Chapter 13: Surgical Lifting and Tightening in Ethnic Skin

INTRODUCTION AND DEFINITIONS

Although 75% to 80% of the planet's people are nonwhites, the majority of the cosmetic surgical literature is limited to the treatment of Caucasians. The fear of increased pigmentary and scarring complications has made cosmetic surgeons in the United States hesitant to perform elective procedures on both African and Asian patients. This fear should be replaced by knowledge of unique racial differences and modifications of surgical technique to accommodate ethnic patients who desire cosmetic surgery.

Understanding and accepting the attitudes of different cultures are extremely important for the cosmetic surgeon. Cultural traditions and resistance often have a profound psychologic influence on the nonwhite person who is contemplating cosmetic surgery. Changing ethnic appearance (e.g., “Westernization” of the Asian eyelid or reduction cheiloplasty in blacks) can cause feelings of guilt. Because elders play a dominant role in many nonwhite societies, their acceptance or rejection of cosmetic procedures has a psychologic influence on the ethnic patient. Altering shape while preserving the ethnicity of the nonwhite patient is a challenge to the cosmetic surgeon.

The surgeon who contemplates performing procedures in nonwhite patients should have an understanding of the morphologic differences between white and nonwhite skin, specifically in patients of African and Asian descent. The most apparent difference between white skin and black skin is the amount of epidermal melanin.¹ Although there is no difference in the quantity of melanocytes between the two groups,² the concentration of melanin within the melanosomes is increased in African skin compared with white skin (Table 13.1). In addition, the degradation rate of melanosomes within the keratinocytes of African skin is slower than that of Caucasian skin. Although the increased melanin affords protection from the harmful effects of ultraviolet light, both the melanocytes and mesenchyma in African skin seem to be more vulnerable to trauma and inflammatory conditions than those in Caucasian skin. Post-traumatic or postinflammatory dyspigmentation can take the form of either darkening, or hyperpigmentation (Figure 13.1) or lightening of the skin, or hypopigmentation. Increased mesenchymal reactivity can result in hypertrophic scars (Figure 13.2) or even keloids (Figure 13.3), raised scars that have expanded beyond the boundaries of the original wound.¹