Non-surgical Face Lifting Techniques: Asian versus Western

Over the past decade, Asia has seen a significant rise in the popularity of non-surgical facial treatments, such as facial injectables, non-ablative skin resurfacing, and other non-invasive procedures. This surge in demand can be attributed to various factors, including advancements in technology, better outcomes achievable through treatments like botulinum toxin and hyaluronic acid fillers, a growing societal acceptance of appearance enhancement, increased affordability and accessibility of non-surgical options, and the emergence of a burgeoning middle class in Asia.

A prevalent preference among Asian aesthetic patients, regardless of age, is to avoid surgical interventions whenever possible, while aiming for natural-looking results. Consequently, healthcare professionals in Asia have had to adapt to these patient expectations. They have delved into the study of Asian facial aesthetics, encompassing facial shape, structure, proportion, and the unique impact of the aging process on Asian faces.

Most of the available studies and recommendations regarding facial injectable treatments, especially when used in combination, are predominantly based on Western populations. However, ethnic Asians exhibit distinctive facial features and underlying structural facial anatomy. Additionally, the signs and rate of onset of facial aging differ in Asians compared to Western populations. As a result, applying existing Western-centric recommendations directly to Asians is not always suitable. Moreover, there is a scarcity of published research on the use of botulinum toxin and hyaluronic acid fillers in Asian populations, and only a limited number of papers discuss their combined use on Asian faces.

The Consensus Behind Asian Face Lifting

The challenge is that data from clinical trials often do not align with real-world practice because clinical trials typically focus on standardized treatments in a single facial area, whereas aesthetic treatments are usually multi-faceted and customized to individual needs. This gap underscores the necessity for expert guidance on facial aesthetic treatments for Asians. To meet this need, a group of experts from the Asian Facial Aesthetics Expert Consensus Group, comprising anatomists, plastic surgeons, and dermatologists from 11 Asia-Pacific countries, convened to deliberate on current practices surrounding non-invasive aesthetic treatments for Asians. Their primary goal was to understand concepts of facial beauty and attractiveness in the Asian context, as well as to address key aesthetic concerns, facial anatomy, and the aging process specific to Southeastern and Eastern Asians. The outcome of this meeting was the development of consensus opinions on the most commonly sought-after aesthetic treatments and how they can be best delivered to Asian patients.

The proceedings of this meeting are intended to serve as a guide for physicians who provide both surgical and non-invasive facial aesthetic treatments to Asian patients, particularly in the absence of published clinical evidence. The cultural perspectives on facial beauty in Asia and delves into the crucial understanding of the unique facial anatomy and aging process specific to Asian populations. The term "Asians" is herein defined as comprising diverse ethnic groups from East Asia (e.g., China, Korea, Japan, Hong Kong, Taiwan) and Southeast Asia (e.g., Thailand, Singapore, Indonesia, Philippines), with the exclusion of individuals from the Indian subcontinent.

Facial Beauty in Asian

Individuals from diverse racial backgrounds who are considered attractive often share common ethnic features characterized by a sense of symmetry, harmony, and equilibrium. A notable similarity in facial shape is observed when comparing these aesthetically appealing individuals across different regions of the world. Facial configuration plays a pivotal role in the perception of facial beauty, with an oval face shape universally regarded as attractive and associated with youthful appeal, transcending racial boundaries.

In Asian context, an oval face is defined as having a seamless, egg-shaped contour encompassing the entire face. This contour smoothly transitions from the forehead through the temples, encircling the cheeks, the preauricular region, the angle of the jaw, and the jawline, culminating at the chin, devoid of any notable deviations or protrusions. Furthermore, a well-proportioned nose and chin are also considered attractive features. Among individuals of Asian descent, regardless of their specific ethnic backgrounds and age, a paramount emphasis is placed on possessing clear, unblemished, fair, and youthful skin.

Facial features tend to exhibit more pronounced ethnic distinctions. For example, individuals of Caucasian descent generally present with more pronounced three-dimensional features, including larger and more deeply set eyes, greater forward projection of the brow, nose, maxilla, and chin. Caucasians also tend to have narrower faces with greater vertical height. In contrast, individuals of Asian descent typically exhibit wider faces with shorter vertical height, which may appear flat or concave in the medial maxilla, coupled with a lack of projection in the brow, nose, and chin regions. Nevertheless, they possess enhanced infraorbital volume, fuller lips, and superior skin quality compared to Caucasians, rendering them more resilient to environmental insults and slowing the onset of physiological and anatomical signs of aging.

In the Asian context, patients often seek aesthetic treatments at a relatively early age to address perceived facial features they find undesirable. The physical attributes of the Asian face are linked to specific skeletal and morphological features that distinguish them from Caucasians. While there is considerable ethnic diversity within Asian populations, certain typical facial features can still be identified. As a general observation, Asians tend to have wider and shorter faces. In profile, the Asian face often appears flat, and in some cases, it may even exhibit a concave contour. In comparison to the Caucasian facial structure, the Asian face is characterized by a broader intercanthal width, the presence of epicanthal folds, shorter eye fissures, upper eyelid and lateral brow hooding (resulting in a "puffy" eyelid appearance), a narrower oral width, increased mandibular width leading to a square lower face, and a retruded chin. The nasal structure typically features a flatter dorsum, a broader base, and less tip projection. It's also worth noting that Asians often have fuller lips, with the upper lip being notably more prominent in many cases. Furthermore, ethnic Asians exhibit a thicker layer of soft tissue near the lateral point of the ala nasi compared to Caucasians. These characteristics, coupled with the retrusion of the pyriform margin of the bony structure in Asians, contribute to the concealed columella, wider alar base, and the flatter nasal profile commonly observed in individuals of Asian descent.

Aging in Asian

Skin aging processes exhibit notable differences between Asians and Caucasians in various aspects. Notably, pigmentary issues, such as lentigines and seborrheic keratosis, are more prevalent among Asians. In contrast, wrinkles tend to appear 1 to 2 decades later in Asians compared to age-matched Caucasians. A comparative study of skin aging in Chinese and French populations residing in similar climate conditions indicated that the Chinese population experiences a biphasic trend in wrinkle development. It involves a gradual increase up to the ages of 40-50 years, followed by a more rapid progression afterward. Interestingly, by the age of 60, wrinkle intensity in both the French and Chinese populations appears quite similar. This phenomenon is partly attributed to the increased melanin content in Asian skin, which provides a sun protection factor (SPF) of approximately 7, compared to a SPF of 3.4 in Caucasians.

In another study that examined facial wrinkles among Japanese, Chinese, and Thai women, it was observed that Thai had the highest wrinkle intensity, followed by Chinese, and then Japanese women. While the elevated levels of ultraviolet light exposure in Thailand were a primary factor, other influences, including language and facial expression, also contributed to the variation in wrinkle scores between Chinese and Japanese women. Beyond SPF differences, additional factors that contribute to the reduced skin aging observed in Asians compared to age-matched Caucasians include variations in skin structure, thickness, diets rich in antioxidants (e.g., green tea and omega-3 and -6 fatty acids), and disparities in smoking rates. Moreover, sociocultural elements such as skincare practices and muscle use during language articulation and facial expressions are likely to influence the development of dynamic wrinkles differently among Asian and Western populations.

Concerning non-skin aging or physiological aging processes, Asians undergo similar dynamic and multifaceted changes in their facial appearance, involving the interaction between the soft tissue above and the underlying skeletal structures, akin to Western populations. Aging-related phenomena such as the loss of facial fat and soft tissue volume, deflation, and sagging, as well as bony remodeling, contribute to common signs of aging.

Nonetheless, disparities in skeletal structural support and the propensity of facial soft tissue to sag result in a slower rate of facial aging among Asians compared to Caucasians. Most Asian patients benefit from the dense fat and fibrous connection between the superficial muscular aponeurotic system and the deep fascia, which delays midfacial sagging. Additionally, the combination of increased superficial fat and thickened dermis reduces the incidence of superficial rhytides (wrinkles). Over time, despite initially having thicker skin, the loss of dermal support, coupled with the weight of the malar fat pad and weaker skeletal support in the Asian face, eventually lead to tissue descent, resulting in facial sagging with aging. Nevertheless, Asians tend to maintain a youthful appearance for a longer duration due to the delayed onset of skin aging and sagging in comparison to their age-matched Caucasian counterparts.

Treatment Trends in Asia

The quest for enhancing facial aesthetics has historically been present, albeit somewhat constrained by the cost of plastic surgery and the limited availability of proficient practitioners. Findings from the pre-meeting survey conducted by the Expert Group reveal that a majority of Asian patients seeking facial aesthetic treatments are females. However, there has been a notable increase in the proportion of male individuals seeking such treatments over the past decade, rising from 12% in the period from 2005 to 2009 to 19% between 2010 and 2014. Additionally, there has been a slight uptick in the representation of younger Asian patients, specifically those aged between 18 and 40, who present with aesthetic concerns. This proportion has increased from 44% during the 2005-2009 period to 48% between 2010 and 2014. This may be attributed to a heightened sense of self-identity and self-esteem, as well as the increasing economic empowerment, aspirations, and social autonomy of younger individuals.

Several factors contribute to this growing trend. First, there is a greater understanding that the early utilization of aesthetic treatments can potentially forestall or mitigate the effects of aging. Second, the awareness of aesthetic procedures and treatments has been amplified through exposure to peers and public figures on social media. Third, there has been an increase in both the accessibility and affordability of aesthetic products and treatments. Fourth, the growing number of trained aesthetic physicians has made these services more readily available. Finally, the perceived safety of injectable products has significantly improved over the past 5 to 10 years, instilling greater confidence in individuals considering such treatments.

The survey findings also indicate that individuals aged 40 years or younger most frequently seek aesthetic treatments designed to enhance facial contour and three-dimensionality. While these patients may perceive their requests as purely driven by aesthetic desires, medical practitioners discern that these treatments are often motivated by inherent facial structural traits typical among Asians.. These traits can have a noticeable negative impact on their overall aesthetic appearance. As patients advance in age, their treatment objectives and preferences tend to shift towards addressing issues associated with the natural aging process. Individuals aged over 40 years are more inclined to request interventions and procedures aimed at mitigating concerns related to volume loss, sagging, and wrinkles. Notably, among the younger patient demographic, excluding skin-related concerns, the most prevalent treatment requests stem from these underlying structural features that can potentially detract from their overall aesthetic appeal or indicate relative structural weaknesses.

Western Face Lifting Techniques versus Asian Face Lifting Techniques

Western face lifting techniques showcase a comprehensive approach to facial rejuvenation, incorporating a range of both surgical and non-surgical methods. The traditional facelift, a cornerstone of Western cosmetic surgery, involves meticulous incisions around the hairline and ears to access underlying facial structures. This allows skilled surgeons to lift and reposition sagging tissues, addressing issues such as jowls and loose skin. In parallel, the mini facelift provides a less invasive option, focusing on specific facial areas and catering to individuals seeking a more targeted enhancement. These surgical interventions, deeply rooted in Western aesthetics, counteract the effects of gravitational forces and the natural aging process.

Non-surgical alternatives have gained popularity in the West due to their minimal downtime and more gradual, yet noticeable, results. Thread lifts, utilizing dissolvable threads strategically placed beneath the skin, offer an immediate lifting effect while promoting collagen synthesis for prolonged efficacy. Ultherapy, a non-invasive ultrasound treatment, precisely targets deeper skin layers, stimulating collagen production and achieving a lifting outcome without resorting to surgery. Complementing these techniques are injectables like dermal fillers and Botox, strategically employed to restore facial volume, fill fine lines, and temporarily paralyze muscles responsible for dynamic wrinkles.

Conversely, Asian face lifting techniques reflect a cultural emphasis on subtlety and the preservation of one's unique features. While surgical facelifts are performed, there is a prevalent preference for non-invasive treatments such as laser skin resurfacing and microcurrent facial toning. These methods prioritize achieving a harmonious, natural look over time, aligning with cultural values that appreciate gradual changes and a more timeless appearance. Skincare routines in Asia often incorporate preventative measures, reflecting a commitment to maintaining skin health and preventing premature aging. Cultural beauty standards also influence the goals of Asian facial enhancements, with a focus on achieving facial shapes such as the V-shaped or heart-shaped face. This often involves refining the jawline and creating a small, delicate chin, embodying ideals that vary from those in Western cultures.

In summary, Western face lifting techniques showcase a multifaceted approach, combining surgical and non-surgical interventions for immediate and transformative results. In contrast, Asian techniques often prioritize subtlety, natural enhancement, and the preservation of unique facial features, reflecting a cultural appreciation for gradual changes and a harmonious aesthetic. Individual preferences, cultural norms, and aesthetic ideals collectively shape the choices individuals make in pursuing facial rejuvenation.

Reference:

Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty (2015)

A systematic review of interethnic variability in facial dimensions (2011)

Proportionality in Asian and North American Caucasian faces using neoclassical facial canons as criteria (2002)

Comparison of the aesthetic facial proportions of southern Chinese and white women (2000)

Skin ageing: a comparison between Chinese and European populations (2005)

Comparison of age-related changes in wrinkling and sagging of the skin in Caucasian females and in Japanese females (2003)

A new paradigm for the aging Asian face (2004)

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