The Asian Dermatologic Patient: Review of Common Pigmentary Disorders and Cutaneous Diseases

Stephanie G.Y. Ho; Henry H.L. Chan


Am J Clin Dermatol. 2009;10(3):153-168. 

In This Article

6. Other Esthetic Procedures

Over the last few decades, there has been a surge of interest in, and performance of, esthetic enhancement procedures in Asian countries. There has also been a greater cultural acceptance of esthetic modification and skin rejuvenation using non-surgical techniques to reduce the stigmata of aging.

6.1 Botulinum Toxin Type A

Although wrinkling occurs later in Asians compared with Caucasians, rhytides appear in the same predictable manner as a result of repetitive action of facial musculature. Botulinum toxin type A (Botox®; Allergan, Irvine, CA, USA) blocks the release of the neurotransmitter acetylcholine at the neuromuscular junction, thereby causing paralysis of the affected muscle. It was first reported to be an effective treatment of fine facial wrinkles in the 1990s.[110] Anh et al.[111] found no difference in the longevity of treatment and the amount of toxin required for Asian skin despite the increased dermal thickness and collagen content of the skin of Asian people. Common injection sites for elimination of facial hyperkinetic wrinkles include the lateral canthal area, glabellar area, forehead, and nasal dorsum. Repeated injections are generally required every 4-6 months.[112] Flynn et al.[113] showed that botulinum toxin injected concomitantly into lateral and infra-orbital areas results in successful improvement in infra and peri-orbital wrinkles and also widens the eye. The results were especially notable in Asians.

Botulinum toxin can also be used to reduce a prominent mandibular angle, the so-called 'square jaw,' in Asians. Kim et al.[114] followed up 383 patients who received botulinum toxin injection (100-140 U) [Dysport®; Ipsen Ltd, Slough, UK] into the inferior masseter borders and found an average 31% reduction in masseter hypertrophy on ultrasound 3 months after treatment (figure 7). Ninety-three percent of patients were positive about the outcome. Re-injection was required after 4-7 months. Mild fatigue after vigorous chewing was the main complaint, followed by transient awkwardness when smiling. More recently, botulinum toxin A has also been used for contouring of enlarged gastrocnemius muscles with no functional disabilities. The improvement was well maintained for 6 months.[115,116]

Figure 7.

Use of botulinum toxin type A for masseter hypertrophy: (a) pre-treatment; (b) post-treatment.

6.2 Soft Tissue Fillers for Tissue Augmentation

Asian patients, like their Western counterparts, are increasingly seeking a more youthful face with fewer wrinkles and fuller features. Fillers are therefore increasingly being used in the management of facial lines, lip augmentation, and treatment of distensible atrophic facial scarring. Fillers can be divided into two groups; biodegradable materials that are used for temporary augmentation, such as hyaluronic acid and bovine collagen, or non-biodegradable materials, such as silicon oil or polymethylmethacrylate in combination with bovine collagen, which require some time to obtain a permanent result because of encapsulation. The ideal filler is a non-allergenic, non-toxic, non-migratory replacement for lost collagen or subcutaneous fat. It should be easy to use with a direct result and no adverse effects.

Skin reactions to bovine serum collagen have been well documented, and double skin testing is recommended.[117] There may also be a risk of variant Creutzfeldt-Jakob disease or other pathogenic infections when materials derived from animal origins are used. Hyaluronic acid fillers such as Restylane® (Q-Med, Uppsala, Sweden) and Hylaform® (Biomatrix, Inc, Ridgefield, NJ, USA) are marketed as having minimal allergy risk and not requiring skin testing. Studies comparing the efficacy and tolerability of Restylane® with those of the bovine collagen Zyplast® (McGhan Medical Inc., Santa Barbara, CA, USA) have found Restylane® to be superior in effectiveness and longevity.[118] However, 0.42% of a study population of 709 developed delayed skin reactions. Nevertheless, this is a much lower rate than that reported for bovine collagen, which is between 3% and 4%.[117,119] Hyaluronidase can resolve any undesirable effects of Restylane®.[120]

Artecoll™ (Rofil Medical International, Breda, the Netherlands) is used as a long-lasting, deep dermal augmenting agent. It consists of microspheres of polymerized methylmethecrylate in a bovine collagen vehicle. A randomized controlled, multicenter, clinical trial of 251 subjects reported Artecoll™ to be superior in terms of facial fold reduction and patient satisfaction after 6 months compared with collagen.[121] Early lump formation, especially in the lips, may occur in patients treated with Artecoll™ and is thought to be due to excess movement prior to full encapsulation by host fibrin and fibrinogen. Talking should be minimized in the early days or concurrent use of botulinum toxin may be considered. Granuloma formation is very rare and usually occurs 6-24 months after injection. The granulomas resolve spontaneously after 4-6 years. Intralesional triamcinolone may speed up the process.[122,123] A good technique is important for reducing complications.

Poly-L-lactic acid (New-Fill™; Ashford Aesthetics Inc., Brussels, Belgium or Sculptra™; Aventis Pharmaceuticals, Bridgewater, NJ, USA) has been used for the correction of HIV-related facial lipoatrophy and cosmetic rejuvenation of non-HIV patients.[124] Temporary edema and bruising are common adverse effects. However, a report by Beljaards et al.[125] described three cases with serious giant cell granulomatous reactions after use of New-Fill™ or Sculptra™. Intralesional corticosteroid therapy and topical imiquimod were moderately effective for resolving these reactions.