Men's Aesthetics E-Book

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• Sprache: Englisch

Seitenzahl: 496

Veröffentlichungsjahr: 2023

Beschreibung

Men’s Aesthetics: A Practical Guide to Minimally Invasive Treatment

The first edition of Men’s Aesthetics: A Practical Guide to Minimally Invasive Treatment, edited by leading dermatologist Jeremy Brauer, is a comprehensive and exciting new entry into the fascinating discipline of minimally invasive treatments for men.

This book assembles a group of renowned experts from around the world to cover a range of topics in the field, including aesthetic preferences of men, anatomical changes in men as they age, as well as a variety of treatments and procedures from volumizing the face to the use of neuromodulators and fillers, chemical peels, lasers, lights and energy devices, skin tightening, and treating male pattern hair loss and hair restoration.

The thoughtful discussions on aesthetic concerns in men, men of color and transgender patients will be of particular interest for those interested in building, growing, and maintaining a well-rounded male aesthetic practice.

Key Highlights:

• 12 procedural chapters that cover a wide range of minimally invasive treatments for men
• Clinical pearls that impart best practice, allowing the reader to digest important facts and nuances of the procedures covered in the book
• Instructive, step-wise videos that detail targeted procedures
• 200 illustrations and clinical photos from thousands of procedures performed by the authors

This is an invaluable guide for practitioners interested in the spectrum of male aesthetic topics and will be helpful both to novices as well as seasoned veterans in the aesthetic medicine field.

This book includes complimentary access to a digital copy on https://medone.thieme.com

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Men’s Aesthetics

A Practical Guide to Minimally Invasive Treatment

First Edition

Jeremy A. Brauer, MDClinical Associate ProfessorRonald O. Perelman Department of DermatologyNew York University;Founder and DirectorSpectrum Skin and LaserNew York, New York, USA

204 images

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

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DOI: 10.1055/b000000260

ISBN: 978-3-13-242837-9

Also available as an e-book:

eISBN (PDF): 978-3-13-242838-6

eISBN (epub): 978-3-13-258266-8

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To my wife, Anate, thank you for all of your support, in everything, always, and allowing me to pursue all of my personal and professional dreams.  Thank you to our children, Maddie, Noa, and Sophie−the lights of our life, who continue to keep us young, smiling, and exhausted!  To my mother, Bobbi−your unconditional love, guidance, and support have made me the person I am today.  Lastly, I would like to thank Stephan Konnry, Lewis Enim, and the staff at Thieme for all of their efforts in bringing this book to life.

Contents

Foreword

Preface

Contributors

1The Male Aesthetic Patient: Preferences and Practice

Jeremy B. Green, Terrence C. Keaney, Sebastian Cotofana, and Mildred Lopez-Pineiro

1.1Background

1.2Anatomy

1.3Patient Preferences

1.4Clinical Practice

1.5Conclusion

1.6Pearls

References

2Tincture of Time: Facial Aging and Anatomical Considerations

Jose Raúl Montes and Jonathan J. Dutton

2.1Background

2.2Male Facial Anatomy and Aging Changes

2.2.1Aging and Gender

2.2.2Forehead and Temple

2.2.3Eyelids and Periorbital Region

2.2.4Midface Anatomy and Aging

2.2.5Jawline and Lower Face

2.2.6Hairline and Male Pattern Hair Loss

2.3Conclusion

2.4Pearls

References

3Taking a Hard Look: Soft Tissue Augmentation

Shino Bay Aguilera, Cameron Chesnut, Michael B. Lipp, and Luis Soro

3.1Background

3.2Facial Dimorphisms

3.3The Aging Face

3.3.1Upper Third

3.3.2Midface (Middle Third)

3.3.3Lower Face

3.3.4Pan Facial Revolumization with Poly-L-Lactic Acid

3.4Complications

3.5Conclusion

3.6Pearls

References

4High Brow Approach to Neuromodulators

Edith A. Hanna, Matthew K. Sandre, and Vince Bertucci

4.1Background

4.1.1Motivation

4.1.2Demographics

4.2Anatomy

4.2.1Assessment of the Face

4.3Approach

4.3.1Forehead and Brow

4.3.2Glabella

4.3.3Lateral Canthus

4.3.4Masseters

4.3.5Other Facial Uses

4.3.6ScrotalWrinkling

4.4Approved Indications and Dosing

4.5Pearls

References

5Following the Pattern: Hair Restoration

Nicole Rogers and Marisa Belaidi

5.1Background

5.2Diagnosis

5.3Mimickers of Male Pattern Hair Loss

5.4Treatment of Hair Loss

5.4.1Nonsurgical Options for Hair Loss

5.4.2FDA-Approved Nonsurgical Options

5.4.3Off-Label Nonsurgical Options

5.5Choice of Nonsurgical Therapy

5.6Surgical Options for Hair Loss

5.6.1Consultation and Candidate Selection

5.6.2Methods of Harvesting

5.6.3Surgical Anesthesia

5.6.4Donor Ellipse Harvesting

5.6.5Follicular Unit Excision Harvesting

5.6.6Graft Storage

5.6.7Hairline Design

5.6.8Creation of Graft Sites

5.6.9Graft Placement

5.6.10Post-Op Care

5.6.11Special Situations

5.6.12Camouflage

5.6.13Scalp Micropigmentation

5.7Conclusion

5.8Pearls

References

6Finding the Right Balance: Chemical Peels

Jeave Reserva, Rebecca Tung, and Seaver Soon

6.1Background

6.2Chemical Peels and the Male Skin

6.2.1Peeling Mechanisms and Classification

6.2.2Gender-Linked Skin Differences Relevant to Chemical Peeling

6.2.3Men and Extrinsic Factors Relevant to Chemical Peeling

6.2.4Peel Considerations in Sexual Minority Men

6.3Approach

6.3.1Indications

6.3.2Prepeel Consultation

6.3.3Prepeel Skin Conditioning

6.3.4Postpeel Skin Care

6.4Procedures

6.4.1Salicylic Acid Peel

6.4.2Glycolic Acid Peel

6.4.3Trichloroacetic Acid and Combination Medium-Depth Peels

6.4.4Chemical Reconstruction of Skin Scars Technique

6.4.5Phenol Croton-Oil Peel

6.4.6Combination of Chemical Peeling with Other Minimally Invasive Procedures

6.5Complications

6.6Conclusion

6.7Pearls

References

7The Tech Sector: Lasers, Light, and Energy Devices

Yiping Xing, Derek Hsu, Murad Alam, and Jeremy A. Brauer

7.1Background

7.2Anatomy and Physiology

7.3Introduction to Lasers

7.3.1Resurfacing Lasers

7.3.2Ablative Resurfacing Lasers

7.3.3Nonablative Resurfacing Lasers

7.4Pigmentation

7.4.1Laser Hair Removal

7.4.2Tattoo Removal

7.5Pigmented Lesions

7.6Vascular Lasers

7.7Intense Pulsed Light

7.8Conclusion

7.9Pearls

References

8Keg to Six Pack: Fat and Cellulite Treatments

Deanne Mraz Robinson and Daniel P. Friedmann

8.1Background

8.2Anatomy

8.3Approach

8.4Procedure

8.4.1Cryoadipolysis

8.4.2High-Intensity Focused Ultrasound

8.4.3Nonthermal Focused Ultrasound

8.4.4High-Intensity Focused Electromagnetic Field Therapy

8.4.5Radiofrequency

8.4.6Low-Level Laser Therapy

8.4.7Infrared Diode Laser

8.4.8Injection Adipolysis

8.4.9Tumescent Liposuction

8.5Before and After Examples

8.5.1Case 1: Tumescent Liposuction of the Male Chest

8.5.2Case 2: Tumescent Liposuction of the Male Abdomen,Waist, and Flanks

8.5.3Case 3: Cryoadipolysis of Male Flanks

8.5.4Case 4: High-Intensity Focused Electromagnetic Therapy of Upper Abdomen

8.5.5Case 5: Cryoadipolysis of Male Outer Thighs

8.6Conclusion

8.7Pearls

References

9Not too Tight: Skin Tightening Procedures

Jordan V. Wang, Nazanin Saedi, and Girish S. Munavalli

9.1Background

9.2Indications

9.3Patient Selection

9.4Treatment Options

9.4.1Microneedling

9.4.2Radiofrequency

9.4.3Radiofrequency Microneedling

9.4.4Ultrasound

9.5Postprocedural Expectations

9.6Adverse Events

9.7Conclusion

9.8Pearls

References

10Aesthetic Concerns in Skin of Color Patients

Andrew Alexis and Michelle Henry

10.1Background

10.1.1Anatomy and Physiology of Ethnic Skin

10.2Managing Hyperpigmentation

10.2.1Chemical Peels

10.2.2Laser Treatments

10.3Laser Hair Removal

10.4Injectable Fillers and Neuromodulators

10.4.1Approach

10.4.2Procedure

10.5Hair Restoration

10.5.1Approach

10.5.2Traction Alopecia

10.5.3Central Centrifugal Cicatricial Alopecia

10.5.4Lichen Planopilaris

10.5.5Hair Transplantation

10.6Conclusion

10.7Pearls

References

11Aesthetic Concerns in Transgender Patients

Yunyoung C. Chang and Jennifer L. MacGregor

11.1Background

11.1.1Epidemiology of the Transgender Population

11.2Gender Transitioning

11.2.1Overview: Medications and Surgical Procedures for Gender Transition

11.2.2Quality of Life Relating to Gender Identity and Aesthetic Procedures

11.2.3Barriers to Care

11.3Improving Aesthetic Care through Minimally Invasive Aesthetic Procedures

11.3.1Minimally Invasive Aesthetic Procedures

11.3.2Role of Dermatologists and Other Medical Providers

11.3.3Patient Preferences

11.4Available Procedures and Illustrative Examples

11.4.1Transgender Men (Female to Male Transition)

11.4.2TransgenderWomen (Male to Female Transition)

11.4.3Nonbinary Gender Status

11.5Conclusion

11.6Pearls

References

12Bringing it All Home: Conclusions and Future Considerations

Brian P. Hibler, Merrick A. Brodsky, Andrés M. Erlendsson, and Anthony M. Rossi

12.1Background

12.2Anatomy

12.2.1The Skin

12.2.2Facial Features

12.2.3Body Contouring

12.3Approach to Aesthetic Procedures in the Male Patient

12.3.1Cosmetic Consultation

12.3.2Combination Therapeutic Approach

12.4Procedures

12.4.1Soft-Tissue Augmentation

12.4.2Neuromodulation

12.4.3Hair Restoration

12.4.4Chemical Peels

12.4.5Lasers, Light, and Energy Devices

12.4.6Fat and Cellulite Treatments

12.4.7Skin Tightening Procedures

12.4.8Skin Care

12.5Future Considerations

12.6Conclusion

12.7Pearls

References

Index

Foreword

Minimally invasive treatments made their debut with the development of the pulsed dye laser in the late 1980s. And, since then, there have been rapid and dramatic developments in this field including the development of selective pulsed lasers and lights for treating pigmented lesions, hair removal, treating wrinkles, removing excess fat and hair, growing hair, and the development of a variety of minimally invasive no-downtime procedures using neuromodulators and fillers. This revolution first took place in the female population, but men have slowly but surely joined the party. It is said that up to 10% of all cosmetic procedures performed yearly are done on male patients. And the number is on the upswing.

Perhaps, not surprisingly, it has taken this many years before a well-crafted volume on Men’s Aesthetics has been prepared. Jeremy Brauer, a leader in the field, deserves a huge amount of credit for putting this wonderful text together. He has invited a group of exciting young experts from around the world to cover virtually all the topics in the field including aesthetic preferences of men, anatomical differences and changes in men as they age, and a variety of treatments and procedures from volumizing the face to the use of neuromodulators and fillers, chemical peels, lasers, lights and energy devices, skin tightening, and treating male pattern hair loss and hair restoration. He has rounded out the book with fine discussions of aesthetic concerns in men, men of color, and transgender patients.

Men’s Aesthetics is not intended to serve as a reference textbook, it is rather a guide for practitioners interested in the spectrum of male aesthetic topics. It will be helpful both to novices but also to seasoned veterans in the aesthetic medicine field. The book is beautifully written, and I know you will enjoy it. Happy learning!

Jeffrey S. Dover MD, FRCOC

SkinCare Physicians, Chestnut Hill, Massachusetts

Preface

As greater awareness and acceptance of minimally invasive aesthetic procedures continues, individuals across all demographics are increasingly seeking out these treatments. It was with this in mind, along with a particular focus on the male aesthetic patient, that I set out to create this book. Fortunately, many great minds in the fields of dermatology and plastic surgery from around the world agreed to join me on the journey to bringing you the most comprehensive collective experience in the space of male aesthetics to date.

Our hope and expectation is that, if read carefully, this text will help you to better understand and convey to your patients the risks, benefits and alternatives to these treatments, while optimizing their outcomes. The intention is not to serve as a reference text per se, but instead as a resource for those interested in building, growing, and maintaining a well-rounded male aesthetic practice. The chapters were constructed to be easily accessible, so that you can identify and access the sections most appropriate for your practice and needs.

Across all chapters the reader will have an opportunity to appreciate the broad strokes of a topic of interest as well as glean specific tips or “pearls” regarding best practices. This will allow the practitioner to more readily digest important facts and nuances of the procedures while keeping the big picture in mind, and effectively apply them to their own patients. Utmost effort has been made by the chapter authors to include every minimally invasive procedure currently being performed.

The text opens with an overview of men’s aesthetics and a targeted discussion of the male aesthetic patient. In this chapter, the authors discuss the most recent trends, as well as emphasize the importance of the similarities and differences from their female counterparts as it relates to anatomy and preferences. Perhaps most importantly, the chapter ends with how the patient experience begins–the consultation visit and the first steps toward the development of a strong physician-patient relationship. The importance of this initial visit cannot be overemphasized, as it is your opportunity to evaluate and assess the patient’s goals and needs and develop an appropriate treatment plan.

The second chapter naturally builds off the first, providing a much more in-depth look at the anatomy and aging male face. Methodically working their way from the forehead and temples to the jawline and lower face, the authors provide incredible detail and insight into the structural changes observed over time. While doing so, they seamlessly integrate the identification of target areas for treatment, providing both options and guidance in best approach and practice.

From there, chapters three through nine are dedicated to the review of minimally invasive treatments in male patients. Chapter three seamlessly continues the developing conversation of chapters one and two, highlighting cutting edge techniques and utilization of various fillers to enhance features of the male face. Of significant importance is how well the authors present common adverse reactions and severe complications with filler injections. Avoiding and managing complications of these minimally invasive procedures is paramount to both the patient and physician.

By far the most popular minimally invasive treatment in men, neuromodulators, or botulinum toxins, are discussed in chapter four. The reader is presented with the opportunity to learn not only about best practices and techniques, but also how to optimally perform these procedures with the male perspective and anatomy in mind. Chapter five addresses all aspects of hair loss and restoration, beginning with diagnosis and identification of potential causes, as well as a complete presentation of non-surgical and surgical options. The remainder and majority of this chapter is dedicated to a detailed presentation of surgical options available to practitioners and patients for hair restoration. In chapter six, the reader is fortunate to learn about all aspects of chemical peels, generally, as well as detailed information specific to the male patient. The chapter methodically presents the authors approach, utilizing various peeling agents, but also going much further to include information on indications for treatment, best approaches to the pre-peel consultation and conditioning, as well as post treatment care.

For chapters seven through nine, the focus of the text shifts to treatments with laser, light, and energy-based devices. Considering the risks involved–as with all of the other treatments discussed in the book–it is of the utmost importance to understand and to know how to avoid, minimize, and treat complications associated with these procedures. Chapter seven introduces the topic, with an overview of anatomy and physiology, highlighting the different categories of lasers utilized in addressing the various aesthetic concerns of our male patients. Approaching the evaluation and treatment of unwanted fat with all currently available modalities is what one will gain from reading chapter eight. Then in chapter nine, skin tightening procedures, technologies, and techniques are emphasized to round out the discussion of body contouring.

The final three chapters of the book provide a synthesis of the information in the prior chapters, with an appreciation of the content through a specific lens. Chapters ten and eleven are integral to the conversation about minimally invasive aesthetic treatments in men, identifying the specific concerns of, as well as detailing an approach to, skin of color patients in chapter ten and transgender patients in chapter eleven. In chapter twelve, the reader will find a concise but thorough summary of all of the topics presented in the book, with additional insights as well and discussion of skin care options for our male patients.

It is my sincere hope that you enjoy reading this book and find its content informative and helpful in your own men’s aesthetics practice at whatever stage in your career that may be! I have every expectation that this field will continue to rapidly evolve as more and newer treatments are perfected and performed, so please feel free to reach out with any comments or questions you may have.

Jeremy A. Brauer MD

Contributors

Shino Bay Aguilera, MD

Dermatologist

Shino Bay Cosmetic Dermatology & Laser

Institute;

Clinical Assistant Professor

NOVA South Eastern University

Fort Lauderdale, FL, United States

Murad Alam, MD, MSCI, MBA

Vice Chair Department of Dermatology

Chief of Cutaneous and Aesthetic Surgery

Professor of Dermatology (Cutaneous and Aesthetic Surgery), Medical Social Sciences,

Otolaryngology - Head and Neck Surgery, and Surgery (Organ Transplantation)

Northwestern University

Feinberg School of Medicine

Chicago, IL, United States

Andrew F. Alexis MD MPH

Professor of Clinical Dermatology

Vice Chair for Diversity and Inclusion

Department of Dermatology

Weill Cornell Medical College

New York, NY, United States

Marisa Belaidi, MD

Dermatologist

Hudson Dermatology

New York, NY, United States

Vince Bertucci, MD

Founder and Medical Director

Bertucci MedSpa

Woodbridge, ON, Canada;

Instructor

Division of Dermatology

University of Toronto

Toronto, ON, Canada

Merrick A. Brodsky, MD

Dermatologist

Department of Dermatology

Ohio State University

Columbus, OH, United States

Yunyoung C. Chang, MD

Dermatologist

UnionDerm

New York, NY, United States

Cameron Chesnut, MD, FAAD, FACMS, FASDS

Dermatologist

Clinic 5C

Spokane, WA, United States;

Clinical Assistant Professor

University ofWashington School of Medicine

Seattle, WA, United States

Sebastian Cotofana, MD PhD, PhD

Associate Professor of Anatomy

Department of Clinical Anatomy

Mayo Clinic College of Medicine and Science

Rochester, MN, United States

Jonathan J. Dutton, MD

Professor Emeritus of Ophthalmic Plastic and Reconstructive Surgery and Ophthalmic Oncology

University of North Carolina

Chapel Hill, NC, United States

Andrés M. Erlendsson, MD

Department of Dermatology

Karolinska University Hospital

Stockholm, Sweden

Daniel P. Friedmann, MD, FAAD

Associate and Clinical Research Director

Westlake Dermatology & Cosmetic Surgery

Austin, TX, United States

Jeremy B. Green, MD

Dermatologist

Skin Associates of South Florida

Coral Gables, FL, United States

Edith A. Hanna, MD

Département de dermatologie

Centre Hospitalier Régional du Grand-Portage

CISSS du Bas-Saint-Laurent

Riviére-du-Loup, QC, Canada

Michelle Henry, MD, FAAD

Dermatologist and Founder

Skin and Aesthetic Surgery of Manhattan;

Clinical Instructor of Dermatology

Weill Cornell Medical College

New York, NY, United States

Brian P. Hibler, MD

Dermatologist

Schweiger Dermatology Group

New York, NY, United States

Derek Hsu, MD

Dermatologist

Southern California Dermatology

Santa Ana, CA, United States

Terrence C. Keaney, MD, FAAD

Dermatologist and Founder

Skin DC

Washington DC, United States

Michael B. Lipp, DO, FAAD

Dermatologist

Skinaesthetica Medical Aesthetics

Redlands, CA, United States

Jennifer L. MacGregor, MD

Dermatologist

UnionDerm

New York, NY, United States

José R. Montes, MD FACS, FACCS

Professor

Department of Ophthalmology

University of Puerto Rico School of Medicine;

Medical Director

Jose Raul Montes Eyes and Facial Rejuvenation

San Juan, Puerto Rico

Gilly Munavalli, MD, MHS, FACMS

Medical Director and Founder

Dermatology, Laser, and Vein Specialists of the Carolinas

Charlotte, NC, United States;

Assistant Clinical Professor

Department of Dermatology

Wake Forest School of Medicine

Winston-Salem, NC, United States

Mildred Lopez Pineiro, MD

Medical and Cosmetic Dermatologist

Bellaire Dermatology

Bellaire, TX, United States

Deanne Mraz Robinson, MD, FAAD

Dermatologist

Modern Dermatology

Westport, CT, United States

Anthony M. Rossi, MD, FAAD, FACMS

Mohs Surgeon

Memorial Sloan Kettering Cancer Center

Weill Cornell Medical College

New York, NY, United States

Nicole E. Rogers MD, FAAD, FISHRS

Assistant Clinical Professor

Department of Dermatology

Tulane University

New Orleans, LA, United States;

Private Practice

Hair Restoration of the South

Metairie, LA, United States

Jeave Reserva, MD

Dermatologist

Springfield Clinic

Springfield, IL, United States

Nazanin Saedi, MD

Dermatologist

Dermatology Associates of Plymouth

Meeting

Plymouth Meeting, PA, United States;

Clinical Associate Professor

Department of Dermatology

Thomas Jefferson University

Philadelphia, PA, United States

Matthew K. Sandre, MD

DermatologistBertucci MedSpa

Woodbridge, ON, Canada

Department of Dermatology

Sunnybrook Hospital

Toronto, ON, Canada

Seaver Soon, MD

Dermatologist

The Skin Clinic MD;

Scripps Green Hospital

San Diego, CA, United States

Luis Soro, MD

Dermatologist

Shino Bay Cosmetic Dermatology & Laser Institute

Fort Lauderdale, FL, United States

Rebecca Tung, MD

Mohs and Dermatologic Surgeon

Florida Dermatology and Skin Cancer Centers

Winter Haven, FL, United States;

Professor

Department of Medicine and Dermatology

University of Central Florida

Orlando, FL, United States

Jordan V. Wang, MD, MBE, MBA

Dermatologist

Laser & Skin Surgery Center of New York

New York, NY, United States

Yiping Xing, MD

Dermatologist

Hudson Dermatology

Tarrytown, NY, United States

1 The Male Aesthetic Patient: Preferences and Practice

Jeremy B. Green, Terrence C. Keaney, Sebastian Cotofana, and Mildred Lopez-Pineiro

Summary

This chapter focuses on describing the key differences in gender preferences regarding minimally invasive cosmetic procedures. With the surge in cosmetic procedures performed for men, it is important for clinicians to understand not only anatomic variations in males versus females but also their aging concerns and any possible barriers to treatment.

Keywords: male aesthetics male cosmetics gender differences cosmetic preferences masculine anatomy

1.1 Background

As minimally invasive cosmetic procedures requested by male patients continue to increase, there still remains a dearth of studies focusing on the specifics of male aesthetic preferences (Table 1.1). According to recent statistics, the total number of minimally invasive procedures sought by men has increased by 72% since year 2000, with 1,092,103 reported cases.1 The most common minimally invasive cosmetic procedures performed for men were botulinum toxin type A (BTX-A) and laser hair removal, followed by microdermabrasion, chemical peels, and soft-tissue fillers. Compared to statistics from the year 2000, the procedure with the most growth overall was neuromodulators (BTX-A), with a 381% increase. Interestingly, the three cosmetic procedures that demonstrated a growth pattern year over year (compared to 2017) were vein treatments (including sclerotherapy and laser treatment), laser skin resurfacing, and soft-tissue fillers.1 It is evident that with this advancing and evolving male interest, clinicians need to be more cognizant of men’s anatomy, aging differences, and beauty preferences as compared to females in order to optimize outcomes and patient satisfaction.

Table 1.1 Minimally invasive cosmetic procedures, 2018 (modified from the ASPS 2018 Annual Survey)

Procedure

Total males

Overall total

Botulinum toxin type A

452,812

7,437,378

Laser hair removal

184,668

1,077,490

Microdermabrasion

136, 885

709,413

Chemical peels

102,683

1,384,327

Soft tissue fillers

100,702

2,523,437

Laser skin resurfacing

75,584

594,266

Laser treatment of veins

29,505

217,836

Cellulite treatment

4,721

37,220

Sclerotherapy

5,543

323,234

Total

1,092,103

14,304,601

1.2 Anatomy

Gender differences in male facial anatomy include increased skin thickness, higher muscle mass, higher number of terminal hairs as well as sebaceous glands, higher vascularity associated with pilosebaceous units, and different rates of fat and bone resorption with aging given hormonal variations.2 Men have more strongly developed supraorbital ridges and flatter cheeks. They also have a larger glabella and frontal sinus, smaller orbits, and more acute glabellar angles. The mandible is larger and thicker, and the chin wider and square.3 (Fig. 1.1) The subcutaneous architecture in men is significantly different as men have a more developed superficial fascial system and the number of retinacula cutis per defined area is significantly increased compared to females. This implies that the containment forces of the skin to the underlying soft tissues are increased with a decreased probability for skin laxity in comparable female matching pairs.4 In the perioral area, the amount and thickness of terminal hair increases the stability and adhesion forces between dermis and the lamina propria, resulting in the less frequently observed perioral lines (“barcode wrinkles”) compared to females. These notable variations in skin quality and composition, as well as soft tissue and bony anatomy, are essential to understand and consider when planning facial rejuvenation or enhancement procedures. Additionally, one must also consider these differences when estimating the amount of product that will be required to achieve the desired outcome. Longitudinal changes in male anatomy compared to female aging anatomy are complex (Fig. 1.2). With increasing age, males experience an increase in their forehead angle resulting in a steeper forehead, which resembles the female forehead outline.5 The calvarial volume decreases with increasing age, and bone thickness of the skull (temple and forehead) becomes thinner, a trend that interestingly is not observed in females.6

Fig. 1.1 Gender differences in facial anatomy, (a) female vs. (b) male. (Reproduced with permission from Steinbrech S, ed. Male Aesthetic Plastic Surgery. 1st Edition. New York: Thieme; 2020.)

Fig. 1.2 Longitudinal changes in male facial anatomy. (Reproduced with permission from Steinbrech S, ed. Male Aesthetic Plastic Surgery. 1st Edition. New York: Thieme; 2020.)

1.3 Patient Preferences

There is one published study in the literature describing the male patient preferences in regard to cosmetic procedures. This cross-sectional online study focused on deciphering which facial areas men are more likely to treat first and the correlation with their areas of most concern, awareness to procedures, and their motivations to undergoing minimally invasive injectable treatment, specifically neuromodulators and soft-tissue fillers.7 They enrolled a total of 600 injectable-naive men between the ages of 30 and 65 years who were “aesthetically oriented,” aware of Botox cosmetic, and considering at least one facial cosmetic treatment within the next 2 years.

In this study, they found that most men were open to talking to their physicians about facial wrinkles (48%) and bags under the eyes (44%). Additionally, it was noted that they were least likely to talk about red/vascular facial appearance (14%) and razor burn (16%). Overall awareness for all aesthetic procedures ranged from 2 to 6%. Specifically, for soft-tissue fillers the awareness was 39%, and for surgical procedures such as liposuction and hair transplant, it was greater than 90%. The two main motivators for undergoing cosmetic procedures were wanting to look good for their age (70%) and wanting to look more youthful (51%).7

On the other hand, the main barriers to treatment were not thinking they needed treatment yet (47%) and concerns about safety or side effects (46%). The five areas of most aesthetic concern were hair loss (27%), double chin (22%), tear troughs (22%), crow’s feet (18%), and forehead lines (15%). Not surprisingly, given what we know about men facial anatomy, perioral lines were the area of least concern (3%). Tear trough and crow’s feet were the two areas that were prioritized in terms of receiving treatment (80%). Finally, they noted a strong correlation (r2 = 0.81) between areas of most concern and areas with treatment priority.7

Of interest, aging concerns of men directly correlate with the expected anatomic changes based on gender (Fig. 1.3). As men age, they are more preoccupied by upper facial lines as opposed to females who switch from being worried about upper facial lines to being more concerned with lower facial lines and perioral wrinkling.8 These concerns likely stem from the expected age-related inversion of the triangle of youth where the cheeks flatten and jowls form, as well as the lack of terminal pilosebaceous units in the perioral skin of females. All these changes seem to be more accentuated in the female face given the drastic hormonal changes endured during menopause.

Fig. 1.3 Hallmarks of the aging male face. (Reproduced with permission from Leatherbarrow B, ed. Oculoplastic Surgery. 3rd Edition. New York: Thieme; 2019.)

Moreover, one of the main barriers to treatment identified by this study was lack of knowledge of what minimally invasive cosmetic procedures entail, including risks, benefits, safety, and side effect profiles. This suggests that even “aesthetically oriented” male patients deserve and require a full cosmetic consultation with specific education about procedures that may fit their lifestyle and long-term aging goals. This pretreatment consult visit is a pivotal event in formulating a successful procedural treatment plan that will lead to a positive patient outcome.

Finally, it is important to reiterate that the two main reasons for men to proceed with a cosmetic procedure were to look good for their age and to appear more youthful. These two motivations have social implications in their lives as well, as being youthful gives males a more competitive appeal in the workplace, which can lead to a 5 to 10% higher salary.9 In addition, two studies have demonstrated that cosmetic procedures, such as botulinum toxin neuromodulation, can lead to improved self-esteem and feelings of attractiveness that lead to a better quality of life.10,11 All these represent psychosocial factors to be considered during the cosmetic consult.

1.4 Clinical Practice

The goal of the initial cosmetic visit, as with any patient encounter, is to establish a strong physician–patient relationship in order to prepare for the cosmetic procedure. The first step is to understand the reason for the visit. One must determine, for example, if the patient desires broad improvements such as overall rejuvenation or improvement in skin quality, or perhaps has specific goals such as erasing a few lines prior to an important event, or enhancing their natural bone structure. Given men’s lack of awareness regarding the available aesthetic procedures and their indications, in general, it is not uncommon for male patients to present with vague cosmetic complaints. “I look tired” and “I am getting old” are common concerns that require the treating physician to ascertain what the patient wants. There are clues that a physician can use to identify a male patient’s cosmetic concerns. For example, a male patient who is concerned about “looking tired” may be subconsciously bothered by periocular changes. Once concerns and goals are discussed and understood in detail, a thorough physical examination should be performed. This examination should include evaluation of static and dynamic lines, facial movement, muscle mass, bone structure, and skin quality (Fig. 1.4). The physical examination will help the clinician to understand which products or devices are appropriate for the patient’s skin. It will also serve as a guide in terms of approximating how much product or how many sessions will be required to achieve the discussed outcome. Once a plan is formulated by the physician, the patient should be educated on the possible cosmetic procedures that would best address their specific concerns. In addition to reviewing the risks, benefits, and alternatives, this detailed discussion should include the potential need for multiple sessions or retreatments, as well as anticipated downtime of the recommended procedures. This point is critical, as one of the easiest—and most avoidable—ways to lose a new male patient is an undesired and unanticipated outcome.

Fig. 1.4 Physical examination of the aesthetic male patient. (Reproduced with permission from Steinbrech S, ed. Male Aesthetic Plastic Surgery. 1st Edition. New York: Thieme; 2020.)

In our clinical experience, we have noticed a few key differences in how to approach the male’s first cosmetic treatment session. First, it is important to note that men schedule a 2-week follow-up appointment for potential touch-up treatments after their first ever neuromodulator treatment. We have noticed that male patients are less likely to follow up if they are unhappy versus females. Hence, having that 2-week follow-up appointment scheduled guarantees you can discuss what they liked and what they did not. Injectors can communicate to the patient that this will enable them to have a reproducible treatment plan for subsequent visits that will help ensure desired aesthetic outcome at subsequent visits. When it comes to neuromodulators, keep in mind males may take a 50% higher dose in order to achieve the same result you would expect in a female. This is because anatomically males tend to have a higher muscle bulk and stronger muscles. Males also have a flatter brow to begin with as compared to their female counterparts, and therefore it is acceptable to treat corrugator muscle to its lateral most aspect/insertion into the skin, even if it results in a flatter brow. Females would not be pleased with this result, as this approach may yield unappealing brow ptosis. Finally, the male forehead should be more superiorly than that of females given that they may have a receding hairline, and treating the inferior frontalis while ignoring the superior may result in the unnatural appearance of a “shower cap,” where superior frontalis fibers continue to contract. Once the face is treated with neuromodulators, a map should be drawn or a picture should be taken demonstrating precise injection points in order to use this as a reproducible template for follow-up treatments. The authors have found this approach (immediately after injection photography) to be especially helpful in treating the forehead in men. Male patients tend to be very loyal, but they require proper treatment during their first visit. Hence, providers should make the 2-week follow-up after the first treatment session mandatory in order to ensure the patient is happy and you have a reproducible treatment template for future visits.

1.5 Conclusion

With the continued increase in minimally invasive cosmetic procedures pursued by males, it is important for clinicians to recognize the main anatomic and aesthetic differences in males versus females. Understanding these anatomic variances will lead to correct treatment dosing and placement of product, and therefore a pleased and loyal patient.

1.6 Pearls

•Gender differences in male facial anatomy include increased skin thickness, higher muscle mass, higher number of terminal hairs as well as sebaceous glands, higher vascularity associated with pilosebaceous units, and different rates of fat and bone resorption with aging given hormonal variations.

•The two main reasons for men to proceed with a cosmetic procedure were to look good for their age and to appear more youthful.

•One of the main barriers to treatment identified by this study was lack of knowledge of what minimally invasive cosmetic procedures entail, including risks, benefits, safety, and side effect profiles.

•Men are less likely to follow up if they are unhappy compared to female counterparts, therefore schedule a short-term (2−4 weeks), follow-up visit at the end of their treatment.

References

[1]ASPS 2018 Annual Survey. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2018/cosmetic-procedures-men-2018.pdf. Accessed October 24, 2019

[2]Leong PL. Aging changes in the male face. Facial Plast Surg Clin North Am. 2008; 16(3):277–279, v

[3]Hage JJ, Becking AG, de Graaf FH, Tuinzing DB. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg. 1997; 99(7):1799–1807

[4]Rudolph C, Hladik C, Hamade H, et al. Structural gender dimorphism and the biomechanics of the gluteal subcutaneous tissue: implications for the pathophysiology of cellulite. Plast Reconstr Surg. 2019; 143(4):1077–1086

[5]Frank K, Gotkin RH, Pavicic T, et al. Age and gender differences of the frontal bone: a computed tomographic (CT)-based study. Aesthet Surg J. 2019; 39(7):699–710

[6]Cotofana S, Gotkin RH, Morozov SP, et al. The relationship between bone remodeling and the clockwise rotation of the facial skeleton: a computed tomographic imaging-based evaluation. Plast Reconstr Surg. 2018; 142(6):1447–1454

[7]Jagdeo J, Keaney T, Narurkar V, Kolodziejczyk J, Gallagher CJ. Facial treatment preferences among aesthetically oriented men. Dermatol Surg. 2016; 42(10):1155–1163

[8]Narurkar V, Shamban A, Sissins P, Stonehouse A, Gallagher C. Facial treatment preferences in aesthetically aware women. Dermatol Surg. 2015; 41 Suppl 1:S153–S160

[9]Rieder EA, Mu EW, Brauer JA. Men and cosmetics: social and psychological trends of an emerging demographic. J Drugs Dermatol. 2015; 14(9):1023–1026

[10]Dayan SH, Arkins JP, Patel AB, Gal TJ. A double-blind, randomized, placebo-controlled health-outcomes survey of the effect of botulinum toxin type a injections on quality of life and self-esteem. Dermatol Surg. 2010; 36 Suppl 4:2088–2097

[11]Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg. 2005; 31(10):1297–1303

2 Tincture of Time: Facial Aging and Anatomical Considerations

Jose Raúl Montes and Jonathan J. Dutton

Summary

Genetic aging and photoaging result in thinning of all layers, effacement of the dermal-epidermal junction, loss of collagen, disorganization of elastin fibers, clumping of melanocytes, and advancing dermal elastosis. This process driven by extrinsic and intrinsic factors occurs equally across genders, male and female, however it has been published that extrinsic factors such as sun exposure and tobacco usage are more associated with male behavior. Therefore, the skin aging changes are expected to be accelerated in the male patient population sooner than in females.

The face and scalp are arranged in six concentric tissue which are thicker and heavier in men, accounting for more gravitational pull with aging and consequential tissue descend, which translates into lowering eyebrows with aging, more pronounced than in females. Furthermore, the forehead is greater in height and width, and the supraorbital rims form a more prominent ridge in men than in women. In men, temples are expected to be flat or slightly convex in contrast to their woman counterpart where temples are flat or slightly concave. The midface region in the male patient is characterized by a nose with a more straight and wider dorsum. In general, the female cheek fuller with a higher point light reflection (or projection) laterally.  Men’s cheeks are usually flatter and present with a wider bizygomatic distance. On this chapter anatomic male features will be discussed as a guiding compass for surgical and non-surgical cosmetic treatment planning in the male patient.

Keywords: anatomy of aging male anatomy male and female anatomic differences male aesthetic procedures approachs to facial aging

2.1 Background

The number of aesthetic procedures performed in the United States has significantly increased over the past several decades. Between 1997 and 2016, there was a 99.2% increase in the number of cosmetic surgical procedures performed annually in the United States, and a massive 650.2% increase in nonsurgical procedures.1 In 2014, Americans spent more than $12 billion on combined surgical and nonsurgical cosmetic procedures, of which eyelid surgery, nose surgery, botulinum toxin, fillers, and chemical peels ranked among the top procedures performed. More than 40% of all cosmetic procedures were performed on individuals between the ages of 35 and 50 years. Almost 70% of adults in the United States are currently considering a cosmetic procedure.2 While 90% of cosmetic procedures are performed in females, interest among males continues to increase. Between 1997 and 2014, there was a 273% increase in the number of cosmetic procedures performed on men, with botulinum neurotoxin and dermal fillers being the most common. This compares to a 429% increase for females during the same period.

Facial aging is a multifactorial process and results in a broad range of physiologic and morphologic changes affecting every tissue system, including bones, ligaments, muscles, fascia, deep and subcutaneous fat, and skin. The process of aging is the same for everyone, although the age of onset and the rate of aging changes vary considerably between different individuals, genders, ethnic groups, and among various lifestyles. Age-related changes of the facial skeleton underlie alterations in the soft tissues that are suspended from it, and are recognized as key elements in the aging process.3,4,5,6

Men age differently than women largely because of differences in genetic and hormonal characteristics, facial anatomy, environmental exposure, and behavior. In a survey of 600 aesthetically oriented men, facial areas of primary concern were facial and forehead wrinkles, baggy eyelids, tear troughs, sagging skin, and hair loss reflecting the importance of the upper face in social interaction.7 Considering the growing number of men seeking surgical, and especially noninvasive cosmetic, procedures each year, the aesthetic provider must become comfortable with the facial anatomy of men, and the most important aspects of facial aging. Although the procedures performed in men and women are similar, anatomical details may vary, as do aesthetic objectives of men.8

2.2 Male Facial Anatomy and Aging Changes

2.2.1 Aging and Gender

Numerous soft-tissue changes gradually evolve during the aging process in the face. Both intrinsic and extrinsic factors contribute to skin aging. Smoking and ultraviolet (UV) radiation are the most important extrinsic risk factors for aging skin and for the formation of coarse wrinkles.9,10,11,12 Smoking reduces capillary blood flow, decreasing collagen and elastin fibers in the dermis and impairing elasticity. UV exposure leads to accelerated degradation of dermal collagen matrix. In general, men develop more wrinkles earlier in life than women. Although these have sometimes been attributed to higher occupational sun exposure in men, the difference remains significant even after adjusting the wrinkling for occupational sun exposure. 13 Other extrinsic factors include gravity, which acts on facial soft tissues, as well as other environmental insults, such as pollutants (e.g., heavy metals), and pesticides. Personal habits, such as diet and lack of sleep, also contribute to the onset and degree of aging changes.

Age and genetic background are the major intrinsic factors related to facial aging and the formation of fine wrinkles. Men tend to show aging phenomena more than women because of reduced innate antioxidant capacity, and increased levels of oxidative stress.14 Men are more likely to participate in behavior such as smoking, alcohol use, and UV exposure, which accelerate the aging process.15 The facial skeleton is larger in men and facial muscles have increased mass, which contribute to contraction-induced static wrinkles over time. Under the influence of these intrinsic and extrinsic factors, all of the facial skin undergoes major changes with age that progress at variable rates for each individual. Genetic aging and photoaging result in thinning of all layers, effacement of the dermal–epidermal junction, loss of collagen, disorganization of elastin fibers, clumping of melanocytes, and advancing dermal elastosis.16 This results in loss of dermal understructure with the development of ridges and wrinkles, uneven pigmentation, loss of elasticity, and stretching of small blood vessels with areas of patchy redness (Fig. 2.1).

Fig. 2.1 A male patient with deep frontal ridges and wrinkles before and after neuromodulator treatment (45 units total on glabella, lateral orbicularis oculi, and frontalis muscle). (a) Before. (b) After.

2.2.2 Forehead and Temple

The face and scalp are arranged in six concentric tissue layers that consist of skin, subcutaneous tissue, superficial musculoaponeurotic layer, loose areolar tissue, deep fascia and periosteum, and bone.17 Except for thickness, the skin and subcutaneous layers are basically the same over the entire face and scalp. The musculoaponeurotic fascial layer is attached above to the skin and subcutaneous layers by fine connective tissue bands called retinacula cutis fibers. Over the scalp and forehead, the musculoaponeurotic layer is formed by the galea aponeurotica and its two muscular components, the occipitalis muscle posteriorly and frontalis muscle anteriorly. Here, the skin, subcutaneous layer, and galea form a single functional unit that is mobile over an underlying loose avascular areolar tissue layer.

These six tissue layers are thicker and heavier in men, accounting for more gravitational pull with aging and consequential tissue descend, which translates into lowering eyebrows with aging, more pronounced than in females. In the skull, however, older females have thicker bone thickness as compared to males.

The eyebrows are part of the forehead and scalp anatomy, and their mobility is part of the complex system of facial expression. They are situated over the superior bony orbital rims, at the junction between the upper eyelid and the forehead. The brows extend from just above the trochlear fossa medially, near the frontozygomatic suture line laterally. The flattened glabellar region is central in the midline and separates the two eyebrows. Above the brows, the forehead is covered by skin that becomes thinner closer to the top of the head and thicker closer to the eyebrows. The eyebrow is separated from the superior orbital rim by a prominent underlying fat pad. The skin in this region contains short, course eyebrow hairs that emerge at an oblique angle. Medially these hairs may be directed slightly upward, but they are usually directed more horizontally or slightly downward and laterally in the central and lateral brow. These variable orientations are important to consider during direct brow elevations with resection of skin immediately above the brow line, because cutting the hair follicles will result in loss of cilia and exposure of the scar line.

The eyebrow is capable of a wide range of vertical movement. These movements are accomplished by the interaction of five striated muscles that insert into the dermal tissues along the brow. These are the frontalis, procerus, depressor supercilii, corrugator supercilii, and orbicularis oculi muscles.18 All are innervated by the seventh cranial, or facial, nerve. The frontalis muscle fibers are oriented vertically on the forehead and form the anterior belly of the occipitofrontalis musculofascial complex. The galea aponeurotica covers and invests the frontalis and occipitalis muscles on either end, and carries a rich supply of blood vessels and nerves. The galea is attached to the overlying skin by a firm dense adipose layer, and is separated from the underlying cranial periosteum by a loose areolar fascial space that allows for mobility of the scalp. At 8 to 10 cm above the superior orbital rim, the galea splits into superficial and deep layers that extend anteriorly and surround the forehead muscles. The deep layer of the galea extends below the frontalis muscle and fuses to periosteum 8 to 10 mm above the superior orbital rim. The superficial layer continues downward over the anterior surface of the frontalis muscle to the orbital rim, where it inserts onto a fusion line, the arcus marginalis, around the margin of the orbital rim. From the arcus marginalis, the anterior galea continues downward into the upper eyelid, where it continues as the anterior layer of the orbital septum.

This explains the contribution of the frontalis muscle, not only on eyebrow position but also on the eyelid height. On patients with low borderline eyelid position or documented eyelid ptosis, avoid neurotoxin forehead injections or be very conservative, because an underlying eyelid droop clinically insignificant will be dramatically revealed.

The frontalis muscle is paired and has no bony attachments. Its proximal fibers originate from the galea aponeurotica at about the level of the coronal suture line and extend toward the supraorbital rim (Fig. 2.2).

Fig. 2.2 Forehead muscles (c, corrugator; ds, depressor supercilii; f, frontalis; oo, orbicularis oculi; p, procerus; smas, musculoaponeurotic system superficial; ps, preseptal; pt, pretarsal).

Frontalis muscle fibers interdigitate with the corrugator and the orbital portion of the orbicularis muscles.19 The medial fibers blend with those of the procerus and depressor supercilii muscles. The frontalis muscle does not extend beyond the junction of the middle and lateral thirds of the brow, so that the lateral brow lacks an elevator. Because of this relationship, the lateral brow is under the depressor influence of the lateral portion of the orbicularis muscle.

Owing to the lack of frontalis action, lateral eyebrow or eyebrow tail tends to descend with aging. Neurotoxin injection on the lateral orbicularis is indicated to elevate the lateral eyebrow.

The superficial fascia over the forehead and brows is relatively thin. The skin is closely applied to the superficial layer of the galea over the frontalis muscle by fibrous septa that extend through the galea and superficial fat to the dermis. On its deep surface, the frontalis muscle is separated from the underlying periosteum by a fat layer within the deep fascia of the forehead. This has been referred to as the sub-brow fat pad or the superior retro-orbicularis oculi fat, or ROOF.20 This fat pad measures approximately 1 cm vertically and is about 5 mm in thickness, and helps cushion the brow during movement over the supraorbital bony rim. This sub-brow fat pad may get deflated with aging and is one of the target zones at the periocular area for injectable implants. The frontalis muscle elevates the brow and, together with the posterior occipitalis belly, tightens the scalp providing mobility of the skin along the temples (Fig. 2.3 and Video 2.1).

Fig. 2.3 The procerus and corrugator muscles with supraorbital and supratrochlear arteries.

Video 2.1 Roof Injection.

Forehead and brow ptosis is a prominent feature of the aging face.21,22,23 As brow ptosis progresses, dermatochalasis of the upper eyelids may become more pronounced. When a patient is evaluated for blepharoplasty, it is important to evaluate whether the dermatochalasis is the result of redundant upper eyelid skin, or a manifestation of downwardly displaced forehead skin, or both. Failure to recognize the etiology of this deformity may result in failure to correct the responsible anatomic defect (Fig. 2.4).

Fig. 2.4 An aging male face with horizontal forehead furrows, and horizontal and vertical glabellar creases.

In selected cases, neurotoxin injection, specifically at the glabellar brow depressor muscles and the lateral orbicularis, may result in eyebrow elevation that may correct a “pseudo dermatochalasis”.

Three anatomic findings that may help you predict an effective brow elevation with neurotoxin:

•Patients with thin skin on forehead/eyebrow, usually women.

•Patients with preexisting tarsal plate show.

•Patients with strong lateral orbicularis action (crow’s feet).

The procerus is a small pyramidal muscle closely related to the frontalis muscle complex. It arises by tendinous fibers from periosteum on the lower portion of the nasal bone. The muscle passes vertically upward between the brows and separates into its paired heads, which interdigitate with the medial borders of the frontalis muscle on either side and insert onto the dermis of the skin over the lower central forehead (Fig. 2.2). Contraction of the procerus muscle draws the medial portion of the brow downward and produces transverse wrinkles over the glabella and the nasal bridge. The depressor supercilii muscle was previously believed to be part of the orbicularis muscle, but it is now considered a separate structure.24 It arises from the frontal process of the maxillary bone as two distinct heads, runs superiorly deep to the lateral edge of the procerus, and inserts into the dermis of the medial brow (Fig. 2.2).

Patients with a strong nasalis muscle contraction or “bunny lines” usually have strong depressor supercilii recruitment as well. On these patients, extend your glabellar neurotoxin pattern of injections to include these muscles.

The corrugator supercilii muscle forms a pyramidal band of fibers beneath the medial fibers of the frontalis and orbicularis muscles (Fig. 2.2). It arises from the medial end of the frontal bone at the superomedial orbital rim and divides into two separate heads. The oblique head runs superiorly and slightly laterally and interdigitates through the frontalis and orbicularis muscles to insert into dermis along the medial eyebrow. This head, along with the depressor supercilii, the procerus, and the medial slip of the orbital portion of the orbicularis muscle, acts to depress the medial brow.25 The larger transverse head of the corrugator muscle passes laterally and slightly superiorly beneath the orbital portion of the orbicularis muscle within the galeal fat pad and inserts into the deep fascia of the frontalis and orbicularis muscles along the central one-third of the brow. Contraction of the corrugator muscle pulls the brow medially and downward, and produces vertical glabellar folds.

In gross shape, the forehead is greater in height and width, and the supraorbital rims form a more prominent ridge in men than in women.26 The medial supraorbital ridges in men blend into the central glabella, so that the glabellar region is more prominent than in women.27 Although the orbit is absolutely larger and more rounded in men, the male orbit is proportionally smaller in relation to the overall size of the skull.28 The eyebrow is flatter in contour and sits lower along the orbital rim.29 Men with deep-set eyes and more prominent supraorbital rim may exhibit a slightly lower brow position (Fig. 2.4).30

Stronger and bigger muscles at glabella in men required more units of neurotoxin.31 Low-set eyebrows in men required careful assessment of frontalis muscle action before neuromodulator injection to prevent potential eyebrow droopiness. In the heavy low-set male patient, consider neurotoxin injection at the glabella and the lateral orbicularis; avoid forehead injections (Fig. 2.4).

The temple refers to the anatomic area of the temporal fossa. The borders are the superior temporal line superiorly, the frontal process of the zygoma anteriorly, the zygomatic process of the temporal bone and zygoma inferiorly, and the temporal hairline and the ear posteriorly.32 The temporal fossa contains the temporalis muscle, which originates from the superior temporal fusion line and inserts inferiorly on the coronoid process of the mandible. The surface of the temporalis muscle is covered by a dense fibrous layer, the deep temporal fascia that contains a temporal fat pad inferiorly. Superficial to the deep temporal fascia is a loose areolar layer, the temporoparietal or superficial temporal fascia. The superficial temporal artery runs superiorly, and the temporal branches of the facial nerve course diagonally through this facial layer. These are important structures to be avoided in temporal forehead lift procedures and during temporal zone filler placement since it is recognized as one of the “danger zones.”

Forehead, temples, glabella eyelid, nose, mid face, nasolabial fold are facial “danger zones” because they are connected to the very complex orbital circulation. Accidental intra-arterial filler injection may produce a retrograde embolization reaching to the orbital and retinal circulation with catastrophic outcomes such as blindness33 (Fig. 2.5).

Fig. 2.5 Localization of the main periorbital vascular structures. Note: The best way to locate the main vessels around the eye is to use your patient's pupil as your guiding compass. For instance, to find the foramen (or cleft where the bundle of supraorbital nerves and vessels emerges), use the iris’ medial limbus and the orbit’s superior margin. The neurovascular structures of the infraorbital foramen are aligned between the iris’ medial limbus and the pupil at approximately 8 mm to 1 cm from the lower orbital rim. Remember that the supratrochlear artery is located approximately 1 cm medial to the supraorbital artery. All these structures emerge from deep within these foramina.

It is well recognized that bone remodeling occurs throughout life, with a gradual additive projection of bone in the forehead by thickening of the frontal bone.34,35 The upper forehead also shows some regression due to loss of calvarial height and volume with increasing age.36 Temporal hollowing is a prominent feature of the aging face, often attributed to atrophy of the temporal fat pad. However, more recent studies suggest that redistribution of fat inferiorly rather than atrophy is more likely responsible for the relative superior hollowing in this region.37

In men, supraorbital or frontal bossing is common with an increased concavity at central forehead with aging; consider a combination of neurotoxin and filler injections in selected cases to improve the appearance of deep rhytids without lowering the “heavy” brow complex (Fig. 2.6 and Video 2.2).

Fig. 2.6 A 61-year-old patient with exemplary men’s features: low set eyebrows, frontal bossing, prominent chin, and squared jawline. (a) Before (front). (b) Before (right side). (c) Marking for injection. (d) After.

Video 2.2 Mid forehead injection in combination with neurotoxin; lip augmentation with cannula; injection jawline with cannula.

The “young” women temples are usually flat; with aging, they may become dramatically concaved. In men, temples are expected to be flat or slightly convex. For filler injection to temple, there are two schools of thought: superficial/subcutaneous injection or deep supraperiosteal injection. In our opinion, deep injection over bone is safer (Fig. 2.7 and Video 2.3).

Fig. 2.7 Superficial temporal fascial.

Video 2.3 Temporal fossa injection, deep needle injection technique.

2.2.3 Eyelids and Periorbital Region

In the young adult, the interpalpebral fissure measures 10 to 11 mm in vertical height, but with advancing years the upper eyelid assumes a more ptotic position, resulting in a fissure of only about 8 to 9 mm (Fig. 2.8). The horizontal length of the fissure is 30 to 31 mm by the age of about 15 years. The upper and lower eyelids meet medially and laterally at an angle of approximately 60 degrees. The interpalpebral fissure is usually inclined slightly upward at its lateral end, such that the lateral canthal angle generally is about 2 to 3 mm higher than the medial canthal angle. In the primary position of gaze, the upper eyelid margin usually lies at the superior corneal limbus in children and 1.5 to 2.0 mm below it in the adult. The upper eyelid marginal contour usually reaches its highest point just nasal to the pupil, and the lower eyelid margin rests at the inferior corneal limbus. These anatomic landmarks are similar in both men and women.

Fig. 2.8 External eyelid and the periorbital region (EP, eyelid platform; LC, lateral canthal angle; MC, medial canthal angle; UC, upper eyelid crease).

Patients with upper eyelids that rest close to their pupils, at less than 3 mm of a light reflex to the pupil, may have an underlying eyelid droop that can be aggravated by neurotoxin treatment to the forehead complex. Likewise, if lower eyelid margin is resting lower to the inferior corneal limbus, with scleral show, neurotoxin injections at the pretarsal orbicularis or the lower eyelid should be avoided, since they will only accentuate an “undesired” lid retraction or descend.

The orbicularis oculi is a periocular striated muscle sheet that lies just below the skin. It is divided anatomically into three arbitrary segments: the orbital, preseptal, and pretarsal portions in the upper and lower eyelids (Fig. 2.9). The orbital portion overlies the bony orbital rims. It arises from insertions on the frontal process of the maxillary bone, the orbital process of the frontal bone, and from the common medial canthal ligament. The fibers pass around the orbital rim to form a continuous circle, and insert medially just below their points of origin. The palpebral portion of the orbicularis muscle overlies the mobile eyelid from the orbital rims to the eyelid margins. Although this portion forms a single anatomic unit in each eyelid, it is customarily further divided topographically into two parts, the preseptal and pretarsal orbicularis.

Fig. 2.9 Orbicularis oculi muscle.

The preseptal part is positioned over the orbital septum in both upper and lower eyelids, and the pretarsal part overlies the tarsal plates. The postorbicular fascial plane is an avascular loose areolar layer between the orbicularis muscle and the orbital septum–levator aponeurosis fascial complex. This plane is an important surgical reference that allows easy and bloodless dissection and identification of the underlying orbital septum. The orbital septum is a fibrous, multilayered membrane that begins anatomically at the arcus marginalis along the orbital rim (Fig. 2.10).

Fig. 2.10 Orbital septum (am, arcus marginalis; la, levator aponeurosis; lc, lateral canthal ligament; mc, medial canthal ligament; t, tarsus; os, orbital septum).

The multilayered structure of the orbital septum is easily noted in most individuals during eyelid surgery and provides a critical landmark that separates the anterior from the posterior eyelid lamellae. Immediately behind the orbital septum are the yellowish preaponeurotic fat pockets. These are anterior extensions of extraconal or peripheral orbital fat (Fig. 2.11). There are two pockets in the upper eyelid, medial and central, and three in the lower eyelid, medial, central, and lateral. These fat pockets are surgically important landmarks that help identify a plane immediately anterior to the major eyelid retractors, the levator aponeurosis in the upper eyelid and the capsulopalpebral fascia in the lower eyelid.

Fig. 2.11 Superior eyelid suspensory apparatus (cpf, capsulopalpebral fascia; la, levator aponeurosis; lc, lateral canthal ligament; mc, medial canthal ligament; t, tarsal plate; wl, Whitnall’s ligament).

With aging, upper eyelid fat pads experience changes. The medial fat pad tends to grow and the central fat pad gets atrophic.38 These fat pad volume changes make the upper eyelid look deflated or sunken centrally, more prominently in women due to thinner upper eyelid skin. A low-concentration hyaluronic acid filler placement below the orbicularis muscle may correct this involutional change (Video 2.4).

Video 2.4 Tear through orbito malar grove correction with hyaluronic and cannula techniques.