Men are a fast growing segment of the cosmetic surgery population, representing 9% of all cosmetic procedures in 2012. Men have a particular interest in minimally invasive cosmetic procedures with little downtime. More than 1 million minimally invasive procedures were performed in men last year, an 8% increase from 2011.1 Men are spending more time and money on their appearance than ever before. Men’s grooming products are one of the beauty industry’s fastest growing segments, with global revenues rising by an average of 6% a year — reaching almost $33 billion in 2011, according to Euromonitor International. In the US, Mintel forecasts that men’s toiletries will be a $3.2 billion market by 2016.2
The increase in male patients undergoing cosmetic procedures is multifactorial. A desire to be more competitive and youthful in the workforce, the growing social acceptability of cosmetic procedures and increased awareness of the safety and efficacy are all contributing factors to the increase in male patients. In addition, age-related concerns have men seeking cosmetic procedures. With younger urban male professionals, gender conventions are blurring, and these men also understand the importance of maintaining their youthful look. The constant sharing of photos on social media is also driving pressure on younger men to look fashionable, well groomed and fit.
Despite the increased demand, the scientific community and the medical aesthetics industry largely have ignored men. The study of beauty and aging typically focuses on the female face, while mass media marketing of aesthetic treatments tends to target women. Some aesthetic practices have realized that men offer an untapped market. While their interest has steadily increased, men still represent only a fraction of the patients undergoing minimally invasive cosmetic procedures. Increased attention to male cosmetic patients, both academically and commercially, will not only lead to better treatment, but also attract more male patients to cosmetic procedures.
Successful cosmetic treatment of men requires dermatologists 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. Achieving success also requires a gender-specific approach to counseling, treatment and follow-up.
Biologic Differences
Sexual dimorphism refers to the phenotypic differences between genders of the same species. In humans, these 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.3 Sexual dimorphism in facial anatomy and cutaneous physiology4 is well documented, yet these differences are rarely discussed in aesthetic dermatology literature.
Gender differences are primarily mediated by sex hormones. In men, the increase in androgens affects several functions of human skin and its appendages. Male skin, both epidermis and dermis, is thicker at all ages with the extent varying with anatomical region.5 Male cutaneous appendages also show greater activity with men having an increase in sebum and sweat production. The increased sebaceous gland activity may contribute to the larger pore size found in men. 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. Male skin also has a diminished response to outside insults with a greater sensitivity to ultraviolet radiation and delayed wound healing.
Subcutaneous structures are important to consider when evaluating a male cosmetic patient. The male skull is not only unique in its overall larger size,6 but also in its unique shape. Men tend to have a large forehead with prominent supraorbital ridges,7 wide glabella,8 square orbit and a prominent protruding mandible. Men have increased skeletal muscle mass9 including facial memetic muscles.10 Men also have a highly vascularized face11 leading to ruddy complexions. 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.12 The gender differences in adipose distribution are often described as comparing “apples and pears.” Men are more likely to accumulate adipose tissue in the upper body (trunk, abdomen), whereas women usually accumulate adipose tissue in the lower body (hips, thighs). The anatomical differences 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 rhytides13 except in the perioral area.14 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.
While these anatomical gender differences are critical, it is important that dermatologists do not overlook the behavioral differences that also need to be acknowledged when evaluating male cosmetic patients.
Behavioral Differences
Men are generally poor consumers of healthcare and dermatology services. Men consistently underutilize preventive healthcare services compared with women regardless of income or ethnicity even when reproductive services are accounted for.15 Men are also passive patients in that they tend to have shorter doctor visits, are less likely to ask questions, pay less attention to bodily changes and visit their doctors later in the course of a condition than women.16 In regards to dermatology, men are less likely to see a dermatologist, participate in a skin cancer screening, perform self-skin exams or use sunscreen. With that in mind, avoiding unnecessary follow-up visits and performing combination treatments will minimize missed appointments. When close clinical follow up is necessary, it is important to emphasize the need for a return visit at the time of treatment and to consider contacting the male patient with a reminder prior to the appointment.
Men favor treatments with minimal downtime and are generally less informed about the range of available cosmetic services. Because men are less cosmetically savvy, they need to be more thoroughly educated about the various options, including a full discussion of their individual risks and benefits. Careful discussion of the side effects is critical, as men tend to have a lower risk tolerance than women. Male patients appreciate details about the procedures. This requires a greater educational effort on the part of the physician, but will make a strong impression on skeptical new male patients. Adopt a “less is more” philosophy with men by starting with a safe efficacious treatment such as neurotoxins before advancing to more aggressive treatments.
Men have different aesthetic goals. In contrast to women who are more aesthetically driven, men are less likely to be looking for perfection. Men prefer subtle, natural looking results and want to avoid feminization. However, dermatologists should not presume this would make men easier to manage. Men want quick, fast results with no downtime so they can return to work immediately. Often these expectations are not possible to fill, and the need for patience and multiple treatments must be emphasized.
Popular Male Procedures
Cosmetic procedures performed in men can be divided into 2 categories: those procedures that are popular in men and those procedures that require a male-specific approach. Surprisingly, there are cosmetic concerns that are more relevant to male patients. Hair is a common concern for men. Too much hair on the body and too little hair on the head is a common complaint. Men drive the market for hair loss treatments and also are increasingly seeking hair removal treatments.
Because traditional methods for hair removal are temporary and can cause irritation, laser hair removal is increasingly popular among men. According to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2012.1 When treating male patients with laser hair removal, it is important to set treatment expectations in terms of efficacy, the need for multiple treatments and the pain associated with the procedure. If their treatment expectations are not met, it is more likely that men will not return rather than complain. Because male hair is typically thicker and more heavily pigmented, it often requires a lower fluence and longer pulse duration. However, with more chromophore present, there is more absorption and, subsequently, pain. Men tend to have poor pain tolerance with elective cosmetic procedures. To alleviate some of the discomfort, the use of topical anesthetics can be beneficial when performing laser hair removal.
While androgenetic alopecia is common, many men are under the impression that there are few treatment options available to slow or even correct the hair loss. If a male patient has hair loss, it is critical for the dermatologist to address it, even if the patient does not bring it up. Men are often uneducated about the medical and surgical options. Hair transplantation continues to evolve with newer technologies allowing accurate follicular unit extraction (FUE) or refined surgical techniques in strip harvesting (FUT). If your practice does not perform hair transplantation, it is important to identify a local hair transplantation surgeon to whom you can refer potential patients.
Treatment of hyperhidrosis, or excessive sweating, is also a popular procedure in male patients. While botulinum toxin is effective, it is only temporary. Men like finality, and the MiraDry device offers male patients a more permanent solution. Two treatments can result in up to 80%-90% reduction in sweating. Body contouring with noninvasive devices using cold temperatures or heat generated from ultrasound and radiofrequency devices is also trending with male patients. Men are good candidates due to their tendency to develop abdominal and truncal fat deposits. It is important to ensure that the excess adipose is not intraabdominal visceral fat, which will not respond to the treatment. A common obstacle to body contouring treatments in men is their lack of familiarity regarding the treatments. Men tend to be more skeptical so an explanation about the principles and the modest, but real, results is helpful when discussing with male patients.
While rosacea is common in both genders, treatment of the background erythema and telangiectasias is one of the most common reasons for men to seek cosmetic treatment. Higher density of facial blood vessels may make men more susceptible to developing erythema. Vascular laser treatments are effective but can require more treatments than women. In addition, phymatous rosacea is a unique subtype that typically develops in middle-aged white males. While there is no gold standard treatment, early identification and aggressive treatment with a fractionated ablative laser can be effective.
Gender Specific Approach
Botulinum toxin 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 was the single most common cosmetic procedure in 2012, accounting for over 40% of all cosmetic procedures performed in men. The number of men seeking botulinum toxin injections has increased by 7% since 2011.1 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 2 studies that accounted for gender in either the study design or subgroup analysis and only one dose-ranging study.17 The studies that accounted for gender in their study design found abobotulinumtoxinA (Dysport, Medicis) less effective in men at similar doses. The dose ranging study suggested that higher doses of onabotulinumtoxinA (Botox, Allergan) 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 fillers is the procedure that many men are relunctant to have given their concerns for feminization. Their concern is justified given that men require larger volumes due to the size of the face and extent of volume loss, yet excess volume may feminize the patient. It is a fine balance when treating men with fillers. It is best to start conservatively and bring the patient back in 2 weeks at which time more filler can be added if needed. In addition, starting with a filler that will provide a more immediate effect, such as hyaluronic acid products and calcium hydroxylapatite (Radiesse, Merz Aesthetics), is recommended in new male patients. Considering that men are less accepting of posttreatment adverse events, using a cannula for delivering fillers can minimize vascular injury and subsequent bruising.
Enhancement of the lower face is a major focus of filler injections. The filler should be injected along the mandible and below the mentalis muscle to strengthen the mandibular line and give prominence to the chin. Fillers in men are also often used in the upper face to enhance the male forehead prominence by injecting the material into the bony sulcus over the eyebrows.
Filler augmentation of the cheeks is also performed in men to provide structure, lift and to reduce nasolabial folds. However, the site of the injections is more medial to avoid creating wide lateral cheeks, which is a feminine characteristic. 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.
Male Marketing
A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive, men should feel comfortable in the office’s space. Most general dermatology offices do that, but cosmetic dermatologists veer much more toward women because they are the majority of their patient population. For example, at our Washington, DC, cosmetic dermatology practice designed exclusively for men, the new clinic has created an environment where men will feel at ease discussing their dermatologic and aesthetic needs, which they might be less comfortable doing in a dual gender setting (Figure 1 and 2).
Figure 1 and 2. A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive men should feel comfortable in the office’s space.
Photos courtesy of Terrence Keaney, MD
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 increases, dermatologists are reminded to account for gender when evaluating a cosmetic patient. It would also behoove the dermatology community to expand our understanding of the male face and its appropriate treatment with minimally invasive cosmetic procedures. n
Terrence Keaney, MD, is associate dermatologist, with the Washington Institute of Dermatologic Laser Surgery, and co-founder, W for Men, the nation’s first dermatology practice for men.
Disclosures: Dr. Keaney has no conflicts of interest to report.
References
1. American Society for Plastic Surgery 2012 statistics. Available at: s https://www.plasticsurgery.org/news-and-resources/2012-plastic-surgery-statistics.html. Accessed June 1, 2013.
2. JWTintelligence Trend Report: State of Men June 2013. Available at: https://www.jwtintelligence.com/trendletters2/#axzz2Z35xnXZu. Acessed July 1, 2013.
3. Gallagher D Heymsfield SB. Muscle distribution: variations with body weight, gender and age. Appl Radiat Isot. 49(5-6): 733–734, 1998.
4. Giacomoni PU, Mammone T, Teri M. Gender-linked differences in human skin. J Dermatol Sci. 2009;55(3):144-149.
5. Shuster S, Black M, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975;93(6):639–643.
6. Krogman WM. Sexing skeletal remains. In: The Human Skeleton in Forensic Medicine. Springfield, IL: Charles C. Thomas; 1973:112.
7. Garvin HM, Ruff CB. Sexual dimorphism in skeletal browridge and chin morphologies determined using a new quantitative method. Am J Phys Anthropol. 2012;147(4):661-670.
8. Russell MD. The supraorbital torus: a most remarkable peculiarity. Curr Anthropol. 1985;26(3):337–360.
9. Janssen I, Hemsfield S, Wang Z, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18–88 years. J Appl Physiol. 2000;89(1):81–88.
10. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod. 2001;71(2):132-140.
11. Moretti G, Ellis RA, Mescon H. Vascular patterns in the skin of the face. J Invest Dermatol. 1959;33:103–112.
12. Sjostrom L, Smith U, Krotkiewski M, Bjorntorp P. Cellularity in different regions of adipose tissue in young men and women. Metabolism.1972;21(12):1143–1153.
13. Tsukahara K, Hotta M, Osanai O, Kawada H, Kitahara Takema Y. Gender-dependent differences in degree of facial wrinkles. Skin Res Technol. 2013;19(1):e65-e71.
14. Paes EC, Teepen HJ, Koop WA, Kon M. Perioral wrinkles: histologic differences between men and women. Aesthet Surg J. 2009;29(6):467-472.
15. 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;64(4):475-487.
16. Banks I. No man’s land: men, illness and the NHS. BMJ. 2001;323(7320):1058–1060.
17. Keaney TC, Alster TS. Botulinum toxin in male patients: a review of relevant anatomy and clinical trial data. Dermatol Surg. Publication Accepted.
Men are a fast growing segment of the cosmetic surgery population, representing 9% of all cosmetic procedures in 2012. Men have a particular interest in minimally invasive cosmetic procedures with little downtime. More than 1 million minimally invasive procedures were performed in men last year, an 8% increase from 2011.1 Men are spending more time and money on their appearance than ever before. Men’s grooming products are one of the beauty industry’s fastest growing segments, with global revenues rising by an average of 6% a year — reaching almost $33 billion in 2011, according to Euromonitor International. In the US, Mintel forecasts that men’s toiletries will be a $3.2 billion market by 2016.2
The increase in male patients undergoing cosmetic procedures is multifactorial. A desire to be more competitive and youthful in the workforce, the growing social acceptability of cosmetic procedures and increased awareness of the safety and efficacy are all contributing factors to the increase in male patients. In addition, age-related concerns have men seeking cosmetic procedures. With younger urban male professionals, gender conventions are blurring, and these men also understand the importance of maintaining their youthful look. The constant sharing of photos on social media is also driving pressure on younger men to look fashionable, well groomed and fit.
Despite the increased demand, the scientific community and the medical aesthetics industry largely have ignored men. The study of beauty and aging typically focuses on the female face, while mass media marketing of aesthetic treatments tends to target women. Some aesthetic practices have realized that men offer an untapped market. While their interest has steadily increased, men still represent only a fraction of the patients undergoing minimally invasive cosmetic procedures. Increased attention to male cosmetic patients, both academically and commercially, will not only lead to better treatment, but also attract more male patients to cosmetic procedures.
Successful cosmetic treatment of men requires dermatologists 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. Achieving success also requires a gender-specific approach to counseling, treatment and follow-up.
Biologic Differences
Sexual dimorphism refers to the phenotypic differences between genders of the same species. In humans, these 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.3 Sexual dimorphism in facial anatomy and cutaneous physiology4 is well documented, yet these differences are rarely discussed in aesthetic dermatology literature.
Gender differences are primarily mediated by sex hormones. In men, the increase in androgens affects several functions of human skin and its appendages. Male skin, both epidermis and dermis, is thicker at all ages with the extent varying with anatomical region.5 Male cutaneous appendages also show greater activity with men having an increase in sebum and sweat production. The increased sebaceous gland activity may contribute to the larger pore size found in men. 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. Male skin also has a diminished response to outside insults with a greater sensitivity to ultraviolet radiation and delayed wound healing.
Subcutaneous structures are important to consider when evaluating a male cosmetic patient. The male skull is not only unique in its overall larger size,6 but also in its unique shape. Men tend to have a large forehead with prominent supraorbital ridges,7 wide glabella,8 square orbit and a prominent protruding mandible. Men have increased skeletal muscle mass9 including facial memetic muscles.10 Men also have a highly vascularized face11 leading to ruddy complexions. 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.12 The gender differences in adipose distribution are often described as comparing “apples and pears.” Men are more likely to accumulate adipose tissue in the upper body (trunk, abdomen), whereas women usually accumulate adipose tissue in the lower body (hips, thighs). The anatomical differences 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 rhytides13 except in the perioral area.14 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.
While these anatomical gender differences are critical, it is important that dermatologists do not overlook the behavioral differences that also need to be acknowledged when evaluating male cosmetic patients.
Behavioral Differences
Men are generally poor consumers of healthcare and dermatology services. Men consistently underutilize preventive healthcare services compared with women regardless of income or ethnicity even when reproductive services are accounted for.15 Men are also passive patients in that they tend to have shorter doctor visits, are less likely to ask questions, pay less attention to bodily changes and visit their doctors later in the course of a condition than women.16 In regards to dermatology, men are less likely to see a dermatologist, participate in a skin cancer screening, perform self-skin exams or use sunscreen. With that in mind, avoiding unnecessary follow-up visits and performing combination treatments will minimize missed appointments. When close clinical follow up is necessary, it is important to emphasize the need for a return visit at the time of treatment and to consider contacting the male patient with a reminder prior to the appointment.
Men favor treatments with minimal downtime and are generally less informed about the range of available cosmetic services. Because men are less cosmetically savvy, they need to be more thoroughly educated about the various options, including a full discussion of their individual risks and benefits. Careful discussion of the side effects is critical, as men tend to have a lower risk tolerance than women. Male patients appreciate details about the procedures. This requires a greater educational effort on the part of the physician, but will make a strong impression on skeptical new male patients. Adopt a “less is more” philosophy with men by starting with a safe efficacious treatment such as neurotoxins before advancing to more aggressive treatments.
Men have different aesthetic goals. In contrast to women who are more aesthetically driven, men are less likely to be looking for perfection. Men prefer subtle, natural looking results and want to avoid feminization. However, dermatologists should not presume this would make men easier to manage. Men want quick, fast results with no downtime so they can return to work immediately. Often these expectations are not possible to fill, and the need for patience and multiple treatments must be emphasized.
Popular Male Procedures
Cosmetic procedures performed in men can be divided into 2 categories: those procedures that are popular in men and those procedures that require a male-specific approach. Surprisingly, there are cosmetic concerns that are more relevant to male patients. Hair is a common concern for men. Too much hair on the body and too little hair on the head is a common complaint. Men drive the market for hair loss treatments and also are increasingly seeking hair removal treatments.
Because traditional methods for hair removal are temporary and can cause irritation, laser hair removal is increasingly popular among men. According to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2012.1 When treating male patients with laser hair removal, it is important to set treatment expectations in terms of efficacy, the need for multiple treatments and the pain associated with the procedure. If their treatment expectations are not met, it is more likely that men will not return rather than complain. Because male hair is typically thicker and more heavily pigmented, it often requires a lower fluence and longer pulse duration. However, with more chromophore present, there is more absorption and, subsequently, pain. Men tend to have poor pain tolerance with elective cosmetic procedures. To alleviate some of the discomfort, the use of topical anesthetics can be beneficial when performing laser hair removal.
While androgenetic alopecia is common, many men are under the impression that there are few treatment options available to slow or even correct the hair loss. If a male patient has hair loss, it is critical for the dermatologist to address it, even if the patient does not bring it up. Men are often uneducated about the medical and surgical options. Hair transplantation continues to evolve with newer technologies allowing accurate follicular unit extraction (FUE) or refined surgical techniques in strip harvesting (FUT). If your practice does not perform hair transplantation, it is important to identify a local hair transplantation surgeon to whom you can refer potential patients.
Treatment of hyperhidrosis, or excessive sweating, is also a popular procedure in male patients. While botulinum toxin is effective, it is only temporary. Men like finality, and the MiraDry device offers male patients a more permanent solution. Two treatments can result in up to 80%-90% reduction in sweating. Body contouring with noninvasive devices using cold temperatures or heat generated from ultrasound and radiofrequency devices is also trending with male patients. Men are good candidates due to their tendency to develop abdominal and truncal fat deposits. It is important to ensure that the excess adipose is not intraabdominal visceral fat, which will not respond to the treatment. A common obstacle to body contouring treatments in men is their lack of familiarity regarding the treatments. Men tend to be more skeptical so an explanation about the principles and the modest, but real, results is helpful when discussing with male patients.
While rosacea is common in both genders, treatment of the background erythema and telangiectasias is one of the most common reasons for men to seek cosmetic treatment. Higher density of facial blood vessels may make men more susceptible to developing erythema. Vascular laser treatments are effective but can require more treatments than women. In addition, phymatous rosacea is a unique subtype that typically develops in middle-aged white males. While there is no gold standard treatment, early identification and aggressive treatment with a fractionated ablative laser can be effective.
Gender Specific Approach
Botulinum toxin 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 was the single most common cosmetic procedure in 2012, accounting for over 40% of all cosmetic procedures performed in men. The number of men seeking botulinum toxin injections has increased by 7% since 2011.1 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 2 studies that accounted for gender in either the study design or subgroup analysis and only one dose-ranging study.17 The studies that accounted for gender in their study design found abobotulinumtoxinA (Dysport, Medicis) less effective in men at similar doses. The dose ranging study suggested that higher doses of onabotulinumtoxinA (Botox, Allergan) 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 fillers is the procedure that many men are relunctant to have given their concerns for feminization. Their concern is justified given that men require larger volumes due to the size of the face and extent of volume loss, yet excess volume may feminize the patient. It is a fine balance when treating men with fillers. It is best to start conservatively and bring the patient back in 2 weeks at which time more filler can be added if needed. In addition, starting with a filler that will provide a more immediate effect, such as hyaluronic acid products and calcium hydroxylapatite (Radiesse, Merz Aesthetics), is recommended in new male patients. Considering that men are less accepting of posttreatment adverse events, using a cannula for delivering fillers can minimize vascular injury and subsequent bruising.
Enhancement of the lower face is a major focus of filler injections. The filler should be injected along the mandible and below the mentalis muscle to strengthen the mandibular line and give prominence to the chin. Fillers in men are also often used in the upper face to enhance the male forehead prominence by injecting the material into the bony sulcus over the eyebrows.
Filler augmentation of the cheeks is also performed in men to provide structure, lift and to reduce nasolabial folds. However, the site of the injections is more medial to avoid creating wide lateral cheeks, which is a feminine characteristic. 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.
Male Marketing
A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive, men should feel comfortable in the office’s space. Most general dermatology offices do that, but cosmetic dermatologists veer much more toward women because they are the majority of their patient population. For example, at our Washington, DC, cosmetic dermatology practice designed exclusively for men, the new clinic has created an environment where men will feel at ease discussing their dermatologic and aesthetic needs, which they might be less comfortable doing in a dual gender setting (Figure 1 and 2).
Figure 1 and 2. A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive men should feel comfortable in the office’s space.
Photos courtesy of Terrence Keaney, MD
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 increases, dermatologists are reminded to account for gender when evaluating a cosmetic patient. It would also behoove the dermatology community to expand our understanding of the male face and its appropriate treatment with minimally invasive cosmetic procedures. n
Terrence Keaney, MD, is associate dermatologist, with the Washington Institute of Dermatologic Laser Surgery, and co-founder, W for Men, the nation’s first dermatology practice for men.
Disclosures: Dr. Keaney has no conflicts of interest to report.
References
1. American Society for Plastic Surgery 2012 statistics. Available at: s https://www.plasticsurgery.org/news-and-resources/2012-plastic-surgery-statistics.html. Accessed June 1, 2013.
2. JWTintelligence Trend Report: State of Men June 2013. Available at: https://www.jwtintelligence.com/trendletters2/#axzz2Z35xnXZu. Acessed July 1, 2013.
3. Gallagher D Heymsfield SB. Muscle distribution: variations with body weight, gender and age. Appl Radiat Isot. 49(5-6): 733–734, 1998.
4. Giacomoni PU, Mammone T, Teri M. Gender-linked differences in human skin. J Dermatol Sci. 2009;55(3):144-149.
5. Shuster S, Black M, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975;93(6):639–643.
6. Krogman WM. Sexing skeletal remains. In: The Human Skeleton in Forensic Medicine. Springfield, IL: Charles C. Thomas; 1973:112.
7. Garvin HM, Ruff CB. Sexual dimorphism in skeletal browridge and chin morphologies determined using a new quantitative method. Am J Phys Anthropol. 2012;147(4):661-670.
8. Russell MD. The supraorbital torus: a most remarkable peculiarity. Curr Anthropol. 1985;26(3):337–360.
9. Janssen I, Hemsfield S, Wang Z, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18–88 years. J Appl Physiol. 2000;89(1):81–88.
10. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod. 2001;71(2):132-140.
11. Moretti G, Ellis RA, Mescon H. Vascular patterns in the skin of the face. J Invest Dermatol. 1959;33:103–112.
12. Sjostrom L, Smith U, Krotkiewski M, Bjorntorp P. Cellularity in different regions of adipose tissue in young men and women. Metabolism.1972;21(12):1143–1153.
13. Tsukahara K, Hotta M, Osanai O, Kawada H, Kitahara Takema Y. Gender-dependent differences in degree of facial wrinkles. Skin Res Technol. 2013;19(1):e65-e71.
14. Paes EC, Teepen HJ, Koop WA, Kon M. Perioral wrinkles: histologic differences between men and women. Aesthet Surg J. 2009;29(6):467-472.
15. 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;64(4):475-487.
16. Banks I. No man’s land: men, illness and the NHS. BMJ. 2001;323(7320):1058–1060.
17. Keaney TC, Alster TS. Botulinum toxin in male patients: a review of relevant anatomy and clinical trial data. Dermatol Surg. Publication Accepted.
Men are a fast growing segment of the cosmetic surgery population, representing 9% of all cosmetic procedures in 2012. Men have a particular interest in minimally invasive cosmetic procedures with little downtime. More than 1 million minimally invasive procedures were performed in men last year, an 8% increase from 2011.1 Men are spending more time and money on their appearance than ever before. Men’s grooming products are one of the beauty industry’s fastest growing segments, with global revenues rising by an average of 6% a year — reaching almost $33 billion in 2011, according to Euromonitor International. In the US, Mintel forecasts that men’s toiletries will be a $3.2 billion market by 2016.2
The increase in male patients undergoing cosmetic procedures is multifactorial. A desire to be more competitive and youthful in the workforce, the growing social acceptability of cosmetic procedures and increased awareness of the safety and efficacy are all contributing factors to the increase in male patients. In addition, age-related concerns have men seeking cosmetic procedures. With younger urban male professionals, gender conventions are blurring, and these men also understand the importance of maintaining their youthful look. The constant sharing of photos on social media is also driving pressure on younger men to look fashionable, well groomed and fit.
Despite the increased demand, the scientific community and the medical aesthetics industry largely have ignored men. The study of beauty and aging typically focuses on the female face, while mass media marketing of aesthetic treatments tends to target women. Some aesthetic practices have realized that men offer an untapped market. While their interest has steadily increased, men still represent only a fraction of the patients undergoing minimally invasive cosmetic procedures. Increased attention to male cosmetic patients, both academically and commercially, will not only lead to better treatment, but also attract more male patients to cosmetic procedures.
Successful cosmetic treatment of men requires dermatologists 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. Achieving success also requires a gender-specific approach to counseling, treatment and follow-up.
Biologic Differences
Sexual dimorphism refers to the phenotypic differences between genders of the same species. In humans, these 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.3 Sexual dimorphism in facial anatomy and cutaneous physiology4 is well documented, yet these differences are rarely discussed in aesthetic dermatology literature.
Gender differences are primarily mediated by sex hormones. In men, the increase in androgens affects several functions of human skin and its appendages. Male skin, both epidermis and dermis, is thicker at all ages with the extent varying with anatomical region.5 Male cutaneous appendages also show greater activity with men having an increase in sebum and sweat production. The increased sebaceous gland activity may contribute to the larger pore size found in men. 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. Male skin also has a diminished response to outside insults with a greater sensitivity to ultraviolet radiation and delayed wound healing.
Subcutaneous structures are important to consider when evaluating a male cosmetic patient. The male skull is not only unique in its overall larger size,6 but also in its unique shape. Men tend to have a large forehead with prominent supraorbital ridges,7 wide glabella,8 square orbit and a prominent protruding mandible. Men have increased skeletal muscle mass9 including facial memetic muscles.10 Men also have a highly vascularized face11 leading to ruddy complexions. 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.12 The gender differences in adipose distribution are often described as comparing “apples and pears.” Men are more likely to accumulate adipose tissue in the upper body (trunk, abdomen), whereas women usually accumulate adipose tissue in the lower body (hips, thighs). The anatomical differences 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 rhytides13 except in the perioral area.14 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.
While these anatomical gender differences are critical, it is important that dermatologists do not overlook the behavioral differences that also need to be acknowledged when evaluating male cosmetic patients.
Behavioral Differences
Men are generally poor consumers of healthcare and dermatology services. Men consistently underutilize preventive healthcare services compared with women regardless of income or ethnicity even when reproductive services are accounted for.15 Men are also passive patients in that they tend to have shorter doctor visits, are less likely to ask questions, pay less attention to bodily changes and visit their doctors later in the course of a condition than women.16 In regards to dermatology, men are less likely to see a dermatologist, participate in a skin cancer screening, perform self-skin exams or use sunscreen. With that in mind, avoiding unnecessary follow-up visits and performing combination treatments will minimize missed appointments. When close clinical follow up is necessary, it is important to emphasize the need for a return visit at the time of treatment and to consider contacting the male patient with a reminder prior to the appointment.
Men favor treatments with minimal downtime and are generally less informed about the range of available cosmetic services. Because men are less cosmetically savvy, they need to be more thoroughly educated about the various options, including a full discussion of their individual risks and benefits. Careful discussion of the side effects is critical, as men tend to have a lower risk tolerance than women. Male patients appreciate details about the procedures. This requires a greater educational effort on the part of the physician, but will make a strong impression on skeptical new male patients. Adopt a “less is more” philosophy with men by starting with a safe efficacious treatment such as neurotoxins before advancing to more aggressive treatments.
Men have different aesthetic goals. In contrast to women who are more aesthetically driven, men are less likely to be looking for perfection. Men prefer subtle, natural looking results and want to avoid feminization. However, dermatologists should not presume this would make men easier to manage. Men want quick, fast results with no downtime so they can return to work immediately. Often these expectations are not possible to fill, and the need for patience and multiple treatments must be emphasized.
Popular Male Procedures
Cosmetic procedures performed in men can be divided into 2 categories: those procedures that are popular in men and those procedures that require a male-specific approach. Surprisingly, there are cosmetic concerns that are more relevant to male patients. Hair is a common concern for men. Too much hair on the body and too little hair on the head is a common complaint. Men drive the market for hair loss treatments and also are increasingly seeking hair removal treatments.
Because traditional methods for hair removal are temporary and can cause irritation, laser hair removal is increasingly popular among men. According to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2012.1 When treating male patients with laser hair removal, it is important to set treatment expectations in terms of efficacy, the need for multiple treatments and the pain associated with the procedure. If their treatment expectations are not met, it is more likely that men will not return rather than complain. Because male hair is typically thicker and more heavily pigmented, it often requires a lower fluence and longer pulse duration. However, with more chromophore present, there is more absorption and, subsequently, pain. Men tend to have poor pain tolerance with elective cosmetic procedures. To alleviate some of the discomfort, the use of topical anesthetics can be beneficial when performing laser hair removal.
While androgenetic alopecia is common, many men are under the impression that there are few treatment options available to slow or even correct the hair loss. If a male patient has hair loss, it is critical for the dermatologist to address it, even if the patient does not bring it up. Men are often uneducated about the medical and surgical options. Hair transplantation continues to evolve with newer technologies allowing accurate follicular unit extraction (FUE) or refined surgical techniques in strip harvesting (FUT). If your practice does not perform hair transplantation, it is important to identify a local hair transplantation surgeon to whom you can refer potential patients.
Treatment of hyperhidrosis, or excessive sweating, is also a popular procedure in male patients. While botulinum toxin is effective, it is only temporary. Men like finality, and the MiraDry device offers male patients a more permanent solution. Two treatments can result in up to 80%-90% reduction in sweating. Body contouring with noninvasive devices using cold temperatures or heat generated from ultrasound and radiofrequency devices is also trending with male patients. Men are good candidates due to their tendency to develop abdominal and truncal fat deposits. It is important to ensure that the excess adipose is not intraabdominal visceral fat, which will not respond to the treatment. A common obstacle to body contouring treatments in men is their lack of familiarity regarding the treatments. Men tend to be more skeptical so an explanation about the principles and the modest, but real, results is helpful when discussing with male patients.
While rosacea is common in both genders, treatment of the background erythema and telangiectasias is one of the most common reasons for men to seek cosmetic treatment. Higher density of facial blood vessels may make men more susceptible to developing erythema. Vascular laser treatments are effective but can require more treatments than women. In addition, phymatous rosacea is a unique subtype that typically develops in middle-aged white males. While there is no gold standard treatment, early identification and aggressive treatment with a fractionated ablative laser can be effective.
Gender Specific Approach
Botulinum toxin 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 was the single most common cosmetic procedure in 2012, accounting for over 40% of all cosmetic procedures performed in men. The number of men seeking botulinum toxin injections has increased by 7% since 2011.1 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 2 studies that accounted for gender in either the study design or subgroup analysis and only one dose-ranging study.17 The studies that accounted for gender in their study design found abobotulinumtoxinA (Dysport, Medicis) less effective in men at similar doses. The dose ranging study suggested that higher doses of onabotulinumtoxinA (Botox, Allergan) 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 fillers is the procedure that many men are relunctant to have given their concerns for feminization. Their concern is justified given that men require larger volumes due to the size of the face and extent of volume loss, yet excess volume may feminize the patient. It is a fine balance when treating men with fillers. It is best to start conservatively and bring the patient back in 2 weeks at which time more filler can be added if needed. In addition, starting with a filler that will provide a more immediate effect, such as hyaluronic acid products and calcium hydroxylapatite (Radiesse, Merz Aesthetics), is recommended in new male patients. Considering that men are less accepting of posttreatment adverse events, using a cannula for delivering fillers can minimize vascular injury and subsequent bruising.
Enhancement of the lower face is a major focus of filler injections. The filler should be injected along the mandible and below the mentalis muscle to strengthen the mandibular line and give prominence to the chin. Fillers in men are also often used in the upper face to enhance the male forehead prominence by injecting the material into the bony sulcus over the eyebrows.
Filler augmentation of the cheeks is also performed in men to provide structure, lift and to reduce nasolabial folds. However, the site of the injections is more medial to avoid creating wide lateral cheeks, which is a feminine characteristic. 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.
Male Marketing
A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive, men should feel comfortable in the office’s space. Most general dermatology offices do that, but cosmetic dermatologists veer much more toward women because they are the majority of their patient population. For example, at our Washington, DC, cosmetic dermatology practice designed exclusively for men, the new clinic has created an environment where men will feel at ease discussing their dermatologic and aesthetic needs, which they might be less comfortable doing in a dual gender setting (Figure 1 and 2).
Figure 1 and 2. A practice environment that is not intimidating to men is key in attracting new male patients. When they arrive men should feel comfortable in the office’s space.
Photos courtesy of Terrence Keaney, MD
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 increases, dermatologists are reminded to account for gender when evaluating a cosmetic patient. It would also behoove the dermatology community to expand our understanding of the male face and its appropriate treatment with minimally invasive cosmetic procedures. n
Terrence Keaney, MD, is associate dermatologist, with the Washington Institute of Dermatologic Laser Surgery, and co-founder, W for Men, the nation’s first dermatology practice for men.
Disclosures: Dr. Keaney has no conflicts of interest to report.
References
1. American Society for Plastic Surgery 2012 statistics. Available at: s https://www.plasticsurgery.org/news-and-resources/2012-plastic-surgery-statistics.html. Accessed June 1, 2013.
2. JWTintelligence Trend Report: State of Men June 2013. Available at: https://www.jwtintelligence.com/trendletters2/#axzz2Z35xnXZu. Acessed July 1, 2013.
3. Gallagher D Heymsfield SB. Muscle distribution: variations with body weight, gender and age. Appl Radiat Isot. 49(5-6): 733–734, 1998.
4. Giacomoni PU, Mammone T, Teri M. Gender-linked differences in human skin. J Dermatol Sci. 2009;55(3):144-149.
5. Shuster S, Black M, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975;93(6):639–643.
6. Krogman WM. Sexing skeletal remains. In: The Human Skeleton in Forensic Medicine. Springfield, IL: Charles C. Thomas; 1973:112.
7. Garvin HM, Ruff CB. Sexual dimorphism in skeletal browridge and chin morphologies determined using a new quantitative method. Am J Phys Anthropol. 2012;147(4):661-670.
8. Russell MD. The supraorbital torus: a most remarkable peculiarity. Curr Anthropol. 1985;26(3):337–360.
9. Janssen I, Hemsfield S, Wang Z, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18–88 years. J Appl Physiol. 2000;89(1):81–88.
10. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod. 2001;71(2):132-140.
11. Moretti G, Ellis RA, Mescon H. Vascular patterns in the skin of the face. J Invest Dermatol. 1959;33:103–112.
12. Sjostrom L, Smith U, Krotkiewski M, Bjorntorp P. Cellularity in different regions of adipose tissue in young men and women. Metabolism.1972;21(12):1143–1153.
13. Tsukahara K, Hotta M, Osanai O, Kawada H, Kitahara Takema Y. Gender-dependent differences in degree of facial wrinkles. Skin Res Technol. 2013;19(1):e65-e71.
14. Paes EC, Teepen HJ, Koop WA, Kon M. Perioral wrinkles: histologic differences between men and women. Aesthet Surg J. 2009;29(6):467-472.
15. 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;64(4):475-487.
16. Banks I. No man’s land: men, illness and the NHS. BMJ. 2001;323(7320):1058–1060.
17. Keaney TC, Alster TS. Botulinum toxin in male patients: a review of relevant anatomy and clinical trial data. Dermatol Surg. Publication Accepted.
