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Uncovering keys to successful cosmetic surgery of minorities
Four physicians share views and techniques for Caucasian and ethnic patient surgeries

By: Lisette Hilton, Cosmetic Surgery Times

Beverly Hills, Calif. - Nearly 1 million, or 13 percent, of the more than 7.4 million cosmetic plastic surgery patients in 2001, were minorities, according to statistics tracked by the American Society of Plastic Surgeons. African-Americans and Hispanics comprised 5 percent each of the cosmetic surgery population, and 3 percent were Asian-American.

Physicians are not only reporting increases in the numbers of African-American and Hispanic patients in their practices, but they are also learning how to work around some of the challenges inherent in the darker skinned populations.

Pearlman D. Hicks Jr., M.D., a plastic and reconstructive surgeon who practices in Beverly Hills, Calif., said 40 percent of his practice is made up of African-Americans. In practice for 24 years, Dr. Hicks has seen cosmetic surgery increases among black and Hispanic populations, but not so much among Asians.

The most popular procedures among black women, according to Dr. Hicks, are rhinoplasty, breast reduction, liposuction, and tummy tucks. Paul Wigoda, M.D., a board-certified plastic surgeon in Fort Lauderdale, Fla., agreed, adding breast augmentation and blepharoplasty to the list of favorite procedures among ethnic patients. Facelifts are not as common or needed among black women as they are among Caucasian women, Dr. Wigoda said. Still, Latinos, experts agree, take advantage of the full range of cosmetic surgery options.

Michael E. Kelly, M.D., a board-certified plastic surgeon in Miami, Fla., whose practice is predominately Hispanic, noted that the Hispanic population in Miami "is very in tune with cosmetic surgery. In some ways they're ahead of the country in terms of the acceptance of cosmetic surgery - the desirability of it," Dr. Kelly said. "They really don't have many of the social stigmas or concerns that a lot of my non-Hispanic patients will express. For example, I have mothers who bring their daughters. Say the mothers have had breast augmentation - they'll bring their daughters in for liposuction. This patient segment is anxious to show their friends and neighbors their new look and are proud of what they've had done."

Hispanic women tend to be so excited to have cosmetic surgery that they sometimes want procedures done earlier than needed, according to Dr. Wigoda. "I see a lot of younger Hispanics who could wait five years for a facelift or midfacelift, for example. I either suggest a more minor procedure or suggest that they wait a few years and see how things change," he said.

The African-American nose Surgeons say most minority women do not want to change their ethnic appearance; rather they want to refine it.

African-Americans who see Dr. Hicks for rhinoplasty often remark that they do not want a Michael Jackson nose. "They just want to refine the nose. If someone comes to me and says 'I want a small Caucasian nose,' I say there's no way we can do that. If someone comes in with a specific problem, like 'my bridge is too fat, my nostrils are too wide, or my tip is round and bulbous,' then we can address those changes," Dr. Hicks said.

According to Dr. Hicks, an African-American nose is totally different from the nose of a Caucasian.

"Most of us trained on Caucasian patients. But the whole idea of doing an African-American nose is that it's more of a building up of the nose than a tearing down of the nose," he said. "The average Caucasian patient has a long nose and a big hump, so we're taking off the hump and shortening the nose. In an African-American nose, we're raising the bridge and making the tip smaller. It's not as destructive as an additive procedure. Some doctors don't realize that."

The other element that surgeons must understand when working on an African-American nose, according to Dr. Hicks, is to be extremely patient during the healing process. African-American skin is thicker and takes longer to heal and settle down.

Final result seen in up to two years In Caucasian patients, surgeons might expect final results in three to four months. An African-American patient, on the other hand, might take from eight to 24 months before he or she exhibits a final result. If you cannot wait and you go in again because the patient is not satisfied and try to rectify something before the nose is settled, you can get a disastrous problem," Dr. Hicks said.

Most African-American breast reduction patients only want reduction by a couple of breast sizes, according to Dr. Hicks. "A lot of the women who have very big breasts also have very big bodies as well, so if you reduce the breasts too much, they look bottom heavy, after being top heavy before the procedure," Dr. Hicks said.

Breast reduction also presents a potential scarring problem in African-American and Hispanic patients.

Dr. Hicks attempts to keep sutures below the skin, without going through and around the skin each time, and often uses only one suture at the base of the breast to hold the rest of the tissue in place. He never uses staples because he said they cause scars, which are difficult to revise.

To meet the scarring obstacle in breast augmentation, Dr. Kelly performs breast augmentations endoscopically, through the axilla. "That way, if they were to have a bad scar it would be in the armpit instead of on the breast, which I think most patients would find preferable," he said.

Liposuction is straightforward, regardless of a patient's ethnicity, experts agreed. Dr. Hicks noted, however, that surgeons should warn African-American liposuction patients that they might get bruising, which could take months to resolve and some permanent discoloration on the skin.

Dr. Kelly prefers using ultrasonic liposuction on minority patients. The approach allows surgeons to take out more fat and better addresses areas in which fat is more resistant to removal.

"Liposuction is a great procedure in patients who may have a tendency toward bad scarring. Especially with ultrasonic liposuction, we may be able to change somebody's shape without having to make a large incision; so, it's a big advantage over even traditional liposuction," he said.

Skip laser treatments Dr. Hicks does not perform laser resurfacing on black or Hispanic patients. Despite articles in the literature that say laser resurfacing in these populations can be successful, Dr. Hicks explains that even laser hair removal should be avoided.

In order to keep hair removal lasers from discoloring the skin of darker skinned patients, some companies advocate lowering the settings, he noted, which results in the hair growing back. "If it is powerful enough for dark skin it is going to burn the skin. I think that's an overzealous attempt to sell the laser to these people," Dr. Hicks said.

Instead, Dr. Hicks uses TCA peels to rejuvenate the skin. Dr. Wigoda agrees and said that results are good for African-American women after TCA peels. "I use the peels if they have any evidence of melasma or for tightening of the skin," Dr. Wigoda said.

Reduce scarring, skin discoloration Doctors approach the issue of scarring in different ways, according to Gustavo Colon, M.D., clinical professor of plastic surgery, Tulane University and Louisiana State University, and head of plastic surgery at Ochsner Clinic in New Orleans.

Some patients are treated intraoperatively or postoperatively with steroids. Or if a keloid scar should become obvious or imminent, some doctors use silicone sheeting or pressure compressions (used to treat burns to break collagen fibers and compress them to make scars less obvious) postoperatively to prevent the scars or their progression, he explained.

Surgical technique is paramount, Dr. Colon noted, and physicians should use the same techniques they would use on any patient to reduce the chances of scarring.

One approach is to decrease the amount of scarring by maintaining good support of the area of incision with Steri strips, which minimizes the tension on incisions.

"At the same time, you try to minimize tension on incisions during surgery. The tighter you close an incision, the greater chance you have of a scar becoming thick," Dr. Colon said. "For example, all scars and incisions should be closed with minimal tension. If you close a scar by pulling on the skin, the skin will give and the scar will be as wide as the gap that you left initially. It's very important that layered closures under minimal tensions be carried out so that when you finish closing the skin you really don't need stitches and the stitches are put in for approximation and equality of the edges."

Sometimes patients should be discouraged from having certain types of surgery, according to Dr. Wigoda.

"If patients have a history of keloids, they may not be candidates for procedures that involve significant incisions, such as the tummy tuck or breast reduction. At least they need know they are taking a big risk," Dr. Wigoda said.

Physicians also should be aware of variations of skin color, particularly among Hispanic patients, advised Dr. Colon.

"It's very important to be aware of the coloration and texture of skin when you perform any type of operation, resurfacing, or skin peeling or even facial cosmetic procedures so that you don't alter the tone. The darker the skin, the greater the chance for the skin to become even darker after surgery or skin resurfacing," he said.

Let patients know you understand them According to Dr. Hicks, minority patients want to know that doctors are experienced in treating their ethnic group; so, doctors should include examples of African-American and Hispanic patients in their patient portfolios.

Speaking the language of large patient populations also helps, advised Dr. Wigoda, who speaks English and Spanish and has a bilingual aesthetician on staff.

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