Understand facial aging in skin of color for cosmetic outcomes

Successful cosmetic treatment of men with skin of color requires dermatologists to recognize their unique differences in anatomy and skin aging. Men of color are a particular challenge because the anatomical differences of both the male gender and skin of color need to be understood in order to provide a successful cosmetic outcome.

Biologic differences

Cutaneous gender differences are wide-ranging¹ and are primarily mediated by sex hormones. In men, the increase in androgens affects several functions of human skin and its appendages. Male skin, both epidermis and dermis, is thicker at all ages with the extent varying with anatomical region.²

The male facial anatomy is significantly different, as men have a larger and uniquely shaped skull. Men tend to have a large forehead with prominent supraorbital ridges,³ wide glabella,⁴ and a prominent protruding mandible. Men have increased skeletal muscle mass,⁵ including facial memetic muscles.⁶ The subcutaneous adipose layer is thinner in men irrespective of age.⁷

The anatomical differences between genders result in differences in aging. Men have more severe facial rhytids⁸ except in the perioral area.⁹ The loss of subcutaneous adipose with age results in deeper expression lines in men because of the thicker skin and more prominent facial musculature, as opposed to the superficial rhytids that women tend to develop.

Facial aging in skin color is unique because the inherent pigmentation protects against photodamage and extrinsic aging.¹⁰ Intrinsic aging predominates with volume loss from fat atrophy, gravity-induced soft tissue redistribution, and bony resorption.¹¹ Patients with skin of color are less likely to develop fine rhytids and solar lentigines than Caucasians.

Cosmetic procedures

Injection of botulinum toxin is the most common cosmetic procedure in men, with 363,018 injections performed in 2011.¹² Injection sites, technique and administered dose do not differ based on ethnicity, but do vary between genders.

When treating the male frontalis muscle, a flat injection technique is recommended to minimize brow arching and maintain the normal flat male eyebrow position. Extra caution is required when treating the inferior portion of the frontalis muscle to avoid eyebrow ptosis. More injections may be required to ensure complete and balanced treatment of the frontalis muscle due to the larger surface area of the male forehead.

Soft tissue augmentation with dermal fillers can be particularly effective in treating soft tissue redistribution seen in men with skin of color. Volume loss is a shared aging process seen in both the male gender and skin of color. Once again, the male facial anatomy dictates a unique injection technique.  

Filler augmentation of the midface should focus on the centromedial cheeks to avoid creating wide lateral cheeks, which is a feminine characteristic. Enhancement of the lower face is also beneficial in men. The filler should be injected along the mandible to strengthen the jawline. Fillers can also be used to enhance the male forehead prominence by injecting into the bony sulcus over the eyebrows. The upper lip is generally avoided in men due to the risk of feminizing, and this is rarely a concern in skin of color patients because their lips tend to be fuller.

There is no “one size fits all” approach when evaluating a cosmetic patient. The gender of the patient and the color of their skin must be considered when choosing the appropriate procedure and technique.

References:

1. Giacomoni PU, Mammone T, Teri M. J Dermatol Sci. 2009;55(3):144-149.

2. Shuster S, Black M, McVitie E. Br J Dermatol. 1975;93(6):639-643.

3. Garvin HM, Ruff CB. Am J Phys Anthropol. 2012;147(4):661-670.

4. Russell MD, Brown T, Garn SM, et al. Curr Anthropol. 1985;26(3):337-360.

5. Janssen I, Hemsfield S, Wang Z, Ross R. J Appl Physiol. 2000;89(1):81-88.

6. Weeden JC, Trotman CA, Faraway JJ. Angle Orthod. 2001;71(2):132-140.

7. Sjostrom L, Smith U, Krotkiewski M, Bjorntorp P. Metabolism. 1972;21(12):1143-1153.

8. Tsukahara K, Hotta M, Osanai O, et al. Skin Res Technol. 2012 Jan 11.

9. Paes EC, Teepen HJ, Koop WA, Kon M. Aesthet Surg J. 2009;29(6):467-472.

10. Kaidbey KH, Agin PP, Sayre RM, Kligman AM. J Am Acad Dermatol. 1979;1(3):249-260.

11. Harris MO. Dermatol Ther. 2004;17(2):206-211.

12. American Society for Plastic Surgery 2011 statistics. Available at http://www.plasticsurgery.org/News-and-Resources/2011-Statistics-.html Accessed Nov. 5, 2012.