local ischemia possible, but stroke induced by filler injection has been reported in this area. 32 The nasolabial fold, medial maxilla, nose, tear trough, glabella, and forehead should F I G U R E 1 46-year-old Asian American female who presented with the complaint that her lower face appeared heavy and was developing jowls, before (A, C) and 1 month after (B,D) treatment with 36 U of onabotulinum toxin-A to the masseters and 44 U to the mentalis, DAO, and platysma. A more youthful shape has been restored while improving her jowls. (Image courtesy of Dr. Sabrina Fabi).
be approached with a high degree of caution in any patient due to increased risk, and the injector should be well prepared to manage adverse events that arise. The following are important safety considerations for these approaches. This list is by no means exhaustive, and the clinician should be aware of the safety considerations for each modality.
• When managing the jowls with chemolipolytic agents, it is important to avoid the marginal mandibular nerve and focus treatment on fat that is superficial to the platysma.

FU N D I N G I N FO R M ATI O N
Funding for this CME event was provided by Abbvie, Galderma, Merz, Solta, and RVL.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

E TH I C S S TATEM ENT
Patients treated as part of this CME event provided informed consent and permission to publish their images.