Clinical Pearls for Dermal Filler Enhancement in Patients With Skin of Color

By Candrice R. Heath MD and Susan C. Taylor MD

INTRODUCTION
Patients of all racial and ethnic groups are interested in maintaining a vital and youthful appearance. As the US population of skin of color patients grows, so too does the number of skin of color patients seeking cosmetic treatments.1-3 Therefore, the goal is to maximize aesthetic results in this population while minimizing potential adverse events.

In general, as individuals with skin of color age, they do not develop fine or deep rhytids, but rather they experience diminution of the underlying facial bony structure, collagen, and ground substance which leads to descent of the malar fat pad.4 Intradermal fillers are appropriate for correction of these defects. However, when considering the use of dermal fillers for cosmetic enhancement in patients with skin of color, adverse events such as the development of hyperpigmentation, keloidal or hypertrophic scarring must be considered.

These unique adverse events prompted the Food and Drug Administration (FDA) to require adequate numbers of skin of color patients in pivotal filler trials or post-marketing phase IV studies to document the rate of these adverse effects in skin of color patients with Fitzpatrick skin types IV–VI. Study results have demonstrated no keloidal scarring, but hyperpigmentation of the nasolabial folds and hypertrophic scars in a small number of patients.5-9 However, these studies excluded patients with a history of hyperpigmentation in the nasolabial fold area, a history of keloidal scarring and/or a family history of keloids. 5-9 Post-approval, many skin of color patients who present for cosmetic consultation and procedures have a history of pre-existing hyperpigmentation or a personal or family history of keloids.

Although all patients with skin of color, or Fitzpatrick skin types IV–VI, are candidates for fillers, it is important to treat patients with skin of color conservatively (Figure 1). Additionally, informed consent with a review of the potential adverse events of hyperpigmentation, hypertrophic or keloidal scarring is essential.

FIGURE 1. Patient with Fitzpatrick skin type V receiving dermal filler. Erythema of the left nasolabial fold is visible immediately following dermal filler enhancement.


CLINICAL BOTTOM LINE
To minimize skin of color specific adverse event during and after injecting filler substances, utilize the following pearls:
• When injecting filler substance, use techniques that minimize the total number of injections, such as linear threading.
• If erythema occurs following a procedure, minimize the potential risk of post-inflammatory hyperpigmentation by utilizing a mid-potency topical corticosteroid twice daily for several days to diminish inflammation.
• Remind patients of the value of sunscreen application to minimize the onset of hyperpigmented macules or UV darkening of macules once present.
• Hydroquinone may be used following filler procedures to either minimize the risk of hyperpigmentation in susceptible individuals or treatment of early onset hyperpigmentation.

DISCLOSURES
Susan C. Taylor has served as investigator, advisory board member, and speaker for Medicis, Allergan, Johnson and Johnson, Merz, and Bioform. Candrice R. Heath has no relevant conflicts of interest to disclose.

REFERENCES
1. Bureau USC. US Census Bureau News: More Diversity, Slower Growth. Available at: www.imdiversity.com/villages/asian/reference/census_2050_asian_projections.asp. Accessed November 2011.
2. Burgess CM. Soft tissue augmentation in skin of color: Market growth, available fillers, and successful techniques. J Drugs Dermatol. 2007;6:51-55.
3. Surgery ASfAPS. Cosmetic Plastic Surgery Research Statistics and Trends for 2001-2008. Available at: http://www.cosmeticplasticsurgerystatistics.com/statistics.html#2008-NEWS. Accessed December 2, 2010.
4. Harris MO. The aging face in patients of color: Minimally invasive surgical facial rejuvenation-a targeted approach. Dermatol Ther. 2004;17(2):206-211.
5. Grimes PE, Thomas JA, Murphy DK. Safety and effectiveness of hyaluronic acid fillers in skin of color. J Cosmet Dermatol. 2009;8:162-168.
6. Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: A randomized, evaluator-blinded comparative trial. Dermatol Surg. 2009;35(suppl 2):1653-1660.
7. Marmur ES, Taylor SC, Grimes PE, et al. Six-month safety results of calcium hydroxylapatite for treatment of nasolabial folds in Fitzpatrick skin types IV to VI. I. Dermatol Surg. 2009;35(suppl 2):1641-1645.
8. Narins RS, Baumann L, Brandt FS, et al. A randomized study of the efficacy and safety of injectable poly-L-lactic acid versus human-based collagen implant in the treatment of nasolabial fold wrinkles. J Am Acad Dermatol. 2010;62:448-462.
9. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg. 2003;29:588-595.
10. Grimes PE. Management of Hyperpigmentation in Darker Racial Ethnic Groups. Semin Cutan Med Surg. 2009;28:77-85

About the author

Candrice R. Heath MD and Susan C. Taylor MD

Candrice R. Heath MD: Society Hill Dermatology, Philadelphia, PA and Children’s Healthcare of Atlanta, Atlanta, GA and Susan C. Taylor MD: Society Hill Dermatology, Philadelphia, PA and St. Luke's Roosevelt Hospital, Department of Dermatology, New York, NY

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