Aesthetic considerations when treating patients of African descent: Thriving in diversity international roundtable series

Black patients of African descent are an ethnically diverse demographic and have unique anatomical features, aging processes, and responses to aesthetic procedures that must be considered when planning treatment.

beauty and youth. For African, African American, and Black patients, an understanding of differences and commonalities in anatomical features, skin characteristics, treatment preferences, and aesthetic concerns is critical for providing culturally aware and biologically appropriate care. This manuscript aims to discuss distinguishing features of Black African American, African Latin American, and African European patients and how these differences can affect aesthetic treatment approaches.
Like other demographic categories in the United States, "African American" is a broad descriptor and can include a wide range of patients with varying genetic and phenotypic influences. Within Africa, there are a large number of ethnic groups with distinctive features, and this diversity is reflected in patients of color (POC) not only on the African continent but across the rest of the world. In addition, within the US Black population, forced migration through slavery, more recent international immigration, and interracial families introduce additional diversity. 1 Thus, the term African American or Black encompasses a wide range of people with many different ethnic and cultural backgrounds, including African, Afro-Caribbean, European, Native American, and Hispanic or Latino. 2,3 Indeed, 13% of Black Americans identify as multiracial, an increase from prior years. 1 For the North American aesthetic practice, this diversity in ethnicity and culture has important implications, especially given that African American and Black patients, who make up roughly 14% of the US population, are an important demographic seeking aesthetic treatment. 2 Overall, 11% of people seeking aesthetic procedures in the United States identify as Black, African American, African, or persons of African descent, and this percentage is only expected to grow. 4 Maintaining a natural look and preserving ethnic features are primary goals of any aesthetic treatment. 5 Patients of African descent not only have unique skin biology, but also unique anatomical features that give rise to a pattern of aging that strongly influences the types of treatments needed as well as patient preferences. 3 Nevertheless, mainstream aesthetic treatment approaches in the United States are primarily tailored to Caucasian features, aging patterns, and beauty standards, and an unmet need for treatment guidance that is tailored to different ethnic populations remains. 6,7 In order to build this body of knowledge, the expertise of physicians who treat patients of color in a range of different cultural settings is needed. Together, these perspectives build a strong basis for culturally sensitive care.

| ME THODS
A continuing medical education (CME) event series of 6 international roundtable discussions focused on diversity in aesthetics was conducted from August 24, 2021

| RE SULTS
During the roundtable, several key considerations arose for clinicians who treat African, Afro-Caribbean, African American, and Black patients. These ideas surfaced during the roundtable and were developed into key ideas that can support culturally aware communication and patient management in clinical practice.
• Patients must be managed as individuals. Individualized treatment is central to the successful treatment of all patients. While generalizations can be helpful to some degree, patients of African descent in the United States and internationally have a broad range of ancestral heritage and multiethnic backgrounds, meaning each individual patient will have unique features and desires that require a tailored treatment approach. A culturally informed clinician will integrate a broad understanding of anatomy as well as cultural and ethnic influences into treatment considerations and conversations with patients, but must also prioritize each patient's individual anatomy as well as personal concerns and desires.
• Perceptions of features may be shaped by regional context and ethnic group. Perceptions of features can be driven by local culture. For example, one African patient who was treated during the CME session was said to have "small" lips; however, this same patient in the United States would be considered to have full lips and would be unlikely to present for treatment of this issue. This instance highlights the importance of diligent communication with patients in order to understand personal preferences. Differences in treatment requests can also be shaped by the ethnic group(s) to which patients belong. For example, a male patient treated by one of the authors who practices in South Africa (NK; Figure 1) demonstrates characteristics of one of the largest ethnic groups in South Africa, Nguni, with features including a strong brow and large orbit that give rise to an intense gaze; these features are also associated with early temporal hollowing. For these patients, treatment for facial contour must both rejuvenate appearance of the under-eye area, brow, and temples while honoring the strong brow and not overtreating the upper face. These patients also have a thin, flat, or slight posteriorly inclined chin. In many males, this is a natural occurring, attractive feature and many do not see it as a so-called "weak chin" as noted in conventional aesthetics. This is just one example of many illustrating that how patients feel about characteristic features of a given ethnicity is highly personal, and diligence in communication with individual patients is critical.

| Patients of color and impact on aging patterns
The most obvious feature distinguishing Black patients of African Descent from other patients is skin color. Patients with darker skin have higher melanin content and a unique melanosome dispersion F I G U R E 1 A 26-year-old male patient before (A-C) and after (D-F) injection of 1 cc of VYC-20 mg/mL (1:1 dilution with bacteriostatic saline) into the anterior temporal fossa, 2 cc of VYC-20 mg/mL in the chin, 1 cc of VYC-25 mg/mL per side to improve mandibular contour and profile. For the anterior temporal fossa, VYC-20 mg/mL was injected in the interfacial plane with access achieved 1 cm medial to the temporal fusion line along the forehead. Darker skin provides increased protection from the sun (SPF is ~13.4 for skin of color vs. ~3 in lighter skin types) and is less prone to photoaging. [15][16][17] Additionally, more pigmented skin is thicker and has increased elasticity, increased collagen, and is often an oilier skin type compared with lighter skin. 18 Together, these features reduce vulnerability to extrinsic and intrinsic changes that lead to the loss of youthful skin tone, thereby reducing susceptibility to fine lines (facial lines that do appear tend to be associated with expression). Furthermore, descent of facial features is derived more from volume loss and descent of relatively thicker, heavier soft tissues than from superficial skin laxity. 3,19 These elements of skin biology delay development of aging hallmarks such as fine lines and wrinkles: patients with darker skin tend to show signs of aging 10-20 years after their Caucasian counterparts and self-recognize the signs of aging at a later age than women with lighter skin. [15][16][17] Importantly, the skin of color is also prone to dyschromia, melasma, benign growths, hyperpigmentation, and pronounced scarring with hyperpigmentation. 18 These issues, along with skin texture, are common presenting aesthetic concerns. A study that surveyed the facial aesthetic concerns of 401 African American women found that 51% were worried about uneven skin tone or color and 48% were concerned with dark circles under the eyes. 11 In the authors' experience, skin pigmentation is the number one presenting concern for this patient group.
While more superficial techniques such as peeling and cosmeceutical strategies are effective, energy-based devices may also be used. 20 To treat dyschromia and tighten the skin, the authors prefer the Q-switched 1064-nm Nd:YAG or the 1927-nm diode laser. 21 For the 1927-nm diode laser, up to 3 treatments spaced 2 weeks apart have been shown to improve melasma and PIH secondary to other issues up to 60% in skin types III, IV, and V, with skin type V responding equally as well as type III. 21 The authors note that the 1927-nm diode is not interchangeable with the 1927-nm thulium laser; the thulium laser is much more heavily powered and in the authors' experience leads to higher incidence of postinflammatory erythema, which can increase the risk of PIH. Clinicians who choose to use thulium laser treatment should be comfortable using the technology, treat conservatively, work slowly, and make every attempt to mitigate non-specific thermal damage. The authors note that while microneedling with radiofrequency is frequently requested, the risk of hyperpigmentation in clinical practice appears to be similar to the risk with laser treatments listed above depending on the insulation of the needle. The authors reserve its use in this demographic for acne scarring. The authors will treat patients with preexisting keloids with caution and recommend performing a spot test to assess how that patient will respond to treatment before addressing a larger area.

| Patterns of aging and common aesthetic concerns
Black patients of African descent have unique skeletal morphology, and the interplay between skin thickness and these skeletal changes, along with volume loss, gives rise to a unique pattern of aging. 3 Compared generally with other ethnicities, patients of African descent have similar vertical proportions but larger horizontal proportions. 7,22 An overall increased facial convexity may also be observed. 23

| The upper face
In general, Black patients of African descent have a relatively long forehead. 3 While the characteristics of skin in POC often lead to a development of lines in the forehead, brow, and glabellar area that occurs only when patients are in their 50s and 60s, these signs of aging are bothersome to patients when they do emerge. 11 In the upper face, lines are most often due to the action of muscles and expression; however, ptosis and rhytids eventually develop due to gravity combined with thicker skin and increased skin laxity. The following were noted as important considerations for treating this patient group: • For Black patients, forehead lines generally emerge in the sixth decade of life (age 50-59 years) and glabellar lines in the seventh decade (age 60-69 years). 20 The way in which management of both skin quality and volume may rejuvenate the appearance is apparent for the patient shown in Figure 2. In the authors' experience, under-eye circles are a common presenting complaint in patients of African descent, and the majority of the roundtable discussion on the midface was focused on this area.
Under-eye circles can be due to issues with pigmentation or volume deficit and have been shown to be a significant aesthetic concern in this patient group. 11 One primary finding of the round table concerning management of the infraorbital area is that management includes not just injection of tear trough itself but also leveraging facial anatomy to obtain indirect effects from injection of other areas. Thus, it is important to educate patients that while the tear trough is the apparent issue, aging is a global occurrence and treatment of more lateral areas, or areas outside of the tear trough itself, can improve appearance and lead to a more natural result. The following were identified as key strategies for managing the infraorbital area for this patient group.
• The skin in the tear trough is the thinnest in the human body, for injection in the tear trough.
• Multimodal treatment is often needed to treat thin skin around the eyes. Externally applied monopolar radiofrequency treatment can be applied within the orbit because it does not penetrate too deeply. In general, radiofrequency is a versatile energy-based treatment that can be used safely in patients of color. It is important to use ample coupling gel so that there is no excessive heating.

| Lower third
The lower face of Black patients of African descent is characterized by wide oral width and full lips, which can be partly attributed to a prominent alveolar ridge and bimaxillary protrusion with strong dentoalveolar support. 6 Patients may have less noticeable descent of oral commissures and minimal development of perioral lines, but the presence of thick skin creates jowling. 3,11,29,33 In conjunction with volume loss and skeletal changes, thick skin can give rise to pronounced sagging of malar fat pads, and midfacial volume loss contributes to deepening of the NLF. 3 In clinical practice and in studies on treatment preferences, sagging underneath the chin/double chin appearance is a leading concern. 11 The following were identified as key strategies for managing these issues in this patient group.
• It is important to manage any submental fat before providing structural support for the jawline with fillers. Once submental fullness has been managed and adequate structural support along the mandible is in place using fillers, residual lack of contour in this area due to skin laxity can be managed using microfocused ultrasound with visualization (MFU-V; Ulthera [Merz]), a device FDA cleared for submental skin lifting. 34 If used appropriately, MFU-V is safe and appropriate for darker skin types. However, the visualization component is critically important, as it prevents inadvertent treatment of the bone, which can cause rebound of the heat energy up to the skin and may lead to PIH. 35 • Replacement of body support with fillers in the chin and jawline to improve contour as well as revolumizing the pre-jowl sulcus are important approaches to improving the appearance of the lower face. In the jawline, a more structural HA filler can be used, with injections performed subdermally, superficial to the platysma and masseter, to avoid the facial artery. Major vessels and nerves are covered by the platysma like a blanket in this region. When defining the angle of the mandible, backflow toward the cannula hub is not desirable; thus, a "lollipop" technique, in which a small bolus is administered and the cannula withdrawn to form a lollipop shape, is recommended, which may also be placed at the bottom of jaw along the gonial angle to lengthen the jawline. The gonial angle, which can become wider with age, can also be restored. 36 • For the jawline, the authors note that more filler than is used in the cheek is often needed to obtain an optimal effect. A 25 mg/ mL Vycross gel (Juvéderm Volux® [Allergan Aesthetics]) is preferred in this area because the product's flow properties permit mimicry of a jaw bone. 37 Another option in this area is calcium hydroxylapatite (CaHA; Radiesse® [Merz North America, Inc.]).
• In most racial groups, the chin shortens and gender-associated changes in projection occur with age. 36  • If using a biostimulatory filler in this area to provide structural support, it is important to consider that POC seem to respond more strongly to biostimulatory agents and may need fewer sessions than their lighter-skinned counterparts to achieve satisfactory results or full correction, likely due to the presence of an increased number of active fibroblasts. 18,39 Full lips are a common aesthetic feature of patients of African descent and are not commonly cited as a direct concern for patients.
However, lip aesthetics and maintaining a youthful lip appearance is an important aspect of global appearance, so it is important to assess and treat this area as needed. Patients seeking lip treatment generally desire restoration of lost volume rather than augmentation. 39 Volume loss due to aging is generally more evident in the upper versus the lower lip, and treatment is most often restricted to management of the upper lip and upper lip rhytids with treatment of the lower lip directed more toward providing adequate structural support. 39 The following elements of treating the lips were noted as important by the authors.
• In African American patients, the "golden ratio" for the lips trends toward a 1:1 relationship and away from the standard 1/3:2/3.
When managing the lips, many "rules" of aesthetic proportions, • Co-treatment of the lower face and the platysma with BoNT-A to relax depressor muscles has a lifting effect and can reduce the appearance of frowning at rest and support a more contoured jawline. 40 Anecdotally, use of BoNT-A increases filler durability in this area.

| Fillers
Adverse events related to filler injection are similar across skin types and may include bruising, tenderness, redness, itching, pain, and hyperpigmentation, all with limited duration. 28

| Energy-based devices
Energy-based devices are useful for improving skin laxity, lifting skin, and improving pigmentation issues. The authors recognize that clinicians may approach the use of energy-based devices in Black patients of African descent with some trepidation due to the susceptibility of darker skin to postinflammatory hyperpigmentation; however, these devices have been shown to be safe and effective when used appropriately in patients with darker skin. 21,43,44 Within POC, a range of skin pigmentation can necessitate different levels of care when using energy-based devices. In the approximately 38% of African American patients who are Fitzpatrick Skin Types III and IV, more aggressive treatment can be used than if the patient is type V or VI. If used inappropriately, energy-based devices can compromise the epidermis with a burn, which may lead to PIH. Cold air cooling helps protect the epidermis during treatment and minimizes discomfort. If the epidermis is compromised, application of a light hydrocolloid dressing creates a false barrier that will help expedite wound healing and minimize PIH. After treatment, application of a topical class 3 steroid immediately after and twice daily for the following 3 days can minimize the risk of PIH. 45 This approach is recommended for skin types IV-VI regardless of the reason for treatment, or for any skin type that is being treated for melasma. After the steroid cream absorbs, a moisturizing balm and a tripeptide-hexapeptide product can be applied and used for at least 1 week. 46 There are published treatment algorithms for preventing and managing PIH, should it occur. 47

ACK N OWLED G M ENTS
Medical writing assistance was provided by Ginny Vachon, PhD, Principal Medvantage, LLC, Atlanta, Georgia under the direction of the authors. Funding for this support was provided by a CME grant funded by Abbvie, Galderma, Merz, Suneva, and Ortho Dermatologics.

FU N D I N G I N FO R M ATI O N
Funding for this CME event was provided by Abbvie, Ortho Dermatologics, Endo Aesthetics, and Merz Aesthetics.