History

The culture of beauty is universal and dynamic. It is expressed in different ways in different parts of the world and in different periods of history. The concept of beauty itself has eluded a precise definition and has defied attempts to quantify it. Commonly published canons of facial proportions usually represent Greco-Roman standards and are not applicable to non-Caucasians. Strict adherence to these norms is therefore not necessary to obtain satisfying results in the non-Caucasian.

The attitude to aging similarly varies from culture to culture, also evolving over time. In many parts of Africa and Asia, old age is revered. There is therefore, little incentive to turn back the clock of aging. Increasing globalization and exposure to the western media coupled with the western culture of youth and beauty have had profound influence on the values and attitudes of these ethnic groups. These evolving changes in perception and attitude have emerged as the current driving force in the rapidly expanding quest for plastic surgery among non-Caucasians.

Census estimates show significant and continuing increases in the ethnic populations in the USA. Minorities are expected to constitute the majority of the USA population by the year 2050.¹ The growing population, in concert with the increasing acceptance of plastic surgery, makes the minorities an important factor in the expansion of plastic surgery for years to come, and a segment that deserves our attention. The volume of cosmetic surgical and non-surgical procedures among ethnic minorities constituted 22% of all procedures in 2006.²

Up until recently however, there has been reluctance among plastic surgeons to offer facial rejuvenation to the dark-skinned population. The reasons for this hesitance include; the fear of hypertrophic scars and dyspigmentation, the incomplete appreciation of the differences in the anatomy and physiology of aging between dark-skinned patients and Caucasians and insufficient understanding of ethnic and cultural differences in the perception of beauty.

It is essential that the plastic surgeon acquires a thorough understanding of these cultural, anatomic and physiologic differences and similarities in order to offer the best care to this population.

Anatomy and physiology of aging

While most of the signs of aging of the face are the result of ultra-violet exposure, the pathogenesis of aging is multi-factorial. They include heredity, the effects of hormonal changes, the weakening of false retaining ligaments, gravitational descent of skin, fat and muscles, decreasing function and content of glandular tissue and skeletal resorption. Progressive photodamage to the epidermis and dermis results, initially, in loss of luster, then dryness, followed by fine rhytids and dyschromia. Histologically, there is thinning of the dermis. The collagen becomes fragile and disorganized and there is quantitative decrease in elastin and fibroblast content.³

In the case of women, estrogen levels begin to decline in women in their late 30s, contributing to the progressive loss of elastin and collagen as well as slowing of the rate of renewal of cells of the skin. This is further accelerated at menopause. Progression of these effects eventually results in wrinkling and sagging. The aging process manifests differently in different parts of the face.

While both ethnic minorities and Caucasians share many of these features of aging, there are important differences that must be understood by a plastic surgeon planning facial rejuvenation of the ethnic face.

Aging in the African-American and Hispanic

To understand the aging process in the African-American one must appreciate the genealogy (the origins).

The African-American originates from three ethnic groups⁴: Africans of West and Central Africa, North European Caucasian and American and Caribbean Indians. Various permutations and combinations of the features unique to the three groups abound in the African-American community. The spectrum therefore, includes African-Americans that are almost indistinguishable from Caucasians (Fig. 17.1), to African-Americans that look mostly African or Indian and therefore age accordingly. Hispanics in the USA, to a lesser degree, show a similar spectrum. The notion of aging of African-Americans and Hispanics must therefore be nuanced, taking into account not only these differences in ethnic content but also the effects of gravity, skeletal resorption, glandular atrophy and hormonal changes, which are not dependent on race.

Fig. 17.1 Caucasian-type aging.

The darker skinned African-Americans and Hispanics are only partially protected from the ravages of ultraviolet light exposure by the melanin content of the skin. As a result, the clinical manifestations of photodamage on the skin tend to progress more slowly. The skin of the face therefore, remains smoother and more youthful, later into old age than in Caucasians and the very light African-Americans and Hispanics. Continued exposure, however, eventually results in pronounced photodamage.

Conversely, the unpredictable response of the melanocytes in this group, to trauma and inflammatory processes, often results in dyspigmentation, which may be temporary or permanent.

Differences in hair structure between Blacks and other ethnic groups have been documented.⁵ These include the flat elliptical shape of the follicles and the spiraled, thinner hair shafts. The spiral shape leads to trichonodosis and brittle hair, by impairing transmission of sebum down the shaft. The ellipsoid shape of the follicles predisposes this population to in-grown hairs and therefore pseudofolliculitis barbae which are a source of much distress to many young African-Americans and Hispanic males.

Upper face

The upper face is perhaps the most expressive part of the human face, serving as a window to various emotions. The aging process combined with years of muscle activities result in forehead rhytids, glabella frown lines and brow ptosis. Prolonged exposure to actinic damage results in skin dryness and textural changes, dyschromias, keratoses and papillomata.

One of the earliest signs of aging in the African-American and the Hispanics is frontal and temporal alopecia, which starts as early as the third decade.⁶ African-Americans males are affected more commonly than females (Fig. 17.2). Hispanics are affected less often than African-Americans. This phenomenon is further accelerated by traction from the popular practice of hair braiding.

Fig. 17.2 Frontal alopecia in an African-American, 5th decade.

However, the complaints that most commonly bring the patients to the plastic surgeon are centered around the brows and periorbital areas. Brow ptosis is a prominent sign of aging occurring a decade or more later than in Caucasians. Descent of the brow often leads to pseudo-dermatochalasis of the upper eyelids.⁷ Atrophy and graying of the brow hair exacerbates the look of advanced age.

In the darker skinned African-Americans and Hispanics, deep forehead and glabella wrinkling appear late, often in the 5th and 6th decades of life.

Lower face

Skin laxity and descent are not early features of aging in African-Americans and Hispanics. Therefore pronounced jowls appear much later in this population than in Caucasians. However, jaw-line adiposity coupled with the smaller jowls, may create the illusion of a round or square face.

Chin atrophy leads to chin wrinkling, marionette lines and down-turning of the commissures (Fig. 17.3). Bimaxillary-prognathism is more commonly seen in the African-American population⁸. This becomes even more pronounced as soft tissue atrophy occurs. Upper and lower lip protrusion and lower lip eversion are not uncommon in aging African-Americans and darker skinned Hispanics. With advancing age, perioral wrinkles appear.

Fig. 17.3 Chin atrophy/melasma.

Neck

Submental adiposity is noted early in the African-American, beginning as early as the 3rd to 4th decade (Fig. 17.4). Skin laxity and platysmal bands appear later, usually in the 5th and 6th decades.

Fig. 17.4 Submental adiposity in an African-American, 3rd decade.

Evaluation

Evaluation of the patient starts from the first meeting. During this initial meeting the plastic surgeon must make the usual observations of the patient’s demeanor, affect, habits and facial symmetry in repose and animation.

The history must include specific questions on the diseases common or unique to African-American and Hispanic patients such as sickle cell disease/trait, glucose 6P-D deficiency, sarcoidosis, hypertension, diabetes, keloids and dyspigmentations. Cultural attitudes relative to the planned procedure must be understood by the surgeon.

Physical examination should take into account the patterns of aging peculiar of these populations. Skin classification using both the Fitzpatrick (Table 17.1) and the Glogau (Table 17.2) classifications to determine skin type and extent of actinic damage, is essential.

Table 17.1 Fitzpatrick skin type classification

Table 17.2 Glogau classification of photoage groups

Physical examination should be performed in an orderly sequence with focus on the patients concerns. However in these populations the following require special attention:

Facial rejuvenation

Over the years, with greater understanding of the aging process, our approach to facial rejuvenation has shifted from operative to comprehensive management (Table 17.3). We believe that it is the surgeon’s responsibility not only to offer the most appropriate surgical treatment but also to assume a primary role in educating these patients on the pathology of photo-aging and the need for preventive measures, especially in light of the prevalent myth that dark skin protects them from sun damage.

Table 17.3 Facial rejuvenation in African-American and Hispanics, skin Types IV–VI

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Patient safety in aesthetic surgery Mastopexy with and without augmentation Belt lipectomy: Lower body lift The multi-vectored rhytidoplasty Abdominoplasty techniques Non-endoscopic limited incision browlift

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