Options and Challenges for Facial Rejuvenation in Patients With Higher Fitzpatrick Skin Phototypes.

People of color comprise approximately 47% of the US population; more than half of the population growth is owing to peoplewhoidentifyasHispanic,andtheAsianpopulationgrew faster than any other ethnic group between 2000 and 2010. The white population of the United States is projected to be in the minority by 2044.1 A recent surveyby theAmerican Society for Aesthetic Plastic Surgery indicates that ethnic minorities constitutednearly 22%ofpatientsundergoing cosmetic procedures in 2014, and this percentage is increasing.2 Despite thesestatistics thatproject agrowth indemandforcosmetic procedures by dark-skinned individuals, there is a paucity of literature regarding the treatment of these patients. In this issueof JAMAFacialPlastic Surgery,Harris andSundaram3 add to thebodyof literaturebydemonstrating the safetyofmicrofocusedultrasound inpatientswithhigherFitzpatrick skin types. The safety of this procedure may be owing in part to the unique characteristics of and challenges posed by Fitzpatrick skin types III to VI. Melanin is photoprotective; therefore, darker-skinned individuals aremore likely to exhibit changes consistent with intrinsic aging (softand hard-tissue volume loss, gravity-induced soft-tissue redistribution, and deep rhytids) later in life compared with fairer-skinned individuals who tend to have a higher incidence of changes related to photo damage (wrinkles, lentigines, keratosis, mottled pigmentation, telangiectasia, lossof translucency, textural roughness, and sallow color) earlier in life. Paradoxically, high skin melanin contentpredisposespatients todyspigmentationand formationofkeloidandhypertrophicscarsafter injury.4,5These complications can result in surgeon consternation as well as patient distress, since evenly pigmented skin is often viewed as aesthetically pleasing by people of color.6 These risks limit the use of ablative therapies, such as laser resurfacing, dermabrasion, andmedium to deep chemical peels, in individuals withhigher Fitzpatrick skin types. Several studies havedocumented the safety of dermal fillers in addressing facial volume loss andbotulinumtoxin in the treatmentofdeep rhytids in patients of color.4,6 However, nonablative techniques to tighten and lift lax skin are preferred in these individuals to minimize the risk of complications. A variety of nonablative technologies have been developed that induce dermal collagen denaturation and contraction, resulting in skin tightening. These systems are growing in popularity yearly owing to decreased recovery time, increased safety, and cost effectiveness.2,4 They limit injury to thedermis and epidermis by coupling epidermal coolingwith electromagnetic radiation delivery (including pulsed dye, 532-nmpotassiumtitanylphosphate, intensepulsed light,Nd: YAG, anddiode and erbiumglass).4,5 Becausenoopenwound iscreatedwith thesesystems,adverseeffectsare limited toerythema and edema, while modest improvements in skin texture and rhytids are expected. Fractional thermolysis can producemore pronounced improvements intheappearanceofrhytidsbycreatingdiscretecolumns ofmicroscopic thermal injury to the epidermis and dermiswith laserswithout apparentwounding.5,7 Several studies havedocumented the safetyofnonablative therapies and fractional resurfacing in patients with Fitzpatrick skin types III to VI, with the caveat that the density and energy of the treatment correlate with postinflammatory hyperpigmentation.4,7 An increased risk of complications indeeply pigmented skin is recognizedwith fractional resurfacingandnonablative lightdelivery systems because dark skin absorbs electromagnetic energymuchmoreefficiently thanfair skin (upto40%morewhen fluenceandexposuredurationremainconstant), increasing the riskof thermal injury inhighlymelanizedskin.Moreover,melanin’swide absorption spectrum (250-1200nm) renders nearly all visible-light and near-infrared dermatologic lasers capable of inducing irreparable wounding in dark skin.5 Nonablative therapies that deliver thermal energy without the absorption of photons can be applied safely regardless of skin type, and thereforemay have lower adverse effect profiles and enhanced predictability. These devices deliver electrical energy through radiofrequency5 or deliver ultrasound energy.3Thecapacityofvisualizing the regionof interest toensure acoustic coupling before delivery of ultrasound energy is another advantage of microfocused ultrasound. The proven safety ofmicrofocused ultrasound in patientswith Fitzpatrick skin types III to VI adds another instrument to the armamentariumofnonablative facial rejuvenationforsurgeonswhotreat patientswith all skin types.3 Further studies are needed to determine the efficacy of this therapy in patients of color.