Each year, it seems, the numbers and kinds of cosmetic procedures performed continues to rise dramatically. And not surprisingly this is reflected by a growing demand for cosmetic services by women and ever increasingly by men coming from all age groups and ethnic backgrounds. But when it comes to cosmetic surgery for darkly complected individuals there are certain extra risks to be aware of.
A number of years back, dermatologists adopted a six category skin classification system based upon an individual’s sun susceptibility, which is still useful today. Types I-III are skin types that seldom tan and may sun burn. Types III-VI are those that always tan and seldom or never burn. People of Mediterranean background, such as Italians, Hispanics, and Greeks are representatives of Types IV and V. Darkly complected Africans would be Type VI. For the purposes of cosmetic surgery, darker skin types refers specifically to persons falling into Types III or higher categories.
When contemplating surgical outcomes, the basic rule is, the more pigment people have to start with, the more likely they are to have something go wrong with their skin coloration during the immediate healing period or even long afterward. The mechanism of this increased risk is that the surgery, by disrupting the pigment-carrying cells in the lower epidermis, can lead to the dropping down of pigment granules deep into the dermis where they may remain for months resulting in what doctors call postinflammatory hyperpigmentation. This, incidentally, is the same disfiguring, blotchy, excessivley dark discoloration that frequently occurs after a traumatic injury or inflammation, such as acne. The process is also seen in pale-skinned individuals, but because of their relative lack of pigment, the dark areas tend to be faint and to fade far more quickly, as well.
Some procedures by their very nature carry smaller risk even in darker skin types. Botox and filler substances, such as collagen, Restylane and Radiesse, which are injected directly below the skin surface to treat lines, wrinkles and furrows are less likely to result in pigmentary alterations since there is no significant disruption of the epidermis. However, postinflammatory hyperpigmentation would likely occur should there be an infection or allergic reaction at the treatment sites. Fortunately, such complications are rare, making these treatments quite useful for skin Types III-VI.
For the same reasons, sclerotherapy, the injection of high concentration salt solutions to close off unwanted “broken blood vessels" in the legs, is also usually no more problematic in darker skinned patients than in the rest of the population. The relatively common discoloration problem that usually follows treatment is more due to leakage of blood products from damaged blood vessels than it is to melanin, and hence darker skin types are no more or no less at risk for this complication than their paler counterparts.
On the other hand, common cosmetic interventions, such as chemical peels, dermabrasion, and laser resurfacing, which indeed disrupt the epidermis, must be performed with extreme caution on darker skin. When such elective procedures are considered for these patients, the need for the particular treatment must clear, the limitations explained in detail, and the risks fully understood by the patient.
Deep chemical peels should be avoided entirely, as these are very likely to result in pronounced, long-term blotchy hyperpigmentation, or even permanent pigment loss. And while most surgeons agree that laserabrasion carries too many risks for the darker skin patient, there are others who feel that, due to the relatively faster healing time as compared to laser surgery, dermabrasion or dermasanding can be more safely performed in these settings.
Medium depth chemical peeling for acne scarring or skin texturing, too, must be performed with extreme caution. Instead, many cosmetic dermatologists would agree that a series of four to six milder chemical peels, using glycolic acid 70%, Jessner’s solution, beta hydroxyacid (salicylic acid), or trichloroacetic acid 10% would yield satisfactory results with little risk of problematic dyspigmentation. Avoidance of sunlight and the assiduous use of sunscreens for several months following treatment is essential for preventing subsequent discoloration. The routine, pre- and post- procedure home use of glycolic acid, tretinoin and vitamin C creams have also proven helpful in this regard.
Since the success of laser hair removal relies on selective laser light targeting of the pigment within the hair shaft, the ideal candidate is a very pallid patient with dark hair. For darker individuals with dark hair, the laser could target both the skin and the hair resulting in postinflammatory hyperpigmentation at some sites, at best, and permanent loss of pigmentation at other areas, at worst.
More recently some laser surgeons have reported success in these patients using longer wavelength lasers, such as the 1064-nm Nd: YAG laser equipped with a cooling device. The longer wavelength used appears to more poorly absorbed by epidermal melanin while the cooling device further limits heat damage to the pigment-laden epidermis. In addition, the long pulsed diode laser and Intensed Pulse Light, (IPL), a non-laser light source, have each also been reported to be useful for epilation in dark skin. Despite these encouraging preliminary findings, laser-assisted hair removal must still be considered, in the words of a prominent laser researcher, “an imperfect, still-evolving art, especially for patients with darker skin tones."
Finally, for reasons that remain unclear, deeply pigmented persons in particular also exhibit an greater risk for the development of keloid scars at sites of prior trauma or surgery. Keloids are permanent, exuberant overgrowths of fibrous tissue. Individuals who have developed them after other procedures, such as ear piercing, are likely to be especially prone to their development and should be extremely cautious about undergoing any elective cosmetic procedures that involve skin cutting or tissue ablation. The good news is that due to the skyrocketing demand for cosmetic surgery by all segments of the population research goes on to find safer and more effective ways to cosmetically serve darker skin.
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