I have had the good fortune of practicing facial plastic surgery in Hawaii since 1976. The composition of my practice has mirrored the ethnic makeup of Hawaii with ~70% Asian and 30% Caucasian. Thus, I have gained considerable experience in cosmetic surgery of the Asian face. As every surgeon who has experience in Asian cosmetic surgery knows, there are considerable differences as compared with a cosmetic surgical practice emphasizing Western patients. These differences are not merely anatomic. In fact, the psychological aspects of Asian cosmetic surgery provide a greater challenge than mastery of the surgical techniques themselves.

Cultural and psychological factors often prove more complex and cannot be underestimated. It is sometimes difficult for many Western surgeons to understand exactly the Asian patient’s needs, which is why much of this surgery is increasingly performed by Asian-American surgeons.

To understand the Asian patient, it is crucial to take into consideration the cultural and sociological particularities.

♦ Anatomic Considerations

The Mongoloid branch of mankind, easily the largest race of our species, originated in eastern Asia and later migrated to areas both contiguous and distant, including Indochina and the Indian subcontinent, Malaysia, Polynesia, Melanesia, and Micronesia, as well as North and South America (i.e., Eskimos and North and South American indigenous peoples, aka “Indians”). Because of the wide geographical diffusion, the physical characteristics of this race show a tremendous variation, as do, for example, the many ethnic subdivisions of the Caucasian race.

Westerners tend to possess a stereotyped conception of the physical traits of Asians: yellow skin pigmentation; straight, coarse black hair; a flat face with high malar eminences; a broad, flat nose; and narrow, slitlike eyes with a characteristic epicanthal fold. Although the stereotype may be loosely applied to the eastern Asian group of people (i.e., Chinese, Koreans, and Japanese), the aesthetic surgeon should appreciate that considerable individual variation exists in all of these physical traits. For example, ~40% of East Asians originating from the more northerly latitudes have a straight or convex nasal dorsum.

Similar variations exist in other Asian subgroups. In general, however, individuals originating from southern Asia tend to have more deeply pigmented skin, exhibit greater flattening and concavity of the nasal dorsum, and display a more westernized eyelid configuration (i.e., a more clearly defined superior palpebral fold, although generally smaller and less well defined than Caucasians, and absent or rudimentary epicanthal fold as compared with the features of northern Asians). The lips of southern Asians tend to be more voluminous than individuals originating from northern Asia.

From the point of view of the aesthetic surgeon, the physical diversity of the Asian population notwithstanding, certain facial features do form a reasonably distinct basis for surgical intervention and justify specialized study of surgical techniques that consistently and reliably produce good aesthetic results in the Asian face. These facial features typically include the following traits:

My observations suggest that microgenia is somewhat more common in Asians than in Caucasians. Many Koreans exhibit prominence of the mandibular angle at times accentuated by masseteric hypertrophy.

♦ Skin Color and Texture

Whereas the classic Western stereotype of Asian skin being yellowish in coloration is not without considerable biological justification, there is actually wide variation in color and texture of the skin in individuals of this race. Generally, skin pigmentation is darker in Asians originating from southern latitudes, and this is consistent with the observation that skin color, as well as other biological traits, evolved as an adaptation to the climatic environment. Approximately 75% of individuals who originate from the northern and central latitudes of eastern Asia (i.e., northern Chinese, Koreans, and Japanese) have light-colored, somewhat milky skin pigmentation; the remainder exhibit varying degrees of brownish coloration. The yellowish hue of Asian skin is largely a consequence of the number and distribution of melanin granules rather than of variations in lipoproteins or other biochemical components of the skin.

A wide variation in skin texture and thickness exists among East Asians, the dermis being thicker and more fibrous in individuals with darker pigmentation. The skin of lightly pigmented Asians, however, tends to demonstrate greater density than that of pale-skinned Caucasians. This greater collagen density is manifested in a tendency toward a more vigorous fibroplastic response during wound healing, which may result in prolonged hyperemia during scar maturation and an increased incidence of hypertrophic scarring as well as occasional keloid formation. Such prolonged hyperemia of incisions tends to occur even in lightly pigmented Asians.

Increases in dermal thickness may account for a substantially lower incidence of fine wrinkles in both darker and more lightly pigmented Asians than in comparably pigmented Caucasians. This may account for the myth that the Asian face ages more slowly than the Caucasian face. Actually, a considerable number of fair-skinned Asians do develop fine wrinkles as aging progresses. Aging is associated with a substantially greater incidence of pigmented dermatosis (lentigines, actinic keratoses, seborrheic keratoses, etc.) as compared with Caucasian skin. In general, however, skin malignancies of all types are considerably less common in the Asian face than in the Caucasian face.

In many Asians, accumulation and/or ptosis of fat, particularly in the jowls, nasolabial mound, buccal area, and submental region, appears to be more marked than noted in Caucasians of comparable age, necessitating special attention in planning facial rejuvenation procedures. In other patients, particularly Koreans, facial aging is accompanied by atrophy of fat in the buccal region and temporal fossa.