Key points

The appearance of aging results from both internal factors, such as genetic predisposition, hormones, and free radicals, as well as external environmental factors, such as solar exposure. UV radiation is responsible for up to 90% of skin aging. Commencing at age 30 years, men have an average reduction of testosterone of 1% per year. A reduction in testosterone is correlated with a decreased thickness of male skin. The combination of genetic, hormonal, and extrinsic factors lead to a loosening of elastic fibers and collagen, producing wrinkles and skin laxity. Men also care about the presence of scalp hair. With regards to hair loss, a large concern among men, males differ from females in that testosterone and dihydrotestosterone play a role in androgenetic hair loss.

A 2007 survey of men regarding their perception of cosmetic procedures revealed that 40% were interested in undergoing a cosmetic procedure. For many men, an initial consultation, without anticipation of performing a specific procedure, is best performed to discuss their specific concerns. This is because men may be less familiar with cosmetic procedures and ask the physician for help with a specific concerning area or simply request a global reduction in visual signs of aging. When asked why men are reluctant to undergo cosmetic procedures, a common reason for hesitation was a fear of appearing feminized. Men are acutely aware of the sexual dimorphism of facial features and wish to maintain or enhance traditionally masculine ones. An example is the different craniofacial shape between men and women. As men develop confidence that physicians are able to maintain a masculine appearance, the number of men seeking cosmetic treatments will continue to increase. Despite the gap between women and men undergoing cosmetic procedures, as of 2015, men were consumers of close to 10% of all cosmetic treatments ( Fig. 1 ). This equates to a 325% increase in cosmetic procedures received by men since 1997. There is an increased trend of nonsurgical interventions and decreased trend of surgical interventions. For those men undergoing surgical cosmetic procedures, the American Academy of Facial Plastic and Reconstructive Surgery reports the most frequent procedure performed is hair transplant, followed by rhinoplasty, blepharoplasty, scar revision, and facelift ( Box 1 ). Dermatologists report that the most frequent noninvasive cosmetic procedure is neuromodulator injections. Jagdeo and colleagues asked 600 men, primarily Caucasian, aged 30 to 65 years, what cosmetic concerns they had. Among that group, facial wrinkles were of concern to 48%; hair loss was a concern to 40%, and appearance of bags under the eyes was a concern to 44%. Dark under eye circles concerned 34%; sagging facial skin was a concern for 29%, and submental fat was a concern for 28%. Back hair was a concern among 20% ( Box 2 ). Pigmentation irregularities, such as lentigines and actinic damage were of concern to 30% to 34% of surveyed patients, respectively. Ross and colleagues reported that in San Diego pigmentation irregularities were the most common presenting concerns for men ( Box 3 ). Men wish to achieve results that minimize apparent age, but maintain a masculine facial anatomy, requiring techniques that differ from than those used to treat women.

Cosmetic procedures for both men and women.

Throughout history, hair has been an important focus of social acceptability. The Romans learned to dye their hair, and the Egyptians wore wigs over close cut hair styles. The terms big wig and bad hair day are examples that demonstrate the value of hair in today’s society. Scalp hair is a sign of youth, while back hair is not universally considered attractive; body hair removal represents 11.4% of male cosmetic treatments.

DHT, an androgen that results from conversion of testosterone by 5-α-reductase in hair follicles, results in male androgenetic hair loss by reduction of the hair’s growth phase. Male hair loss most often results from genetics and aging, with most men demonstrating some degree of androgenetic hair loss by 50 years of age. A reduction in scalp hair may negatively impact a man’s self-esteem. Sixty-six percent of men with androgenetic alopecia wish they had more hair. Sixty-two percent of men reported being teased about hair loss. These rates of male dissatisfaction with hair loss have been found the United States and in Europe. Men who are not in romantic relationships are at greater psychological risk, as they may feel their chances for acquiring a mate are reduced. Balding men may attempt to compensate for hair loss through changes to their physical appearance. Twenty-percent of men with hair loss grow facial hair, and 39% increase their amount of excerise. Reducing the visible hair loss is an additional factor practiced among balding men, with 65% changing their hair style, and 32% wearing a hat. Although self-treatments, such as minoxidil, are available, men who feel the treatment is inadequate may have increased concern about hair loss. Among facial plastic surgeons, male hair transplant remains the number one surgical cosmetic procedure performed.

The sexual dimorphism of facial anatomy is of importance to men seeking cosmetic treatments. Unlike women who have prominent upper facial features, with a tapering heart shape, men have a square, angled jaw with equally proportioned features of the upper and lower face. This impacts what men are interested in receiving, with regards to cosmetic filler. Men prefer to maintain a masculine appearance when receiving injectable filler treatments to restore facial volume loss. They wish to keep the youthful appearance at the malar eminence but want less cheek projection than would be seen in a woman. This natural reduction in malar projection results from men having an average of 3 mm less subcutaneous malar fat than women. The cheek is a common filler location in men, but too large an amount placed medial or lateral will feminize the face. Men also are concerned about under eye festooning and deep tear troughs. Compared with women, men develop a tear trough deformity at a later age. This may explain why the men feel the presence of such a feature is unattractive, as it associated with frality. The continued male concern with malar reduction and periorbital aging is the reason men are currently 7.4% of all patients receiving hyaluronic acid filler. As opposed to women, lip filler is not a commonly requested procedure among men, as a large upper lip may be viewed as feminine. As a whole, men have naturally thinner upper lips than women. With age, lips thin in both sexes, but volume augmentation in men is considered taboo. If requested to use filler in a man’s lips, clear communication and expertise are a necessity. Among injectables, hyaluronic acid is less commonly requested a procedure than neurotoxins.

In the Merchant of Venice, Shakespeare writes “with mirth and laughter let old wrinkles come.” This may have been self-assuring in the sixteenth century, but in the twenty-first century, adult life expectancy is no longer only 60 years, and packaged botulinum neurotoxin type A is available. In men, the forehead is most susceptible to wrinkles, the hallmark of photo aging. The depth of wrinkles results from their thicker skin and facial musculature, as well as propensity to not adopt sun-protective behaviors. Additionally, men have greater muscle mass and muscle movement of the face than women. This explains why men develop deep facial furrows. When surveyed on the issue, 60% of men were concerned about the appearance of their glabellar lines. Consequently, the male increased muscle mass of the glabella area requires an increased dosage of botulinum toxin, up to 5 times more, than is needed to treat the same area in women. Physicians who treat men with neurotoxins must recognize that standard doses used in women may not be sufficient to produce a result in men’s brows, and be conscious that insufficient dosing is not a result of product ineffectiveness. Although interest in neurotoxins is increasing among millennial men, it is men in their sixth decade who are peaking in their careers and aware that they have aged and developed wrinkles. They also have reached a point of confidence with their position in life, but are afraid of looking aged. Among this group there is a fine balance that must be struck between maintaining a few wrinkles, in order to inspire trust, and having too many, which is perceived as brittle. When men between the ages of 55 and 59 years were asked the reason for their interest wrinkle reduction, 51% stated they wished to look more youthful, and 16% stated that they felt it would help them maintain a competitive edge in the workforce. The area where wrinkling is most concerning to men is the forehead. Neurotoxin use in the corrugators and glabella without treatment of the frontalis will produce an elevated brow, a feminine feature. Men prefer a horizontal brow, requiring treatment of the frontalis muscle, if the glabella area is treated. Crow’s feet and tear troughs are also of concern to men. This may result from the importance that eyes play in society, but it is also known that men develop more severe facial rhytids than women. This has not directly correlated to having severe rhytids treated, as men currently represent only 10.3% of patients receiving neurotoxin. But that percentage has increased by greater than 80% over the prior 6 years. The number of men receiving neurotoxin for cosmetic reasons is expected to rise as there is an increase in social acceptability of cosmetic procedures among men and an increased understanding of the minimal post-treatment recovery time.

Men wish to minimize love handles and acquire a V-shaped torso, where the body’s greatest width is the shoulders, and narrowest the waist. The contoured physique is as old as antiquity, highlighted by the famous Belvedere Torso, which dates to first century bc , and the inspiration for Michelangelo’s Adam, which he painted on the Sistine Chapel. In order to achieve this, body contouring remains a large cosmetic request among men. A Turkish survey found that 53% of men considered surgical body contouring, such as liposuction, for improvement of physique. The most common surgical cosmetic procedure for men as of 2015 was liposuction of the abdomen. The fourth was surgical reduction of gynecomastia ( Box 4 ). Among liposuction cases performed between both sexes, 13% are and 50 years. It is not only the abdomen that men are concerned about. Since 1997, male surgical breast reduction has increased by 173%, and increased 26% since 2014. Male breast reduction procedures peak in the 19- to 34-year-old demographic. Gynecomastia, an increase in glandular tissue and pseudogynecomastia, resulting from excess subareolar fat, exists in 40% and 64% of men, respectively. Although surgical treatment may target both true gynecomastia and pseudogynecomastia, noninvasive treatments, such as cryolipolysis, have been successfully utilized to decrease subareolar fat. With social pressure to maintain a trim figure and an increased number of noninvasive fat reduction systems, including cryolipolysis, radiofrequency, high-intensity focused ultrasound, and low-level laser therapy, it should be no surprise that men represent 16.7% of all nonsurgical fat reduction procedures. For men who seek even greater weight loss, bariatric surgery is an option. As of 2011, 19.3% of all patients undergoing bariatric surgery were men. After substantial weight loss, such as from bariatric surgery, there is an interest in lower body lifting to remove redundant tissue. Among those undergoing surgical lower body lifts, men represented 13.0% of cases.

Box 4

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