Skin Thickness

Males have thicker skin, which in the setting of central fat atrophy can lead to exaggerated nasolabial fold deepening, inferior migration of the lid–cheek junction, and jowls. The subcutaneous dissection in males tends to be more fibrous, but usually produces a thicker flap that is well vascularized, less prone to venous congestion, and preserves facial hair follicles. The skin flap is dissected into the malar region and anterior to the masseteric cutaneous ligaments. We have often noted a quicker recovery in male patients, which may be partially contributed to their thicker, well-vascularized skin.

Brow Position

The male brow is heavier, flatter, and less tolerant of surgical alteration than is the female brow. In brow lifting, overcorrection can lead to better long-term brow position; however, this is poorly tolerated by male patients because of the propensity to feminize and create an artificial appearance. For this reason, concurrent brow lift is performed less frequently (10% males vs. 30% females), and when performed, a less invasive technique is used (endoscopic or temporal excision alone).

Abbreviation: SMAS, superficial musculoaponeurotic system.
Source: Adapted from RJ Rohrich, JM Stuzin, S Ramanadham, C Costa, PB Dauwe. The modern male rhytidectomy: Lessons learned. Plast Reconstr Surg.
2017;139(2):295–307.

Facial Hair Patterns

Incision design in male rhytidectomy is guided primarily by patterns of hair-bearing skin and has been modified from techniques used in females by many surgeons. ⁴ Preauricular incision placement is determined by the quality of pretragal skin and tendency of the closure to evert the tragus. ⁵ The intratragal incisions are preferred by both senior authors as the color match is better—preauricular incision often leads to an abrupt transition between the pink skin of the cheek and the pale skin of the ear ( Fig. 16.2 ).

In terms of the beard, J.M.S. requests patients to not shave for 48 hours preoperatively, and hair follicles that are repositioned over the tragal cartilage are resected before flap inset. The pretragal scar has been popular in male face-lifting, as it avoids bringing hair-bearing skin into the ear and is simpler to design and inset, but it carries the disadvantage of visibility. While efforts have been made to reduce the conspicuous nature of the pretragal scar, ⁶ it is our preference to avoid it entirely. Furthermore, particular attention is made to avoid pulling hair-bearing neck skin onto the back of the ear, as this can be unsightly and difficult to shave. To avoid this, the postauricular incision should be placed in the postauricular sulcus and away from the conchal cartilage as previously described by Baker et al. ² However, the incision should not be placed on mastoid skin, as this can lead to visible scarring in patients with short hairstyles. This incision pattern contrasts with the senior author’s technique in females, in which the postauricular incision is made 2 mm onto the posterior conchal cartilage.

The temporal hairline incision is preferred by J.M.S. in males, and care must be taken to avoid excess scalp tension, proper incision into the hair, and precise closure, as many men have a thin hairline and wear their hair short. R.J.R. prefers an anterior curvilinear infrabrow extension from the root of the superior helix. This scar is well tolerated and allows excision of redundant skin, avoids displacement of the anterior temporal hairline, and avoids temporal alopecia.

In 2004, Jones and Grover ⁷ demonstrated less temporal alopecia when tumescent was injected subcutaneously before dissection (7.4% vs. 0.4%, p = 0.006). Modifications have been described by Guyuron et al. ⁸ in 2005 and 2007 to maintain the sideburn shape and to encourage hair growth through the scar. ⁹

Lower and Less Prominent Malar Eminence

The skeletal structure of the ideal female face is generally characterized by a wider upper face with the malar highlights superiorly positioned over the zygomatic eminence, producing an “inverted egg” shape in most ideal female faces. A male’s facial skeleton is wider in the lower face and is less volumetrically accentuated in the malar region. Male malar highlights are typically slightly more medial, inferior, and less projected when compared to the high, lateral malar projection noted in females.

Thus, if high, lateral cheek augmentation is performed, the result can be feminizing. For this reason, volume enhancement is focused centrally and avoided superolaterally. Typically, in females, the SMAS stacking (J.M.S.) is brought high along the lateral malar eminence to restore lateral malar highlights. In males, we prefer not to add volume to this region, rather concentrate volume (SMAS) repositioning to the lateral cheek and central face, both typical areas of deflation in males.

Males benefit from an oblique redraping of the SMAS, which provides greater control in improving both the jawline and neck. As the SMAS is thicker and usually more substantial than in females, it typically provides an excellent material for fixation in terms of repositioning facial fat. While SMASplication is a time-honored procedure in face-lifting, it is the opinion of J.M.S. that plication is of limited utility in males, as the tissues are heavy and typically the degree of laxity along the jawline and neck is great. R.J.R. prefers SMAS-plication to reposition facial fat, while J.M.S. utilizes the extended SMAS dissection. The important point is to securely fixate the SMAS, and utilizing multiple interrupted sutures to improve fixation seems to provide greater control in restoration of facial shape in men (see Case Examples).

Central Face Fat Atrophy

The aging male face is characterized by disproportionate central facial volume loss as a result of deep malar fat atrophy. This leads to midface deflation and skin laxity in the nasolabial fold and jowl. To correct this, fat augmentation is focused centrally in the deep malar fat compartments. We also emphasize the relative higher amount of fat grafting that males required to achieve volumetric enhancement, generally being about 30% to 40% more fat than in women. For this reason, the deep malar fat compartments are preferentially injected with more fat than in female patients. ¹⁰ This results in correction of midfacial hollowing and avoids feminization that is seen with lateral fat augmentation over the malar prominences.

Deeper Nasolabial Folds and Excessive Jowls

The propensity for central facial fat atrophy combined with thicker, heavier skin gives males deeper and more exaggerated nasolabial folds and jowls that require more powerful suspension to address. To effectively efface these areas, we fat graft the deep nasolabial and deep malar fat compartments and utilize the malar portion of the SMAS to resuspend the anterior cheek to ameliorate the depth of the nasolabial fold. If jowling is significant, we release the strong mandibular cutaneous ligaments either through the cheek dissection or through the submental incision.

Excessive Neck Skin Laxity and Platysmal Banding

Often the most important aspect of a male face-lift is cervical contouring, and the aged male neck is characterized by more skin laxity, thicker or heavier skin, and strong medial platysmal bands. This is often an area that male patients will ask to be specifically addressed because of problems with shaving and interference with wearing dress shirts. The vast majority of male patient benefit from the added precision of an anterior approach to the neck (>95%) to address the cervical fascial laxity appropriately, to resect pre- and often subplatysmal fat, and to assist with adequate skin undermining to address the excessive skin laxity.

Opening the anterior neck in the male patient is often daunting, as this frequently is a very vascular dissection and therefore requires extensive time spent to ensure adequate hemostasis. Platysma laxity is usually greater in males requiring additional suture plication and a longer inferior muscular transection to ensure release. After completing the partial transection, the platysma plication should be reinspected to ensure that the muscle has not loosened and often additional suture plication of the platysma is required to ensure it accurately reconstructs the cervicomental angle and provides for clear definition of the mandibular border.

A lateral platysmal window suspension is always performed and is often suspended tighter than in females to accentuate the angle of the mandible and cervicomental angle. This typically is sufficient, but if more suspension is needed, a spanning suture is placed from the submental region to the mastoid fascia.