Terrence Keaney, MD
Washington Institute of Dermatologic Laser Surgery, Washington, DC, USA
Men are a fast growing segment of the aesthetic industry. A review was performed for publications on gender differences in facial anatomy, behavior, and the use of minimally invasive aesthetic procedures in men. There are substantial facial anatomical differences between genders with men having a larger but unique cranial shape, increased skeletal muscle mass, unique subcutaneous fat distribution, and more severe facial rhytides. Men also exhibit poor behavior that can accelerate aging including poor utilization of preventive health care services, higher rates of smoking, and increased ultraviolet light exposure. Despite gender differences in facial anatomy and behavior, few studies have examined the role of gender in cosmetic procedures. Men require a unique injection technique with botulinum toxin and dermal fillers due to differences in facial anatomy.
administration and dosage, anatomy, botulinum toxins type A, cosmetic techniques, dermal fillers, face, gender differences, male, neuromuscular agents, skin aging
Men are a fast growing segment of the cosmetic surgery population, representing 9% of all cosmetic procedures in 2012. More than one million minimally invasive procedures were performed in men, an 8% increase from 2011.1 Despite the increased demand, the scientific community has largely ignored men. The study of beauty and aging typically focuses on the female face. Successful cosmetic treatment of men requires physicians to recognize the gender differences in anatomy, skin biology, skin aging, behavior and rejuvenation goals. The importance of understanding all gender differences is critical in providing a successful cosmetic outcome.
Gender anatomical differences are wide ranging and are reflected in the differences in external genitalia, greater musculature and a larger skeletal anatomy of males relative to females.2 Sexual dimorphism in facial anatomy and cutaneous physiology is well documented, yet these differences are rarely accounted for in clinical practice.3
Male skin is thicker at all ages with the extent varying with anatomical region.4 Male cutaneous appendages also show greater activity with men having an increase in sebum and sweat production. There are significant differences in hair distribution because the growth of sexual hair is dependent on androgens. Androgens convert small, straight, nonpigmented vellus hairs into coarse, pigmented, terminal hairs. Androgen-dependent areas include the chin, upper lip, chest, breasts, abdomen, back, and anterior thighs.
Subcutaneous structures are important to consider when evaluating a male cosmetic patient. The male skull is not only unique in its overall larger size,5 but also in its unique shape. Men tend to have a large forehead with prominent supraorbital ridges,6 wide glabella,7 square orbit and a prominent protruding mandible. Men have increased skeletal muscle mass8 including facial memetic muscles.9 Men also have a highly vascularized face due to the vascular plexus supporting the beard hairs.10 The greater density of facial vasculature may make men more prone to develop bruising with injectables, particularly in the lower face.
The subcutaneous adipose layer is thinner in men irrespective of age, but men have higher rates of visceral abdominal adipose.11 The facial subcutaneous fat also exhibits sexual dimorphism. Facial soft-tissue assessments by using three-dimensional (3D) reconstructed models have demonstrated that men have less soft tissue in the cheek area.12,13 Women have 3 mm more subcutaneous tissue in the medial malar area when compared with men.14 Clinically, this difference corresponds to flatter, more angular cheeks in men.
The anatomical variations between genders result in differences in aging. The aging male face is unique and must be approached and treated differently. Men have more severe facial rhytides except in the perioral area.15,16 The loss of subcutaneous adipose with age results in deeper expression lines in men because of the thicker skin and more prominent facial musculature, as opposed to the superficial rhytides that women tend to develop. The prominent volume loss makes men appear older than their age when compared to women.17
It is important that physicians do not overlook the behavioral differences, which also need to be acknowledged when evaluating male aesthetic patients. Men are generally poor consumers of health care and dermatology services. Men consistently underutilize preventive health care services compared with women, regardless of income or ethnicity even when reproductive services are accounted for.18 In regards to their cutaneous health, men are less likely to see a dermatologist, participate in a skin cancer screening, or perform self-skin exams.
Extrinsic aging factors range from exposure to sunlight, pollution, cigarette smoke, repetitive muscle movements, and diet.19 The two greatest extrinsic aging factors are smoking and exposure to ultraviolet (UV) light.20 Men smoke more often, increasing their risk for cutaneous aging. In 2012, the worldwide prevalence of smoking in men was 31.1% and 10.6% in women.21 Smoking is an independent risk factor for the development of elastosis among both men and women, although smoking was strongly associated with men given their higher incidence of smoking.
Not only are men more likely to smoke, but they are more likely to be exposed to UV radiation. The highly gendered nature of employment results in men being more likely to be employed in outdoor occupations resulting in greater UV light exposure.22 When men are in the sunlight, they are less likely to adopt sun protective behaviors.23 Men use sunscreen less frequently than women.24 One study found that 41% of men never apply sunscreen.25 While females are more likely to sunbathe and indoor tan more frequently than males, men are more likely to develop sunburns.26
Aesthetic Procedures in Men
Injectable botulinum toxin type A and dermal fillers are the main drivers of any cosmetic dermatology practice. Injection technique varies in male patients due to differences in anatomy and patient goals. Success in using dermal fillers and botulinum toxin in men requires a balancing act between masculinizing and feminizing the face, as excessive use of either may result in an undesired cosmetic outcome.
Treatment with botulinum toxin is the single most common cosmetic procedure performed in men.1 Given the anatomic differences, botulinum toxin injections should be tailored to the male face. When treating the frontalis muscle, a flat injection technique is recommended to minimize brow arching and maintain the normal flat male eyebrow position. The lateral aspect of the frontalis also must be treated in order to avoid lateral frontalis contraction leading to arching of the eyebrows. Extra caution is required when treating the inferior portion of the frontalis muscle. Because eyebrow ptosis occurs when the eyebrow falls significantly below the orbital rim, there is not much room for error in men given their naturally low eyebrow position. More injections may be required to ensure complete and balanced treatment of the frontalis muscle due to the larger surface area of the male forehead. Careful inspection and treatment of the superior frontalis muscle in men with androgenic alopecia and high hairlines are needed to avoid unnatural movement in the areas of alopecia. When treating the lower face in men, the perioral area is not a common injection site due to the relative lack of perioral rhytides. Caution is advised in the treatment of masseter hypertrophy in male patients to ensure that a true muscular hypertrophy exists (rather than normal lateral flaring of the mandible).
Despite gender differences in facial anatomy, the use of botulinum toxin in men is inadequately studied with regards to dosing, efficacy and safety. A review on the use of botulinum toxin in men found only two studies that accounted for gender in either the study design or subgroup analysis and only one dose-ranging study.27 The studies that accounted for gender in their study design found abobotulinumtoxinA (Dysport®) to be less effective in men compared with women at similar doses. The dose ranging study suggested that higher doses of onabotulinumtoxinA (Botox®) were more efficacious in treatment of the male glabella. Although there are no studies examining the use of botulinum toxin elsewhere in the male face, this data suggests that men require a higher total dose.
Dermal fillers can be very useful in male patients who struggle with volume loss given their relative lack of subcutaneous fat. Volume replacement with dermal fillers carries the risk of feminization. Mid face augmentation should account for the male cheek anatomy. Fillers should be injected laterally along the zygomatic arch, carefully avoiding too much volume in the anterior and medial cheeks. In contrast to women, for whom lip augmentation is a leading use of fillers, the upper lip is generally avoided in men due to the risk of feminizing.
Men may represent a small proportion of cosmetic patients, but they are a growing segment of the cosmetic industry. Males are an untapped patient population that could serve as an area for growth in aesthetic practices. As the number of male patients seeking treatment increase, physicians need to account for gender when evaluating and treating a cosmetic patient. It would also behoove the medical community to expand our understanding of the male face and its appropriate treatment with minimally invasive cosmetic procedures.
- American Society of Plastic Surgeons. 2012 plastic surgery procedural statistics. Cosmetic surgery in males. Available at http://www. plasticsurgery.org/news/plastic-surgery-statistics/2012-plastic-surgerystatistics.html. Accessed January 18, 2015.
- Gallagher D, Heymsfield SB. Muscle distribution: variations with body weight, gender, and age. Appl Radiat Isot. 1998 May-Jun;49(5-6):733-4.
- Giacomoni PU, Mammone T, Teri M. Gender-linked differences in human skin. J Dermatol Sci. 2009 Sep;55(3):144-9.
- Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975 Dec;93(6): 639-43.
- Krogman WM. Sexing skeletal remains. In: The human skeleton in forensic medicine. Springfield, IL: Charles C. Thomas, 1973; p112.
- Garvin HM, Ruff CB. Sexual dimorphism in skeletal browridge and chin morphologies determined using a new quantitative method. Am J Phys Anthropol. 2012 Apr;147(4):661-70.
- Russell MD. The supraorbital torus: a most remarkable peculiarity. Curr Anthropol. 1985;26:337-60.
- Janssen I, Heymsfield SB, Wang ZM, et al. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr. J Appl Physiol (1985). 2000 Jul;89(1):81-8.
- Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod. 2001 Apr;71(2):132-40.
- Moretti G, Ellis RA, Mescon H. Vascular patterns in the skin of the face. J Invest Dermatol. 1959 Sep;33:103-12.
- Sjostrom L, Smith U, Krotkiewski M, et al. Cellularity in different regions of adipose tissue in young men and women. Metabolism. 1972 Dec;21(12):1143-53.
- Codinha S. Facial soft tissue thicknesses for the Portuguese adult population. Forensic Sci Int. 2009 Jan 30;184(1-3):80 e1-7.
- Cha KS. Soft-tissue thickness of South Korean adults with normal facial profiles. Korean J Orthod. 2013 Aug;43(4):178-85.
- Wysong A, Joseph T, Kim D, et al. Quantifying soft tissue loss in facial aging: a study in women using magnetic resonance imaging. Dermatol Surg. 2013 Dec;39(12):1895-902.
- Tsukahara K, Hotta M, Osanai O, et al. Gender-dependent differences in degree of facial wrinkles. Skin Res Technol. 2013 Feb;19(1):e65-71.
- Paes EC, Teepen HJ, Koop WA, et al. Perioral wrinkles: histologic differences between men and women. Aesthet Surg J. 2009 Nov-Dec;29(6):467-72.
- Bulpitt CJ, Markowe HL, Shipley MJ. Why do some people look older than they should? Postgrad Med J. 2001 Sep;77(911):578-81.
- Pinkhasov RM, Wong J, Kashanian J, et al. Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. Int J Clin Pract. 2010 Mar;64(4): 475-87.
- Bergfeld WF. The aging skin. Int J Fertil Womens Med. 1997 Mar-Apr; 42(2):57-66.
- Kennedy C, Bastiaens MT, Bajdik CD, et al. Effect of smoking and sun on the aging skin. J Invest Dermatol. 2003 Apr;120(4):548-54.
- Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA. 2014 Jan 8;311(2): 183-92.
- Centers for Disease Control and Prevention. Workers Memorial Day – April 28, 2012. Morb Mortal Wkly Rep (MMWR). 2012 Apr 27;61(16):281.
- Sattler U, Thellier S, Sibaud V, et al. Factors associated with sun protection compliance: results from a nationwide cross-sectional evaluation of 2215 patients from a dermatological consultation. Br J Dermatol. 2014 Jun;170(6):1327-35.
- Falk M, Anderson CD. Influence of age, gender, educational level and selfestimation of skin type on sun exposure habits and readiness to increase sun protection. Cancer Epidemiol. 2013 Apr;37(2):127-32.
- Thieden E, Philipsen PA, Sandby-Moller J, et al. Sunscreen use related to UV exposure, age, sex, and occupation based on personal dosimeter readings and sun-exposure behavior diaries. Arch Dermatol. 2005 Aug;141(8):967-73.
- Buller DB, Cokkinides V, Hall HI, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: review from national surveys and case studies of 3 states. J Am Acad Dermatol. 2011 Nov;65(5 Suppl 1):S114-23.
- Keaney TC, Alster TS. Botulinum toxin in men: review of relevant anatomy and clinical trial data. Dermatol Surg. 2013 Oct;39(10):1434-43.