The non-Caucasian face has many unique attributes, including skin tone, texture, elasticity, skin thickness, and subcutaneous fat content. These differences may place the patient at increased risk for scarring and pigmentation issues. In this paper, the authors discuss treatment options, surgical and nonsurgical, for rejuvenation of the upper face and midface, including the periorbital region. The selection of the proper treatment must be coupled with a thorough understanding of the age-related changes that occur in the non-Caucasian face to meet and hopefully exceed the patient’s expectations.
In the nineteenth century, Johann Friedrich Blumenbach popularized the term “Caucasian” to describe a distinct group of people from the Caucasus region with specific craniofacial features. Although the Caucasus region lies between Europe and Asia and includes Russia, Georgia, Armenia, Azerbaijan, and Iran, the term Caucasian has since been used to describe those individuals of European origin. Although age-related changes have some similarities between Caucasians and non-Caucasians, there are also some distinct differences. In this paper, the authors discuss treatment options, surgical and nonsurgical, for rejuvenation of the upper face and midface, including the periorbital region. For the purposes of this paper, the term non-Caucasian includes African American, Middle Eastern, and Asian ethnicities.
Facial analysis
The Upper Third of the Face
The ideal eyebrow shape was defined as an arch where the brow apex terminates above the lateral limbus of the iris, with the medial and lateral ends of the brow at the same horizontal level. This definition has been further refined to provide a framework for the analysis of the upper third of the face and subsequent treatment options for forehead rejuvenation. Biller and Kim studied the ideal location of the eyebrow apex in Asian and white women. Their findings suggested that neither the ethnicity of the models nor the ethnicity of the volunteers who analyzed the eyebrow position had a significant role in determining the ideal eyebrow position. A survey of plastic surgeons and cosmetologists regarding eyebrow shape in women by Freund and Nolan found that a medial eyebrow at the level of the supraorbital rim was ideal and that brow lifting techniques tend to elevate the medial eyebrow above this level. Increasing eyebrow height with age has been previously reported, and this phenomenon has been attributed to habitually contracting the frontalis muscle. Therefore, an overly elevated brow may not only result in a surprised appearance but also impart an aged countenance.
During the evaluation of the upper eyelid, the forehead should be assessed for ptosis, as this may confound the diagnosis of upper eyelid dermatochalasis. The surgeon should evaluate the upper eyelid to rule out the contribution of blepharoptosis. The position of the upper eyelid should ideally rest at the level of the superior limbus. If unilateral blepharoptosis is identified, the surgeon must rule out blepharoptosis in the contralateral eye, as Herring’s Law may apply in this situation. The Asian upper eyelid has several distinct anatomic characteristics including low, poorly defined or absent eyelid crease, narrow palpebral fissure, and/or epicanthal fold.
The Lower Lid/Midface Complex
Evaluation of lower eyelid position and laxity is an essential part of the examination. The ideal position of the lower eyelid margin is at the inferior limbus. A snap test and lid distraction test are key components to the evaluation of lower eyelid laxity. A snap test is performed by grasping the lower eyelid and pulling it away from the globe. When the eyelid is released, the eyelid returns to its normal position quickly; however, in a patient with decreased lower eyelid tone, the eyelid returns to its normal position more slowly. The lid distraction test is performed by grasping the lower eyelid with the thumb and index finger; movement of the lid margin greater than 10 mm demonstrates poor eyelid tone and an eyelid tightening procedure is indicated. A Schirmer test is indicated if there is concern about dry eye syndrome. Progressive loss of elastic fibers and collagen organization lead to dermatochalasis (loss of skin elasticity and subsequent excess laxity of lower eyelid skin). In addition, the orbital septum weakens with age leading to steatoblepharon (pseudoherniation of orbital fat). Orbicularis oculi muscle hypertrophy is also associated with age-related changes of the upper and lower eyelid complex.
The tear trough is also known as the nasojugal groove and is defined as the natural depression extending inferolaterally from the medial canthus to approximately the midpupillary line. A hollowness may be present lateral to the midpupillary line and parallel to the infraorbital rim; this has been referred to by various names, including the lid/cheek junction. Various anatomic explanations for the tear trough deformity have been provided in the literature, including an attachment of orbital septum to arcus marginalis at the level of the orbital rim, a gap between the levator labii superioris alaeque nasi muscle and the orbicularis oculi muscle, and loss of facial fat in the tear trough or pseudoherniation of fat superior to the tear trough. The tear trough and lid/cheek junction occur inferior to the orbital rim and arcus marginalis.
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