Amy Miller
Since its inception, the practice of aesthetic medicine has been dominated by the female patient. Surgical and non-surgical treatments for facial rejuvenation have evolved to conform the idealised feminine standard of beauty. Arguably, the biggest factor contributing to this feminine standard is the appearance of youth. As men have become aware of modern medicine's ability to help ‘turn back the clock’, they too have begun seeking treatment in greater numbers. Initially, many aesthetic practitioners transferred what they knew of the female face to the male face and treated both in the same manner. Unfortunately, this created a feminised appearance in some men, and possibly deterred future male patients (continuing the pattern of female consumer dominance). Over time, greater appreciation of sexual dimorphism and its application in facial aesthetics has helped practitioners realise that male patients require a different approach and treatment technique. Understanding the differences in female and male facial anatomy, as well as the differing goals of the female and male patient, is imperative to successfully treat both sexes. For clarity's sake, treatment of any of non-female and non-male sexual identities is beyond the scope of this article and will not be addressed.
Sexual dimorphism refers to phenotypic differences between sexes of the same species (Farhadian et al, 2015). In most species, these differences are obvious, such as external genitalia and overall size. In humans, facial phenotypic differences in the sexes can be subtle, yet it is important to be aware of the anatomic variances (see Figure 1). In fact, facial anatomy in adult men differs considerably from that of women (Sedgh, 2018). The female skull is approximately four-fifths the size of the male skull and different in skeletal proportion and overall facial shape (Sedgh, 2018). Sexual dimorphism is also evident in nasal shape, chin projection and width, mandibular angle and the zygomatic-maxilla ratio (Rossi et al, 2017). Males have a more prominent supraorbital rim, flatter cheeks, flatter brow, a greater forehead slope from brow to hairline and a more defined hairline (Frucht and Ortiz, 2016). The skin of the male is thicker and rougher, with a less developed subdermal fat compartment (Gutop, 2013). Male skin tends to have an increased hair follicle density and increased sebum production. Male facial skin has increased vascularity with a greater ratio of capillaries per surface area. (Leong, 2008). Men tend to have greater muscle mass, and facial muscles are not an exception. Often, the male venter frontalis musculi occipitofrontalis and masseter muscles are strongly developed (Wolina, 2012). Usually, this is translated to a higher neurotoxin dose for men so as to achieve the same efficacy observed in women.
Figure 1. Some examples of sexual dimorphism in the human face
Men represent a small but growing percentage of consumers in the aesthetic industry. According to the American Society of Plastic Surgeons (ASPS), in 2018, men represented 8% of minimally invasive (non-surgical) cosmetic procedures (ASPS, 2018). This number is supported by statistics from the American Society for Aesthetic Plastic Surgery (ASAPS), which report men accounted for 7.6% of non-surgical procedures in 2018. Interestingly, the ASPS survey noted that the percentage of men having treatments was down 2% from 2017, but when looking at the trend from 2000 to 2018, the percentage of male treatments increased by 72% (ASAPS, 2018). So, men constitute a tiny but growing segment of the minimally invasive aesthetic market.
Men seeking cosmetic treatments
What is it that motivates a man to seek treatment in this predominately female arena? That largely depends on whom you ask, but there do seem to be some common patterns. According to Cohen et al (2017), the rise in male patients' interest in undergoing cosmetic procedures is related to many social factors, including:
- A desire to look youthful and be more competitive at work
- The growing availability of non-surgical options
- Society's acceptability of men undergoing cosmetic procedures.
Additionally, social media and the rise of the ‘selfie’ have contributed to both females and males seeking cosmetic treatments. In his report on male aesthetics, Sister (2016) states that all men seeking aesthetic rejuvenation share common goals: to stay active and to be able to compete with the younger generation. Frucht and Ortiz (2016) hypothesise that the rise of the ‘metrosexual’, the progressive, young, urban, heterosexual men who are meticulous about their appearance, may contribute to the rise in male patient numbers. In their study looking at men and their experiences with aesthetic treatments, Montes and Santos (2018) report that the main motivating reason a male considers undergoing a cosmetic procedure was the pursuit of a youthful appearance for their sense of wellbeing. Unsurprisingly, this is not divergent from the motivating factors of women. In the author's experience, many males report seeking treatment for reasons similar to women, such as a wish to feel more confident and to look less tired.
Focuses of male treatments
Once the ‘why’ aspect of the treatment has been pondered, the next question to answer is the ‘what’—what do men want to have treated? Once again, the answer varies somewhat depending on who is asked. The hairline, periocular area and jawline tend to rank consistently high when men are asked what bothers them about their appearance. Acne scars, effects of sun damage (lentigenes, poilokoderma, telangiectasia, wrinkles, etc) seborrheic keratosis and sebaceous hyperplasia help round out the top 10 most common presenting cosmetic concerns for men (Handler and Goldberg, 2018). However, dentists tend to disagree. An article published in the Journal of the American Dental Association reports that the mouth, among all subcomponents of the face, had the highest effect on the beauty score of the male face, with the eyes, chin and nose being distant second, third and fourth places (Patsco et al, 2018). A study funded by Allergen suggested that men are concerned with submental fullness or a ‘double chin’ and this ranked second only to hair loss (Jagdeo et al, 2016). However, this same study ranked the double chin as eighth on the list of things men would talk to their physician about. The answer to what men want, it seems, depends just as much on who is asking the question as who is answering. To be fair, submental fullness will blur the jawline, so there is some overlap between the two, and a nice smile is an important part of facial aesthetics that can often be overlooked by aesthetic practitioners. The takeaway from this is that each male patient, just like each female, is a unique individual with unique concerns. Men are often concerned with certain issues but it is important to listen to the patient and not make assumptions based on gender.
Technical aspects of male facial rejuvenation with injectables
Despite the fact that men and women often seek cosmetic treatment for similar reasons, the application of neurotoxins, dermal filler and other injectables must be tailored and gender-specific. Traditionally, men need higher doses of neurotoxin, with different placement of injection points, than women. Filler should be more evenly distributed, not placed in rounded pads, to reflect the lower ratio of adiposity in the subcutaneous fat pads of men. For example, ‘pillows’ of filler to mimic the fullness of feminine lower lip tubercles or medial cheeks should be avoided. This technique of maximising the fullness of the subcutaneous fat pads creates a soft, feminised look and, though often requested by female patients, should not be employed in males. In the author's experience, injecting the structural elements of the face, such as the bony foundation/periosteum and deep fat pads, helps to re-volumise the face while maintaining a masculine look. If needed, a thin layer of filler in the superficial fat pads can then complete the picture.
Upper face techniques
The upper third of the face is dominated by the forehead and hairline; of course, a receding hairline contributes to the appearance of a larger forehead. Hair loss treatments for both men and women are constantly evolving and improving, and in both sexes usually have the best results when started early. Often, these treatments are an entry point for men into the cosmetic realm. The male forehead, besides being taller and wider, also has a prominent supraorbital ridge that slopes backward toward the hairline, giving men a more angled and sharper upper face (Rossi et al, 2017). The male brow tends to be thicker and heavier and lies over the superior orbital rim with little arch on a horizontal level (Sedgh, 2018), unlike the female brow that sits above the orbital rim and is arched, peaking approximately at its lateral third.
Manipulation of the brow position with neurotoxins is a popular treatment for women. The brow can be shaped by altering the contraction strength of the frontalis, as well as the superior fibres of the orbicularis oculi muscle. Treatment of forehead rhytides in men involves leaving the eyebrows alone to a large degree and allowing them to rest in their straighter and lower position on the orbital rim. Too much arch and lift of the brow can be feminising and too much lowering can cause upper lid skin redundancy and interfere with vision. This concept is described by Jones and Fabi (2018), who also recommend placing injection points on the frontal scalp in men with androgenic alopecia to prevent an unnatural wrinkling in this area.
Filler in the upper third of the face in men is still relatively uncommon, except perhaps for the temple region. Youthful temples are flat or slightly convex, temple volumisation is indicated for temples that have become overly concave (De Maio, 2015). Depressions in the brow and temple region can accentuate the appearance of brow ptosis and create harsh shadows, giving the temple a hollow, almost cadaveric appearance (Tzikas, 2018). Revolumising this area can be a satisfying treatment for both the patient and practitioner since it can have a big impact on the overall facial aesthetic, creating a healthier, more youthful look.
Volumisation of the temples can be achieved with many different fillers. There are two approaches that are commonly employed: a deep periosteal depositing or a subcutaneous approach. Both may be needed for a natural, complete look. This author prefers the deep technique; it is relatively simple and gives a natural look without excessive oedema. The disadvantage of periosteal deposition is the sheer volume of product that may be needed to properly fill the area. Filling only subcutaneously requires much less product, but without the deep support it may not produce an optimal result.
When filling the temple in both men and women, it is imperative to avoid the deep and superficial temporal arteries. De Maio et al recommend selecting a supraperiosteal location high in the temporal fossa (1 cm up the temporal fusion line and 1 cm lateral and parallel to the supraorbital rim) as this minimises the risk of intravascular events because of the relative avascularity of the this area and thin fibres of the temporalis muscle in this upper region (De Maio et al, 2017). One advantage of this deep approach is that the muscle fibres of the temporalis often help compress and smooth down the product once it is injected. The more superficial approach can be accomplished with needles or cannulas. Cannulas may cause less bruising, but both can cause significant swelling. Patients with severe subcutaneous atrophy may present with irregularities of the skin surface after subcutaneous filling either with needles or blunt cannulas (De Maio and Ranzy, 2014). With either deep or subcutaneous injection planes, it is important to massage the area after treatment to minimise any irregularities.
Mid-face techniques
Generally, there is less call for a neurotoxin in the midface in both sexes. Men tend to be less concerned with lateral canthal rhytides, nasalis induced rhytides or nasal flaring than women. If treating the lateral canthi in a male patient, it is recommended to not inject directly underneath the tail of the brow (Scheuer et al, 2017). This can cause a lifting of the lateral third of the brow and may be feminising on a male face.
Male mid-face volume deficits became more widely recognised in the 1990s during the AIDS epidemic. The facial lipoatrophy associated with HIV was often recognizable and stigmatising for these patients. Poly-L-lactic acid became a popular filler due to its longer duration of action, and practitioners gained more experience treating male patients. Many injectors realised that lipoatrophy from any cause, whether it was due to chronic disease or simply ageing, could be treated with injectable fillers.
When treating the male mid-face, it is important to understand that the male cheek has more fullness anteromedially than the female cheek, a wider based malar prominence and an apex that is more medial and flatter (Gutop, 2013).
The female cheek has thicker subcutaneous fat compartments and is more projected from all angles. Effective treatment of male face volume loss should concentrate on filling the loss in the midface without creating a curve (Bhojani-Lynch, 2017). The male subcutaneous fat pads are more uniform and thinner; thus, the contours of the cheek are more dependent on the underlying structures (Benito and Wong, 2018) of the skull and deep fat pads (see Figure 2). Revolumising the deep cheek fat pads, while depositing a thin, more uniform layer of filler in the subcutaneous fat compartments, can retain a more masculine aesthetic.
Figure 2. Superficial and deep mid-face fat pads 
Figure 3. Mid-face retaining ligaments and common corresponding surface folds
When injecting the cheek area, whether by cannula or needle, knowledge of the vascular anatomy is paramount. When filling medially, injectors must be careful to avoid the infraorbital artery and nerve, the angular artery and its branches and avoid treatment within the orbital rim. When filling laterally or preauricularly, one must avoid the transverse facial artery and parotid gland (De Maio et al, 2017). Respect must be paid to the facial retaining ligaments in this area as well. It is important to not ‘weigh down’ the orbital retaining ligament or the zygomatico-cutaneous ligaments by injecting product on or just superior to them. The ligaments attach the skin to the underlying bone and do not stretch. Improper placement of product on the ligaments will only serve to accentuate the corresponding surface folds, the orbital malar crease and the mid-cheek crease.
Ideally, the male nose is wide and straight, following a straight line from the radix to the tip (Farhadian et al, 2015). In contrast, the female nose is smaller, with a slight upturn of the tip, making it slightly concave from the lateral view (see Figure 4). The inflection point before the tips starts to elevate is known as the supratip break and, typically, this is absent in men (Rohrich et al, 2003). This explains the smaller nasolabial angle in men. The nasofrontal angle tends to be smaller in men as well, with a slightly more projected radix than in females. In males, the radix starts more superiorly, around the tarsal fold and blends into the glabella (Rossi et al, 2017). Creating a smaller or deeper nasofrontal angle by injecting filler to radix can create a more masculine nose. This area must be approached with caution due the presence of anastomosis of periorbital vessels in the subcutaneous plane (De Maio et al, 2017). Intra-arterial injection of filler in this area can cause an inadvertent flow of product to the ophthalmic artery, triggering blockage and subsequent retinal death/blindness.
Figure 4. Nasal angles/anatomy
Lower face techniques
The angle of the mandible and chin are perhaps the most defining part of the masculine face. Sometimes, this strongly defined, heavily muscled jawline is referred to as the ‘warrior's jaw’. This warrior's jaw has sharp gonial angles with an intergonial width the same as the widest part of the upper face, contributing to a squared off look. The masseter is clearly defined, as if the warrior is clenching his teeth prior to going into battle. According to a survey by Mommaerts, the ideal male jaw has a slope in frontal view nearly parallel to (with a maximum 15-degree downward deviation from) a line extending from the lateral canthus to the alare (Mommaerts, 2016). The male chin is wider and more squared compared to the V-shaped chin in the female (Jack, 2017) (see Figure 5). The ideal chin is as wide as the oral commissures with well-defined lateral tubercles and strong projection. An imaginary line drawn from the most prominent projection of the lip inferiorly should just touch the anterior most point of the chin, the pogonion, indicating ideal chin projection. Too much projection past this line creates an emphasis on the lower face and disrupts the harmony of the vertical thirds of the face. If chin projection (or width) is inadequate, the adjacent neck and jowl soft tissues appear prematurely aged (Sykes and Fitzgerald, 2016). Chin recession is an ideal condition to treat with injectable filler, as long as it is mild to moderate. Severe or significant retrusion may be best treated surgically.
Figure 5. Sexual dimorphism in the human skull 
The male mid-face has an apex that is more medial and flatter, and a wider based malar prominence
Injections of neurotoxin in the lower face may best be confined to the DAOs and playtmus, in other words, any muscle that aids gravity in its downward pull of the soft tissues. Unless a male patient has issues with teeth grinding or temporomandibular joint pain, the masseters are best left alone (or even augmented by filler) as the muscles are a key factor in the ‘warrior jaw’. However, if the masseters are hypertrophied, causing a widening of the lower face beyond the intergonial angle width or, in fact, masking the gonial angles, neurotoxins can be helpful. The same theory applies to the mentalis muscle—muscle mass on the chin helps with projection of the pogonion but hyperactivity will cause deepening of the horizontal chin crease and can lead to peau d'orange appearance of the overlying skin (Jones and Fabi, 2018). It is still somewhat taboo to treat the lips or perioral area in a man, as fuller lips are generally considered a female trait.
Injections of dermal filler in the lower male face are most often aimed at squaring off the jaw, projecting or widening the chin and improving the melomental crease area (see Figure 6). As is the case with neurotoxins, filler in or around the lips is still taboo for most male patients. This will probably change over time, as more men seek treatment, but most men do not lose volume in the perioral region as much as women. This is perhaps because of the thicker terminal hairs of the beard and moustache area, which require more dermal structural support and help camouflage perioral rhytides.
Figure 6. Before and after jawline augmentation with calcium hydroxyapatite
Filler to the gonial angle, ramus and mentum can have a striking effect on the jawline and make a patient appear more masculine. In his paper on jaw augmentation in men, Hamilton (2009) discusses a technique of tracking or laying filler on the periosteum at the gonial angle and tracking superiorly along the ramus and inferiorly on the mandible. He defines tracking as depositing as many strands as necessary in a retrograde manner to provide optimal correction. This technique has served this author well. Rebuilding the basic foundation of the area helps to give a natural, not overly done, appearance. Additional volume can then be added to the masseter area, ideally above or below the muscle itself, to mimic the appearance of the ‘warrior’ jaw.
When injecting in the buccal zone of the body of mandible, it is important to palpate and avoid the facial artery and vein. The facial artery may be palpable as it crosses the lateral border of the mandible, anterior to the insertion of the masseter (Moradi et al, 2019). An embolus of filler inadvertently injected into the facial artery can travel to the angular artery, where it can access the ophthalmic artery and lodge itself in the retinal artery, which, as previously discussed, can cause blindness. There have been reports of reversed flow in the retinal artery (when injecting in the glabellar region) and applying prolonged pressure to the plunger. This can cause retrograde embolisation, which can then access the internal carotid artery and subsequently reach cerebral circulation (Sito et al, 2019). These reports involve injections of the central upper face, but caution is warranted in any facial location as the vessels can have long, tortious paths and varying size, location and anastomosis. In addition to arterial anatomy, knowledge of the facial nerve anatomy is imperative. The terminal branches of the facial and trigeminal nerves reside in the mandibular area. Compression of a nerve or pinching or the nerves during injection can cause paraesthesia. Caution is advised in patients with a history of trigeminal neuralgia as any procedures performed in the jawline area may act as inciting stimuli and trigger onset of a recurrence (Moradi et al, 2009).
To recreate a squared lower face that is a classically appreciated masculine feature, it is appropriate to use the anterior chin projection and angle of the mandible as ‘anchoring points’ (Rossi et al, 2017). An appropriately projected chin can add balance to the lower face and in the case of chin retrusion, restore the horizontal ‘rule of thirds’ that is commonly used to assess facial proportions. Chin projection can be disguised by excess submental adiposity, and reduction of the so called ‘double chin’ can be quite helpful in revealing a masculine jawline and chin. Lipolytic agents such as deoxycholate acid, laser lipolysis and/or targeted liposuction are helpful in these cases. Filler injected on the mandibular tubercles and, if needed, the mental protuberance will help project the chin and lessen the melomental folds by slightly pulling the overlying skin taut and forward.
A mental cleft or vertical line in the centre of chin is often considered a masculine trait. This cleft is the result of visible diathesis of the bellies of the mentalis muscle.
When attempting to project the chin with filler, practitioners should be sure not to fill this area in if the patient prefers a strong cleft. The cleft can actually be augmented with filler placed in the more laterally in the superficial chin fat compartment, while avoiding midline volumisation (see Figure 7).
Figure 7. Before and after chin projection treatment with hyaluronic acid filler
Conclusion
Men often seek aesthetics treatments for the same reason women do, they just present in much lower numbers than women. As the societal stigma continues to regress and more men become aware of the benefits of aesthetics treatments, male aesthetics will become a more prominent part of everyday practice. Understanding sexual dimorphism and the phenotypic differences in male and female faces is crucial to successfully treating both sexes. What looks beautiful and youthful in a female face may look odd and weak in male face; it is important to avoid feminisation of the male patient. If, as aesthetic practitioners, we want to grow this segment of our patient population we need to create Superman and not Wonder Woman.
Key points
- Male patients require a different approach and treatment technique from practitioners, otherwise results can be inadvertantly feminised
- Injectables, such as dermal fillers and neurotoxins, require different volumes and placement in men, for example, men need higher doses of neurotoxins
- The differences in men and women's faces need to be taken into account when focusing on the lower, mid-or upper face.
CPD reflective questions
- What is sexual dimorphism and how is it expressed in the human face?
- What are some of the most often expressed aesthetic concerns of male patients?
- How is the aesthetic treatment of a masculine face similar and different from treatment of a feminine face?
- What are some anatomic ‘danger’ areas to be aware of when injecting dermal fillers and neurotoxin to the face?