Noninvasive body contouring is an attractive therapeutic modality to enhance the ideal male physique. Men place higher value on enhancing a well-defined, strong, masculine jawline and developing a V-shaped taper through the upper body. An understanding of the body contour men strive for allows the treating physician to focus on areas that are of most concern to men, thus enhancing patient experience and satisfaction. This article discusses noninvasive body contouring techniques, taking into account the unique aesthetic concerns of the male patient by combining an analysis of the existing literature with our own clinical experience.
Key points
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Noninvasive body contouring is an attractive therapeutic modality to enhance the ideal male physique.
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An understanding of the body contour men strive for allows the treating physician to focus on areas that are of most concern to men.
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Patients of physicians with an understanding of body counter have an enhanced experience.
Introduction
The male cosmetic patient tends to gravitate toward treatments that require minimal downtime, involve minimal discomfort, and be associated with no visually apparent side effects. In the realm of body contouring, men place higher value on enhancing a well-defined, strong, masculine jawline and developing a V-shaped taper through the upper body. To achieve this contour, the areas of focus are the submental region, the male chest, the abdomen, and the flanks ( Fig. 1 ). Contouring of the lower body, including thighs, knees, and calves, is of lesser importance to men who tend not to develop excessive adiposity in those areas and are typically more interested in developing muscle mass. In this review, we discuss noninvasive body contouring techniques while taking into account the unique aesthetic concerns of the male patient by combining an analysis of the existing literature with our own clinical experience.
Introduction
The male cosmetic patient tends to gravitate toward treatments that require minimal downtime, involve minimal discomfort, and be associated with no visually apparent side effects. In the realm of body contouring, men place higher value on enhancing a well-defined, strong, masculine jawline and developing a V-shaped taper through the upper body. To achieve this contour, the areas of focus are the submental region, the male chest, the abdomen, and the flanks ( Fig. 1 ). Contouring of the lower body, including thighs, knees, and calves, is of lesser importance to men who tend not to develop excessive adiposity in those areas and are typically more interested in developing muscle mass. In this review, we discuss noninvasive body contouring techniques while taking into account the unique aesthetic concerns of the male patient by combining an analysis of the existing literature with our own clinical experience.
Submental and jawline contouring
Cryolipolysis
Cryolipolysis relies on adipocyte response to acute cold injury by inducing a lobular panniculitis, which results in subcutaneous fat layer reduction. Initial proof of concept studies were performed in porcine models with tissue temperatures typically below the freezing point. Subsequent clinical work revealed that treatment efficacy is achieved at skin surface temperatures between 10°C and 17°C and subcutaneous fat temperatures between 9°C and 14°C. Cryolipolysis is now widely performed on a large variety of anatomic sites. The male aesthetic patient, however, typically tends to focus on the submentum, the abdomen, the flanks, and the breast. Indeed, clinical trials involving cryolipolysis to otherwise common areas, such as the medial and lateral thighs and the posterior upper arms, have typically lacked male participation even though this population was not directly excluded.
Excess adiposity in the submental region is a common concern among men. An aesthetically pleasing masculine jawline strongly demarcates the lower face from the neck, and excess submental fat is obscuring. Two prospective clinical trials examining the safety and efficacy of cryolipolysis in this region have been performed with a cumulative male subject proportion of 19% (14 of 74). In both trials, one to two treatment cycles were performed 6 weeks apart with a 3-month follow-up. Subjects were generally pleased. Ultrasound measurements detected a roughly 2-mm fat layer reduction.
Synthetic Sodium Deoxycholic Acid
Another option for male submental contouring is injectable synthetic sodium deoxycholate (SDOC). SDOC disrupts adipocyte cell membranes leading to cell death and a subsequent inflammatory response that clears cellular debris. Four phase III randomized, double-blind, placebo-controlled clinical trials have examined the safety and efficacy of SDOC for the reduction of unwanted submental fat. These trials included a total of 1744 subjects of which 194 were men who received SDOC (11.1%). Subjects were treated up to 6 times with treatment intervals of 28 days. The results uniformly demonstrated significant submental fat reduction and increased patient satisfaction in the active treatment arm versus placebo. The percentage of subjects who achieved a one-point or greater reduction in submental fat score ranged from 50% to 70% with SDOC versus 20% to 30% with placebo. Two of these trials performed MRI assessment of submental fat reduction and found that 40% to 46% of SDOC-treated subjects achieved a 10% volumetric reduction versus 5% with placebo. No increased skin laxity was detected posttreatment.
Successful application of injectable SDOC for submental contouring is heavily dependent on appropriate patient selection. Good candidates for treatment exhibit submental fullness caused by excess subcutaneous fat rather than other causes, such as thyromegaly or lymphadenopathy; do not exhibit excessive platysmal banding or skin laxity; and have not had previous surgical treatments in the area that may complicate subsequent SDOC therapy. Management of patient expectations is also critical because multiple treatment sessions over an extended period of time are typically required to achieve optimal outcomes. Furthermore, unavoidable side effects, such as pain, bruising, and significant edema during and posttreatment, must be fully explained. Simple measures, such as oral ibuprofen or coinjection of lidocaine, can reduce treatment pain. Additionally, in our experience, mixing a small amount of triamcinaolone with the SDOC (1–2 mg/mL) produces a significant decrease in pain and treatment-related edema without compromising treatment efficacy.
Subsurface Monopolar Radiofrequency
Subsurface monopolar radiofrequency is a minimally invasive technique that is designed to simultaneous reduce excessive submental adiposity and tighten loose skin of the neck and jawline. The proper application of this technology has the potential to enhance a strong and defined male jawline. By applying heat at temperatures of 55°C to 70°C to the dermal-epidermal junction and subcutaneous fat while maintaining an epidermal surface temperature below 46°C, adipocyte necrosis, dermal neocollagenesis, and epidermal sparing are achieved. Prospective clinical trials involving men using subsurface monopolar radiofrequency have not been published. Two retrospective studies with 17% male participation reported good clinical efficacy and safety. In our experience, subsurface monopolar radiofrequency for contouring of the neck and jawline is a pleasing minimally invasive therapeutic option in men.
Enhancement of the V-taper
A pleasing V-tapered male body contour relies on an ideal shoulder to chest ratio; a slim waist; and a flat, defined abdomen. This ideal is enhanced by reducing male pseudogynecomastia and unwanted flank and central abdominal fat.
Pseudogynecomastia
One anatomic site that is exclusively a concern among men is the excessive male breast. Pseudogynecomastia is the benign enlargement of the male breast caused by excess subareolar fat. This unwanted fullness tends to be accentuated in the inferior aspect of the male chest, obscuring the ideal V-taper by decreasing the shoulder to chest ratio. Munavalli and Panchaprateep treated 21 men for pseudogynecomastia. Following two treatments, 95% of subjects reported improved visual appearance and 89% reported reduced embarrassment associated with their condition. Additionally, ultrasound measurements detected a mean fat layer reduction of 1.6 mm ± 1.2 mm. We performed a split-breast study in 10 male subjects with pseudogynecomastia and found an 8.12 mm ± 6.94 mm versus a 1.03 mm ± 6.03 mm fat layer reduction by ultrasound measurement in the treated versus untreated breast at 6 weeks post–single cryolipolysis treatment ( P = .03; Jones and colleagues, unpublished data). Mean patient satisfaction was significantly higher for the treated breast versus the untreated breast ( Fig. 2 ). Treatment in this area tends to be well tolerated, although one of the subjects in our trial withdrew because of pain and one subject in the Munavalli trial experienced paradoxic adipose hyperplasia (PAH).
Reduction of Abdominal and Flank Girth
Reducing frontal abdominal protrusion and narrowing of the waist are of paramount importance to men seeking noninvasive body contouring. These areas remain the focus of most noninvasive body contouring technologies including cryolipolysis, nonthermal focused ultrasound, high-intensity thermal focused ultrasound (HIFU), and focus field radiofrequency.
Cryolipolysis
The safety and efficacy of cryolipolysis to the abdomen and flanks is well-documented. There are seven prospective clinical trials that have included male subjects. The cumulative proportion of male subjects was 30% (38 of 127). Fat layer thickness was reduced by 14% to 20% via caliper measurement after one to two treatment sessions corresponding to roughly 40 mL of volumetric loss. In our experience, cryolipolysis to the abdomen and flanks in the male population is an effective and pleasing treatment ( Fig. 3 ). When evaluating male patients for this procedure, particular attention should be paid to the degree of subcutaneous versus visceral fat that is present because cryolipolysis has shown no efficacy in the reduction of visceral abdominal fat.
Adverse events secondary to cryolipolysis tend to be mild and transient, potentially consisting of erythema, edema, bruising, tenderness, and skin numbness. Two rarer side effects have been reported in the literature: delayed pain and PAH. Keaney and colleagues performed a retrospective analysis of 125 patients who received 554 cryolipolysis treatments to analyze variables that may influence the development of delayed posttreatment pain. In this study, risk factors identified included young age (mean, 39 years), female gender, and abdominal treatment area. However, all cases of delayed pain were self-limited and resolved within 3 to 11 days without long-term sequelae. Management of this phenomenon includes mild analgesics, such as lidocaine 5% transdermal patch; gabapentin, 300 mg twice daily; and/or acetaminophen with codeine.
PAH is an even rarer potential adverse side effect of cryolipolysis with an estimated incidence of 1 in 20,000. It is thought to be more common in men with potential risk factors including excessive visceral abdominal fat and the presence of firm, nondistensible, fibrous fat within the treatment area. However, further studies are required to isolate the true cause and consequence of PAH following cryolipolysis. Tumescent liposculpture has been suggested as a possible treatment modality for PAH, although a recent case was reported refractory to even this technique.
Radiofrequency
Contactless focused field radiofrequency has demonstrated safety and efficacy in the treatment of excess abdominal girth in men ( Fig. 4 ). This technology operates on the principle of oscillating electromagnetic fields that force collisions between charged ions causing the production of heat. When applied specifically to the subcutaneous fat layer, adipose tissue temperatures reach 45°C while skin temperatures remain below 40°C. This selective heating leads to adipocyte apoptosis while sparing the overlying skin. Three prospective clinical trials have been performed assessing the ability of focused field radiofrequency to reduce abdominal circumference. A cumulative total of 60 subjects were treated, of which 13 were men (22%). After a series of weekly treatment sessions, these trials demonstrated a 3-cm abdominal circumferential reduction, 5.36-mm reduction in subcutaneous fat layer thickness by MRI, and a 4.17-mm reduction by ultrasound examination at 1 to 3 months post final treatment session. Although the study populations were small, the preclinical and clinical data to date suggest that focused field radiofrequency is a viable therapeutic option for the reduction of unwanted abdominal girth in men. Of note, two clinical trials with this technology have been performed for the contouring of the thigh but of the 82 subjects enrolled, none were men suggesting that this is not an area of high cosmetic concern for men who have an interest in noninvasive body contouring.
