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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
Mid-face considerations Cheeks 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). Nose Another common treatment request by Asian patients is nonsurgical rhinoplasty. There are common nasal anatomic features in the Asian population which include a wide, flat dorsum and a
Figure 2: A 25-year-old Asian patient before and immediately after non-surgical rhinoplasty using 0.5ml of Juvéderm Voluma.
Figure 1: A 23-year-old Asian patient before and immediately after medial malar treatment using 0.6ml of Juvéderm Voluma on each side and tear trough treatment with 0.4ml of Teosyal Redensity II on each side.
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).
Figure 3: A 22-year-old Asian patient before and immediately after lower-face treatment using 3ml’s of Juvéderm Volux to reconstruct the chin using a combination of injection and cannula techniques. This was following the injection of 4 units of BoNT-A into each mentalis.
Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020