Rejuvenation of the Aging East Asian Face

Jeffrey M. Ahn and Jason P. Sulkowski

It has been a traditional maxim that the peoples of East Asia (hereinafter, Asians) “age better” than Caucasians do.¹ Even so, increasing numbers of Asian patients have been seeking out facial rejuvenation surgeries including facelifts and blepharoplasties. As the nations of East Asia become wealthier and progressively more Westernized, there is less bias against individuals seeking cosmetic procedures to reverse the aging process.²

The differences that contribute to the younger appearance of Asian adults are also responsible for causing standard cosmetic procedures that were developed on a primarily Caucasian population to need varying degrees of adjustment. Asians have thicker skin with more elastic fibers and do not develop fine wrinkles such as Caucasians do.³ This thick skin, however, gives Asians a propensity to develop hypertrophic scars, obliging the surgeon to take care to conceal the incisions. The Asian mesocephalic face is rounder and flatter than the Caucasian face, which tends to be long and narrow. This is due to more prominent zygomatic arches and zygomas. As a result, surgeons must adjust their facelift technique to avoid complications of excessive stretching of skin over these more prominent areas. Bearing in mind features such as these allows one to better accommodate the specific idiosyncrasies of the Asian face.

One should not immediately assume that all Asians have thicker, more pigmented skins. Among the peoples of East Asia, those from Northeast Asia (roughly Korea, Japan, and northern China) tend to have lighter-color skin with less pigmentation than do the peoples of Southeast Asia. Therefore, it would be prudent to subclassify their skin type into finer categories to enhance the rejuvenation treatment result and minimize the possibility of complications. In this chapter, we will focus on the surgical treatments available that are tailored to the aging Asian face. But before this, we would like to briefly discuss the less invasive treatment options for these patients such as Botox (botulinum toxin type A; Allergan, Inc., Irvine, CA) and filler injections, peels, and intense pulsed light (IPL) and laser treatments.

♦ Minimally Invasive Treatments of the Aging Asian Face

Just as in Western countries, Botox injections for facial wrinkles are widely popular among Asians for the treatment of wrinkles. It is the senior author’s experience that Asian patients tend to require larger dosages of the toxin than do Caucasian patients to achieve the equivalent results. Also, in thicker-skinned patients, the combination of Botox injection and filler injection is ideal for the treatment of deeper wrinkles with permanent skin changes such as glabellar furrows. Thicker Asian skins tend to accommodate the filler injections well with less possibility of skin irregularities.

On the other hand, one should be extremely careful about applying chemical peels and skin resurfacing lasers on Asian faces because of the possibility of hyperpigmentation and hypertrophic scars. In fact, only light to medium-depth chemical peelings are recommended, and one should refrain from deep peels on these patients. These patients should be fully warned about prolonged erythema (typically 2 to 3 times longer than in Caucasian skin) and possible worsening of pigmentation that can become permanent.

Hyperpigmentation is a popular concern among Asians in general. Therefore, laser and IPL treatment are widely sought-after procedures in East Asian countries. The senior author recommends the use of the second-generation intense pulsed light (I2PL) device with an extra filter as an added safety feature. Again, it would be prudent to start these treatments at the lowest settings and try spot testing whenever possible. This principle also applies to other laser and skin-tightening procedures in Asian patients with thicker skin to avoid the complication of permanent scarring and hyperpigmentation.

Fig. 14.1 (A) Preoperative view of the Asian eyelids with no supratarsal folds. (B) Postoperative view of the Asian eyelids after the creation of the supratarsal folds.

♦ Upper Blepharoplasty

The upper blepharoplasty is a common procedure sought by Asian patients, many of whom are younger individuals who desire creation of a supratarsal fold to have a more aesthetic appearing eye (Fig. 14.1). In an elderly individual, this same procedure is able to correct mild blepharoptosis that makes the eyes look tired. By simply creating a supratarsal fold in an eyelid without it, mild to moderate form of blepharoptosis is corrected by the tucking effect that the double eyelid fixation has on the excess eyelid skin.

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