INTRODUCTION
As the skin of color population steadily increases, the cosmetic industry is evolving in response to these changing demographics as evidenced by a multitude of skin of color targeted and specially formulated products.1,2 Patients with skin of color interested in maintaining a vibrant and youthful appearance are not only turning to over-the-counter
products to address concerns of aging skin, but are seeking both non-invasive and invasive cosmetic procedures as well.2,3
The American Society for Aesthetic Plastic Surgery reported that over 10 million cosmetic procedures were performed in the United States in 2008 (17% surgical and 83% non-surgical) representing a rise of 162 percent since 1997. In 2008, the top non-surgical procedures included botulinum toxin injection, laser
hair removal, hyaluronic acid dermal fillers, chemical peels and laser skin resurfacing.3 Between 2007 and 2008, approximately
20 percent of all cosmetic procedures were performed on skin of color patients (Hispanics 8%, African-Americans 6%, Asians 4% and other non-Caucasians 2%).3 Dermal filler devices
are on the forefront of anti-aging therapy. Among all races in 2004, over 882,000 hyaluronic acid filler injections were performed
and the number rose to over 1.2 million in 2008.4
Since patients of all ethnicities are seeking cosmetic procedures, knowledge of the facial aging patterns in skin of color patients, maneuvers to minimize adverse outcomes and safety data from clinical trials are all important factors to consider while developing
a treatment plan with skin of color patients. A familiarity with these factors is not only a part of delivering good patient care, but optimizes the aesthetic results in skin of color patients.
Aging Patterns in Skin of Color Patients
Due to the photoprotective effects of eumelanin, the manifestations
of aging in skin of color patients are often delayed by 10 to 20 years in comparison to their Caucasian counterparts.5,6 Unlike
patients of lighter skin tones, solar lentigines as well as fine and deep rhytids are not a significant manifestation of aging. Rather, textural changes, uneven skin tone, loss of volume and the presence of laxity predominates. Overall, manifestations of aging result from the interplay of fat atrophy, soft-tissue redistribution
due to gravity, bone remodeling and photo-damage.7
In assessing the aging face, it can conveniently be divided into three zones: upper face, mid-face and lower face. The aging upper face of skin of color patients displays brow ptosis, forehead
rhytids and crow's feet (but often to a lesser extent than in Caucasians), accentuated tear trough deformity, infraorbital hollowing and temporal depression. Patients may also report concerns about upper eyelid fullness and redundant skin as well as lower eyelid bags.7
The aging mid-face exhibits downward migration of the malar fat pad, hollowing of the cheeks, deepening and prominence of the nasolabial folds and marionette rhytids and nasojugal groove prominence.
The lower face often develops prominent jowls. Additionally, African-Americans may experience flattening of the lower lip with time but because they tend to have larger and fuller lips at baseline, this is rarely a cosmetic concern.
In skin of color patients, treating surface lines and creases is less of a concern.2 However, volumizing with an array of dermal fillers successfully addresses the loss of collagen, fat and bone in this patient population. As demand has increased for filler substances, product safety has not always been adequately addressed
in skin of color populations.
