Dr Varna Kugan explores the aesthetic ideals and key differences when treating Asian versus Caucasian patients and why this is important to consider in today’s clinical practice
This article draws upon publications and my clinical experience at PICO Clinic in London to outline the key differences in treating and managing the aesthetic expectations of Asian versus Caucasian patients requesting non-surgical aesthetic treatments. Asians are not a homogenous group but rather comprise many varied ethnic origins.1 It is important to note that when referring to ‘Asian’ patients, I will be referring to females from mainland China.
The majority of my patients are from mainland China, with very different perceptions of beauty and, hence, treatment requests when compared to Caucasians. They are also predominantly students and young working professionals in the age range of 20-35. Their perceptions and requests are mainly influenced by differences in facial morphology, cultural beliefs (physiognomy) and social trends. Notably, the most common treatment concerns among younger Asian patients are the result of underlying structural features.1
There is a growing number of Chinese tourists, students and working professionals coming to the UK. In fact, the number of visitor visas granted to Chinese nationals in 2018 rose by 11% to 587,986 and the number of Tier 4 (sponsored study) visas rose by 13% to 99,723 when compared to the previous year.2,3 The medical aesthetics market in 2018 in China totalled US $32.4 billion and in the past three years, the average annual growth rate of this industry was 31.83%.4
The significance of these statistics, coupled with the differences in aesthetic ideals, warrants a greater understanding of this demographic for UK-based aesthetic practitioners so that they can provide better treatment outcomes with higher patient satisfaction.
When assessing and treating the Asian patient it is important to first consider the face shape. A large national survey on the ideals of facial beauty amongst the Chinese population, published by aesthetic practitioner and Aesthetics Clinical Advisory Board member Dr Souphiyeh Samizadeh and Singaporean plastic surgeon Dr Woffles Wu in 2018, found that the most preferred facial shapes were oval (38.94%, long, thin face with pointy chin), followed by heart shape (24.06%, inverted triangle).5
The next important element to take into account is the deficiency in the projection of midline facial structures such as the forehead, glabella, medial cheek, nose and chin; giving a flatter appearance. By providing anterior projection to these midline structures one can create the illusion of ‘narrowing’ the whole face, as well as adding a more three-dimensional profile.6,7
An overview of the key objectives in treating Asian patients is outlined in Table 1, and discussed in more detail according to anatomical area below.
Whilst upper face volumisation of the forehead and glabella is common in East Asia to enhance projection and to create a more convex upper third of the face,6 in my practice I am seeing younger Asian patients requesting volumisation for temple hollowing. The hollowing in this age range, in most cases, is due to the anterolateral projection of the zygoma creating a wide bizygomatic distance,1 together with a lower frontoparietal index.8 By volumising the temples, one can create a smoother transition from the upper face to the mid-face, and thus also diminishing the prominence of the zygomatic arch. As such, lateral cheek contouring with hyaluronic acid is not welcomed by this demographic of patients, which contrasts with Caucasians.9,10
It is also important to note that Asian patients often have fewer rhytids in the upper face compared with age-matched Caucasians,11 which is due to lower recruitment of muscles in facial expression and communication in the forehead area.12
The first area that I will discuss with my patients in the mid-face is the medial malar and infraorbital regions. A lack of anterior projection in the midline is a contributing factor to the lack of three-dimensional profile in the Asian population.1,13 There is an important relationship between the infraorbital region and the medial cheek; East Asians tend to display undergrowth of the medial maxilla, and, as a result, the orbit appears smaller with a hypoplastic infraorbital rim. This can result in a tired, depressed look, with flattening of the medial cheek and infraorbital region.1,13
A common presentation is the flat medial malar and the request for central projection, so-called ‘apple’ cheeks. By volumising this region, one can add fullness to the medial cheeks and, hence, anterior projection in this area. I prefer to treat the medial cheek with a cannula technique due to the close proximity of the infraorbital neurovascular bundle.14 My entry point is at the intersection between a vertical line from the lateral canthus and a horizontal line from the tragus to the alar fossa. I place the product in retrograde threads in the deep medial cheek fat and inferior part of the medial suborbicularis oculi fat (SOOF) planes, followed by a gentle massage, and I use between 0.5ml to 1ml of Juvéderm Voluma on each side depending on the degree of concavity.
I usually see Asian patients present for correction of the tear trough deformity in isolation, but, in most instances, there is also lower eyelid bulging in association with a concave medial cheek. As such, I explain to the patient that by treating the tear trough as well as the medial cheek with hyaluronic acid fillers, we can provide more support to the lower eyelid and lid-cheek junction15 in addition to adding volume to the mid-face to enhance the anterior projection (Figure 1).
Another common treatment request by Asian patients is non-surgical rhinoplasty. There are common nasal anatomic features in the Asian population which include a wide, flat dorsum and a wide, flat alar base associated with a short columella and low radix point.16 It’s important to understand that in general, I find the Asian population do not want to look ‘Western’ but rather would prefer subtle enhancements that add anterior projection in the midline.1 Chinese cultural beliefs suggest that a person with a short, flat nose is likely to be weak, inquisitive and dependent in nature.17 In addition, a higher nose signifies better self-confidence.18 In my experience, the most common presenting complaint with regards to the nose is a flat dorsum and low radix point. I add anterior projection to the dorsum with a cannula using an entry point at the nasal tip and I place the product in the midline in the supraperiosteal and perichondrial planes. When treating the dorsum, I will also treat the radix if necessary with a deep bolus injection onto the bone so that it is in line with the upper eyelash line to further enhance the aesthetic outcome. My product of choice is a highly cohesive one such as Restylane Lyft or Juvéderm Voluma. In most cases, there is also treatment indication for a short columella due to a recessed anterior nasal spine and so I will deposit a small bolus at this point using the same cannula entry point (Figure 2).
The Asian lower face is generally characterised by a wide bigonial distance due to well-developed mandibular angles, giving the appearance of a square shape from the frontal view.1,19 According to Samizadeh et al., the majority of Asian females prefer an obtuse jaw angle in comparison with an angular well-defined jaw angle.5
Masseteric hypertrophy in non-East Asians is mainly due to bruxism compared to the East Asian population, where it is mainly due to benign masseteric hypertrophy.20 Treating hypertrophic masseters with neuromodulators can help to create a more obtuse angle to the jaw and thus help achieve the aesthetic ideal. This is one of the most common treatment requests in young Asian women and I have also noticed this in my practice.19 Cultural beliefs state that a woman with a wide and square face is thought to bring unhappiness to her husband and that a person with a square jawline can imply that they are stubborn or ill-fated.19 I use 24 units of botulinum toxin A (BoNT-A) spread across three injection points in a triangular configuration on each side, ensuring I stay 1cm away from the anterior border of the masseter to avoid the risorius muscle. I also place my injections deep onto the mandible using a 20mm needle in the region of the inferior pole of the muscle belly for optimal results.
A hypoplastic mandible can be a common finding in the Asian population, resulting in a retrognathic or retruded chin.1 This can also be associated with a hyperactive, high-riding mentalis, which exacerbates the poor vertical height and chin contour.21 By enhancing the vertical and anterior projection of the chin, one can create a more balanced three-dimensional profile. At the same time, I will usually augment the shape of the chin to create a slightly pointy chin with a rounded to triangular apex, which helps create the Asian aesthetic ideal chin shape.5 The patient in Figure 3 provides a good treatment example.
There is a Chinese proverb that states, ‘learning is a weightless treasure you can always carry easily’, which means that unlike material goods, your education is something you always take with you. With the growing influx of Asian tourists, students and working professionals to the UK, it would be highly advantageous for aesthetic practitioners to educate themselves to respect and be familiar with the main structural differences, cultural differences, presenting complaints and treatment objectives when treating this demographic. Thus, ensuring better aesthetic outcomes, higher levels of patient satisfaction and retention.
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