Rejuvenation of the Aging African Face

Anthony E. Brissett and Jose P. Zevallos

Persons of African descent represent the most rapidly growing group of patients seeking cosmetic surgery within the United States. When considering surgical rejuvenation procedures, it is imperative that the facial plastic surgeon recognize the unique characteristics of the aging African face. Because of the photoprotective effects of melanin, persons of African descent experience cutaneous photoaging to a much lesser degree than do Caucasians with similar ultraviolet light exposure. The brow and forehead regions demonstrate minimal signs of aging in Africans compared with those of Caucasians. The periorbital and midface regions represent the most prominent and earliest regions of facial aging in blacks, as a result of the unique skeletal morphology found in this population. Additionally, the effects of thicker skin and subcutaneous tissues on a hypoplastic underlying support system make Africans susceptible to develop the signs of lower face aging. A thorough understanding of the distinctive characteristics of facial aging within the African population allows the facial plastic surgeon the ability to tailor one’s surgical management, thus improving outcomes and increasing patient satisfaction.

Over the past several years, there has been a marked increase in the number of African-American patients seeking facial plastic surgery. According to the American Society of Plastic Surgeons, African Americans are one of the most rapidly growing groups of patients seeking cosmetic surgery in the United States. In 2006, African Americans accounted for more than 780,000 cosmetic procedures performed.¹

The effects of aging on the face are complex and include a multitude of factors such as exposure to ultraviolet radiation, nutrition, and medical comorbidities. When one considers facial rejuvenation in persons of African descent, it is critical to have a thorough understanding of how the aging process may differ from the traditionally described features of facial aging.^2–4

The African-American population represents a diverse cultural group composed of multiple ethnicities; therefore, generalization about facial structure and the impact of aging is difficult. There are key features of the African face, however, that distinguish it from the faces of other racial or ethnic groups. The purpose of this chapter is to draw attention to the facial features unique to persons of African descent and describe how they change and evolve with age, highlighting important differences from the traditionally described models of facial aging.

♦ Cutaneous Changes Associated with Aging

Anatomic and Physiologic Features of African Skin

The hallmark feature of black skin is the quantity and epidermal distribution of melanin. Melanin has been shown to protect the skin by absorbing and deflecting UV radiation. Racial differences in skin color are determined by variations in the number, size, and aggregation of melanosomes within melanocytes. Whereas it has been established that all races have a similar number of melanocytes, black skin is characterized by having large, nonaggregated melanosomes dispersed throughout the entire epidermis. In contrast, Caucasian skin has aggregated, compact groupings of melanosomes that tend to be found only in the stratum basale. The larger, individually dispersed melanosomes found in African skin have a higher melanin content and are able to absorb more UV energy than do less aggregated, smaller melanosomes in Caucasians.⁵

In addition to differences in pigmentation, important structural variations exist in black skin that impact upon facial aging. The stratum corneum in persons of African descent tends to be thicker than in Caucasians and has increased lipid content.⁵ There are also marked differences in the epidermis between black and white skin that become more pronounced over time. Facial skin in older Caucasians has been noted to have numerous areas of focal atrophy and necrosis when compared with facial skin of persons of African descent exposed to similar amounts of UV radiation.⁶ The most significant difference between African-American and Caucasian skin lies at the level of the dermis. African-American facial skin has a thicker and more compact dermis, as well as an increased number of active, multinucleated fibroblasts. Additionally, the collagen fiber bundles are smaller and more compact and run more parallel with the epidermis.⁶ This preserves the structural integrity of soft tissues in blacks and accounts for the youthful appearance of skin into late life (Table 13.1).

**Table 13.1** Key Characteristics (and Their Implications) of the Skin of Persons of African Descent
Characteristics	Implications
Epidermis
Increased melanin content	Less pronounced photoaging
Dermis
Multinucleated, large fibroblasts	Skin elasticity is preserved Increased incidence of keloid formation
Hair
Angulated hair follicles/spiral hair type	Pseudofolliculitis
Fewer elastic fibers anchoring follicles to dermis	Increased incidence of alopecias

Photoaging and Its Effects on African Skin

Exposure to solar UV radiation is the main environmental factor that contributes to premature aging of skin. UV radiation results in a decreased production of type I collagen by interfering in the procollagen production pathway. An increased rate of collagen breakdown accounts for a deficit in the structural organization and integrity of the dermal extra-cellular matrix. The accumulation of damaged, imperfectly organized collagen over years of exposure to UV radiation translates into the clinical findings associated with facial aging, such as fine wrinkles, rhytides, and thinner skin.⁷

Because of the photoprotective effects of melanin, persons of African descent experience photoaging to a much lesser degree than do Caucasians. It has been demonstrated that black skin shows only minor changes with long-term exposure to sunlight compared with profound alterations noted in white skin.⁶ The clinical features of photoaging in black skin include fine wrinkling and mottled pigmentation. Unlike Caucasians, the signs of photoaging tend to become apparent in the fifth and sixth decades of life.⁸^,⁹

♦ Structural Changes in the Aging African Face

Because of the minimal impact of photoaging on African-American skin, the signs of aging in the African face are primarily a manifestation of changes to the deep structures of the face, including the superficial musculoaponeurotic system (SMAS), muscular layers, fatty tissues, and underlying facial skeleton. In this section, we will review the structural changes associated with facial aging in persons of African descent and examine the upper, middle, and lower thirds of the face in detail.