12 Bringing it All Home: Conclusions and Future Considerations

Brian P. Hibler, Merrick A. Brodsky, Andrés M. Erlendsson, and Anthony M. Rossi

Summary

This chapter summarizes the fundamental approaches to the male cosmetic patient with regard to various aesthetic treatments. Increasingly, men are becoming more conscious about the health and appearance of their skin, and the demand for cosmetic procedures among male patients is steadily rising. Appreciating differences in anatomy, biochemical differences in skin, and different aesthetic ideals between male and female patients is critical for achieving the best outcome. Alterations in current aesthetic techniques and dosing, gender-specific uses of existing devices, and overall approaches need to be modified to obtain results suitable for the male patient. More than ever, tailoring minimally invasive cosmetic procedures to match an individual’s gender (or gender identity) is becoming an important objective. Herein, we review the key take-home points and approaches to the male cosmetic patient.

The demand for cosmetic procedures among male patients is steadily rising. Additionally, younger male patients are becoming more proactive by choosing preventative skin care treatments. Appreciating differences in anatomy, biochemical differences in skin, and different aesthetic ideals between male and female patients is critical for achieving the best outcome.1,2 Alterations in current aesthetic techniques and dosing, gender-specific uses of existing devices, and overall approaches need to be modified to obtain results suitable for the male patient. Although once overlooked, tailoring minimally invasive cosmetic procedures to match an individual’s gender (or gender identity) is becoming an important objective. In this chapter, we summarize the key take-home points and approaches to the male cosmetic patient.

12.2 Anatomy

Similar to women, men deal with signs of intrinsic and extrinsic aging, including issues such as photoaging, fat loss, and wrinkles. However, male skin—on both the face and the body—has several important differences to consider. Moreover, differences in key defining facial and body features produce what is considered a “male” or “female” physique, knowledge of which is paramount for physicians performing cosmetic procedures.

12.2.1 The Skin

There are a number of anatomical and biochemical differences between male and female skin. In general, male skin is thicker,^3–6 and androgens have been shown to play a major role in regulating dermal thickness.⁷ As men age, the collagen content decreases at a steady rate; meanwhile, due to the effects of estrogen, female skin maintains its thickness until more abrupt thinning occurs after menopause. This later but more rapid decline leads to increased signs of aging relative to male counterparts in the late fifth to sixth decades of life.⁸ Overall, men have greater skeletal muscle mass than women.⁹ There are sex differences in facial muscle movement, with men having greater facial movement after adjusting for facial size¹⁰; when combined with their thicker skin, these factors can result in deeper facial furrows. Decreased adherence to photoprotection can also lead to increased signs of extrinsic photoaging in men, including dyspigmentation, rhytid formation, and solar elastosis. For example, the Favre–Racouchot disease is a cosmetic dermatosis induced by chronic sun exposure often seen in concert with other signs of photoaging (e.g., cutis rhomboidalis nuchae, periorbital rhytids), and is more common in fair-skinned male patients with history of significant ultraviolet (sun) exposure.¹¹

Male facial skin typically has a greater sebum output than female skin, leading to more oily and acne-prone skin, though there can be variability between individuals.¹² Sebum production may be increased by androgens¹³ and decreased by estrogens,^14,15 and the greatest gender differences in sebum production are observed after age 50.^12,13 On the other hand, the increased number of sebaceous glands translates to decreased risk of facial xerosis compared with females, and can result in having naturally shinier facial skin. Various hygiene practices can also lead to different skin concerns in men versus women, such as frequent shaving resulting in sensitive skin and local irritation or “razor burn.”

12.2.2 Facial Features

A major concern among men considering facial cosmetic procedures is a worry about “looking done,” or drastically changing their appearance. Although they may not be able to communicate the specific features differentiating a traditionally “male” versus “female” face, most men are subconsciously aware of factors that are considered more masculine or feminine (Table 12.1).

Table 12.1 Differences in key male and female facial/body characteristics

The overall skeletal framework of the head is different between men and women, with women having a skull about four-fifths the size of the male skull.¹⁶ Men and women have different craniofacial shapes; as such, women seek to have a tapered, heart-shaped face with more prominent upper facial features, whereas men desire a more square, chiseled jawline with equally proportioned facial features between the upper and lower face.¹⁷

Assessment of the upper, mid, and lower face highlights key sexual dimorphic traits. Men prefer a more horizontal, lower-set eyebrow position than females, which is an important consideration when performing neuromodulation of the forehead. Additionally, the male forehead is flatter compared with a convex, feminine forehead. Tear troughs can be a cosmetic concern for both men and women, though men tend to develop more severe sagging of the lower eyelid at a later age.18 The inferior orbital rim tends to recede laterally in females, whereas males have recession of the entire inferior orbital rim, which may contribute to the gender differences in periocular aging.¹⁹ The development of malar mounds and festoons is likely multifactorial, including the natural aging process, genetics, sun exposure, and smoking. Of note, at the malar eminence, where there is maximal cheek projection, women have, on average, 3 mm thicker subcutaneous fat.²⁰ Men naturally have thinner upper lips than women, and although lip augmentation with fillers may not be as commonly requested, for the right patient it may be aesthetically appealing. Although thinning of the lips occurs with age in both sexes, restoring volume to produce a large upper lip should be done conservatively for a natural-appearing outcome. Male pattern baldness and treatment of facial and neck hair are other common cosmetic concerns. Treatment of male pattern baldness can produce a more youthful, masculine look. However, when it comes to hair reduction treatments for excess growth, overtreatment on the face and beard area may create a feminine appearance, necessitating appropriate skill and experience of the treating physician. The lower face, particularly a square jawline, is considered a defining male feature that is highly sought after. A strong jawline can be achieved through multiple avenues, which may include reduction of jowls, submental fat reduction, or enhancement of the jawline with dermal fillers.

12.2.3 Body Contouring

The ideal male body entails a trim, athletic build with a “V-shaped” torso, where the body’s greatest width is at the shoulders and tapers to the narrowest point at the waist. As men age, however, they often develop areas of fat, which accumulate in the abdomen, flanks, breast, and the neck and chin. These are often targeted via either invasive, minimally invasive, or noninvasive body contouring techniques.

One of the first steps in achieving a “V-shaped” torso includes reduction of fat deposits at the flanks, or “love handles,” and sculpting of the abdomen. Liposuction of the abdomen was the most common surgical cosmetic procedure for men as of 2018.²¹ Along with contouring the abdomen, surgical breast reduction for gynecomastia and pseudogynecomastia is increasing in popularity and was the second most popular surgical cosmetic procedure for men in 2018. Male surgical breast reduction increased by nearly 50% between 2014 and 2018, and increased by almost 200% over the past 20 years.^21,22 Increasingly, less invasive treatments including cryolipolysis, radiofrequency (RF) treatments, and low-level laser therapy are being employed to target focal areas of excess fat. A temperature-controlled multifrequency monopolar RF device (truSculpt 3D, Cutera, Brisbane, California, United States) was shown to decrease abdominal fat by 24% at 12 weeks after a single treatment.²³ In a similar fashion, a monopolar RF device with targeted pressure energy (BTL Unison, BTL Industries, Boston, Massachusetts, United States) significantly improved gluteofemoral cellulite after four weekly treatments as measured by clinical and ultrasound assessment.²⁴

For men who desire increased definition of a particular muscle group, implants, such as pectoral or calf implants, may be placed to create cosmetic fullness. Other strategies, including pectoral and abdominal wall “etching,” can be performed to create the perception of increased tone. New devices utilizing high-intensity focused electromagnetic (HIFEM) technology (Emsculpt, BTL Industries) are showing promising results for abdominal body sculpting via abdominal muscle hypertrophy and simultaneous reduction in subcutaneous fat.25 This approach is also being explored for noninvasive buttock lifting and toning of gluteal muscles.²⁶ Small applicators have been approved by the Food and Drug Administration (FDA) for use on the arms, calves, and thighs, though studies of their efficacy at this time are limited.²⁷

12.3 Approach to Aesthetic Procedures in the Male Patient

There are many ways in which performing cosmetic procedures in male patients differs from that in female patients. This may include modifications in the cosmetic consultation or alterations in the technique of the procedure. Although the key aspects of various cosmetic procedures have already been reviewed in extensive detail in the earlier chapters, here we will summarize important points regarding the general approach to cosmetic procedures in male patients.

12.3.1 Cosmetic Consultation

One of the most important aspects of performing cosmetic procedures on any patient is the initial consultation. It is important to assess the patient’s own perception of their body and what enhancements they would like to make. Men often seek cosmetic treatment to appear “good for their age,” to appear more youthful, and improve their perceived competitiveness in the workplace.²⁸ In a study of male patients seeking elective cosmetic procedures, the crow’s feet and tear troughs were rated most likely to be treated first, followed by forehead wrinkles.²⁸ Unlike females who are often more in tune to cosmetic trends, male patients are frequently unsure of their options for rejuvenation. Other times, male patients may present for consultation at the behest of their partner, and don’t know what they want other than to look “refreshed” or “more youthful.” As such, it is always important to have the patient look into the mirror and describe what features concern them and what they desire to change. At this point, depending on the desired outcome, they can be informed of their surgical and nonsurgical options,

The timing of specific cosmetic procedures may vary between men and women. Increasingly, younger males are looking for preventative rejuvenation to maintain their appearance. The cosmetic concerns of younger versus older patients may shift focus; younger males may be more concerned with body contouring and fat reduction, whereas older males may be concerned by deep static rhytids and loss of soft tissue in the face. When starting to perform cosmetic procedures in male patients, it is important to take a staged approach. Men often desire subtle augmentation, such that it is not readily apparent they had cosmetic work performed.

Concerns about body image are often assumed to relate predominantly to females, but are becoming increasingly prevalent among men. Although most bodily concerns are not pathological, 1 in 50 men meet the diagnostic criteria for body dysmorphic disorder (BDD).²⁹ Signs of BDD include mirror checking or avoidance, reassurance seeking, touching disliked areas, excessive exercise, comparing appearance with that of others, excessive tanning, and seeking cosmetic procedures.³⁰ Patients with BDD are prevalent in aesthetic practices, and it is important to be able to identify these individuals.

BDD typically starts during teenage years and without proper intervention continues throughout adulthood.³¹ Individuals with BDD exhibit poor insight into the condition and will seek cosmetic or dermatological treatment to treat the perceived “defects” rather than confront the underlying dysmorphia. Patients with BDD are hard to satisfy, and cosmetic procedures rarely improve their bodily perception. Dissatisfied BDD patients are more likely to threaten with malpractice lawsuits than others, and thus, extensive documentation is especially important when consulting these patients.³² Treating BDD patients cosmetically may also feed into their dysmorphia by acknowledging that there is a “defect” to treat and that can potentially make the condition worse. If concerns about BDD arise during a consultation, BDD screening instruments such as “Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder” can be used to assess the patient.³³ Trying to reassure the patient that their body is “normal” is not advised. Instead, focusing on the time, distress, disability, cost, or lost opportunities triggered by the bodily obsession can help put the problem into context and support a conversation about their issue. Effective treatment options are available and most often include a combination of cognitive behavior therapy and pharmacological agents, such as selective serotonin reuptake inhibitors.³⁴

12.3.2 Combination Therapeutic Approach

To achieve desired aesthetic results, combining different treatment modalities is often required. Determining the optimal therapies and the order they should be administered is crucial for optimizing patient outcome and satisfaction.³⁵

As a first step, it is important to review the patient’s skin care routine. Most patients should use a moisturizer with proper sun protection factor (SPF) during the daytime and topical retinol at night. In younger patients, hair thinning, or androgenetic alopecia may be the main contributing factor to their perception of aging, and thus, addressing and treating their hair concerns should be conducted before other interventions are pursued. In these patients, utilizing topical and/or oral medications may help prevent further loss and promote growth, respectively. For eligible patients, hair transplantation should be considered, as it improves satisfaction with appearance and visual age considerably.³⁶ Furthermore, any concurrent hyperpigmentation or other dermatological conditions, such as acne, rosacea, or telangiectasias should be properly addressed. Treatment for hyperpigmentation may be achieved with pigment-specific wavelengths (depending on skin type) with pico-, nano-, or millisecond pulse duration, and for facial redness and telangiectasias treatment with intense pulsed light, pulsed dye laser, or potassium titanyl phosphate laser is effective.^37,38 In men with poikiloderma where dyspigmentation consists of both melanin and prominent blood vessels, the appearance of hyperpigmentation can be significantly reduced by targeting the ectatic vessels alone.³⁹

Facial aesthetic procedures including neuromodulation, volume enhancement, chemical peels, energy devices, and lasers are almost always used in combination (Fig. 12.1). Neuromodulator injections should always be conducted in a resting face to properly assess wrinkles and hypertonic muscles. Large studies on the safety and efficacy of combining laser- and light-based treatments, neuromodulator therapy, and dermal fillers on the same day is limited. Injectable fillers complement neuromodulator treatments,⁴⁰ and can often be conducted in the same session, though some authors advocate performing fillers first to avoid manipulating the neuromodulator during injection and to assess the degree of edema after filler placement.⁴¹ Occasionally, letting the neuromodulator take effect over a period of 2 weeks or longer can be of value as the ensuing muscle hypotonia may influence the amount of dermal filler required for optimal results.

Related posts:

Aesthetic Concerns in Skin of Color Patients Keg to Six Pack: Fat and Cellulite Treatments Taking a Hard Look: Soft Tissue Augmentation Finding the Right Balance: Chemical Peels High Brow Approach to Neuromodulators Tincture of Time: Facial Aging and Anatomical Considerations

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