Universal and Ethnic-specific Considerations on Facial Rejuvenation: Where Do You Inject Your Fillers?

1 Sir: I May 2016, Plastic and Reconstructive Surgery published updated guidelines for aesthetic use of hyaluronic acid fillers and botulinum toxin type A, developed by a Global Aesthetics Consensus Group including a multinational panel of key opinion leaders in plastic surgery and dermatology from Asia, Australia, Europe, and North and South America.1 Notably, in recognition of increasing patient diversity in clinical practice, the panel recommended a broad perspective, encompassing patient age, ethnicity, and sex, to achieve the more accurate objective of facial harmonization rather than mere rejuvenation. We aim to further explore this topic with a special regard to universal and ethnic-specific facial features in females. Universal ideals are traditionally based on neoclassical canons developed by artists and anatomists in the 17th and 18th centuries and derived from the Ancient Greece culture, yet representing mostly white.2 Review of the modern literature identifies 7 key facial features that subconsciously impact perception of beauty.3 Four of those (facial shape, eyebrow shape, nose, and lips) are amenable to injection contouring with fillers, whereas 3 (forehead height, eye size and intereye distance, and skin tone and texture) are beyond the domain of injection therapy.3 However, the growing heterogeneity of our society in terms of multiple ethnic groups makes these ideals not applicable to a large extent of the US population. Analysis of studies recently published in Plastic and Reconstructive Surgery reveals midface and lips to be the regions of the face with the higher degree of interethnic variability, which can be effectively reshaped with injectables.4–6 This and our daily practice allow to formulate practical and simplified guidelines on appropriate facial injection areas in Asian, black, and Hispanic patients compared with their white counterparts (Fig. 1). Because of underlying skeletal and morphological features, Asians tend to present a shorter face, with wider bitemporal, bizygomatic, and bigonial width and structural low projection of the central third of the face.4 Therefore, in distinct contrast with patients of European descent, who commonly seek augmentation of lateral maxilla and zygoma, adequate treatment of Asian patients should be limited to medial maxilla volumization to enhance central projection and avoid the creation of facial disharmony by further widening the midface. Lip augmentation is normally not indicated in Asians, especially those of South-Eastern origin, who present greater lip fullness and may more likely desire lip reduction to balance the lower third of the face. Women of African descent may experience fewer issues requiring facial soft-tissue augmentation, as a consequence of specific characters of their skin, such as less thinning of collagen bundles and elastic tissue.5 However, aging black patients may seek to restore the youthful fullness of their lips. To this end, injectable products are placed only in the upper lip, as the lower lip usually maintains its volume. Finally, Hispanics, who have mainly originated by the intermingling of European immigrants and native populations of the Americas, may present with predominately white or Native American facial features.2,6 Practically, the white aesthetic standards apply well to Hispanic patients of European descent, whereas patients with predominant Native American characters, including a strong mongoloid component on their facial features, can be treated by referring to the abovementioned recommendations formulated for Asians. Carlo M. Oranges, MD Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery Basel University Hospital Spitalstrasse 21 4031 Basel, Switzerland E-mail: carlo.oranges@usb.ch