Dr Armand Abraham shares his technique for successful mid-face treatment in men
Since I began practising aesthetics, I have built a loyal patient base, of whom approximately 70% are men. I have found that their usual treatment preferences are for jawline contouring and wrinkle-relaxing injections in the upper face, while also requesting regular treatments for general facial rejuvenation. In this article I outline the case of a 42-year-old male patient, who was a smoker, who presented to my clinic for the first time to discuss treatment options for his nasolabial folds, which were causing him significant concern. He had not undergone any aesthetic treatment previously and was particularly concerned with the risk of feminisation.
Assessment and consultation
Upon assessment I noted that as well as his prominent nasolabial folds, the patient also had volume loss in the cheeks. While his cheeks could benefit from treatment, volumising this area presented a stronger risk of feminisation due to the fact he was bald. In my experience, the absence of a hairline can limit the approach and amount of filler used in cheeks.
I then discussed some of the treatments which can contribute to mitigating the patient’s concerns, such as injectable dermal filler treatment, non-surgical skin tightening and microneedling, explaining that the first two are known as the best treatments for nasolabial folds.1 I also answered the concerns and questions of the patient, which related to the risk of feminisation, how effective the treatment would be, and the side effects and complications that could occur.
To alleviate his concerns I explained that my treatment approach is more on the conservative side, tending to be more restorative and focused on correcting concerns rather than changing or compromising patients’ masculine features. I explained that I do this by ensuring appropriate product selection, while phasing treatments so that results are gradual and subtle. This of course also helps reduce the risk of side effects and complications. Together we decided that the most effective treatment for his nasolabial folds would be hyaluronic acid (HA) filler.
I believe this was the best course of action because, in this patient’s case, he had nasolabial folds rather than creases, which had become deeper over time. In my experience, they are better targeted with HA filler to provide the cushioning support needed to push the fold up, while being able to shape it and massage it into place. Of course, being able to dissolve HA in case of an emergency or if the patient was not satisfied with the result was also of benefit. Treatment
The plan for this patient was to aim to conservatively restore the mid-face volume loss that was caused by downward migration of the malar cheek pads, which greatly contribute to the fold formation.1,2 I used a combined technique of needle and cannula, starting with a 27 gauge needle, direct onto periosteum of the zygomatic bone. I was able to remodel the cheeks and offer volume restoration using Stylage XL in a concentration of 21mg/g, which comprises cross-linked HA, with mannitol and lidocaine. I administered boluses of 0.5ml, 0.4ml, 0.3ml, respectively moving upwards and outwards, following the zygomatic bone close to the lower border and as inferiorly as possible.
I then moved to using a 25 gauge 40mm cannula to administer 0.4ml of the same product in a fanning technique, which extended the filler upwards and outwards close to the zygomatic arch in the deep dermis, while avoiding the creation of the sharp angle usually desired by female patients. This was followed by careful massage from observing the outline of cheeks from above the patient’s head and taking in consideration the skull outline visible on his forehead.
The patient’s concerns related to the risk of feminisation, how effective the treatment would be, and the side effects and complications that could occur
The second step involved an entry point 1cm below and lateral to the labial commissures using a 25 gauge 40mm cannula to administer Stylage L, a 24mg/g cross-linked HA with mannitol and lidocaine. I started in a bolus and a fanning manner in the upper third of the fold at the deep dermis level, before moving to a linear technique in the middle third of the fold, followed by a short fanning injection in the lower third at the level of the labial commissures, administering 1.3ml of filler on each side.
Now returning to needle injection, I targeted the middle third of the fold, again using a cross-hatching deep and superficial technique to provide the support needed to lift the fold, without flattening, which was not desired in this patient. My final step was to gently massage the fold to avoid any bumps and lumps, again without flattening, to emphasise the scaffolding effect created for the middle third.
Potential side effects
The most common side effects that could occur as a result of treatment includes bruising and redness on cheeks. The patient experienced a little bit of redness on his face which was managed with a cold compress.
Inflammatory reactions such as oedema, erythema, redness, swelling, possibly combined with itching or pain when pressure is applied, can occur for several days in some cases. Haematomas, indurations or nodules may appear at the site of the injection. Very rare cases of bleaching of the injected area have been reported. In addition, following injections of HA, rare cases of abscess, granuloma and some cases of necrosis or hypersensitivity have been observed.3
Patients should of course be informed of these risks in consultation and advised that if any of these adverse effect persist after their appointment, they must be reported to the treating practitioner. It is essential that practitioners are well-versed in complication prevention and management prior to treatment.
It must be noted that in case of serious inherited predisposition to allergies, dermatological disease, problems with haemostasis or inflammatory disease, or if the precautions for use are not adhered to, the incidence of adverse effects may be increased.
As per usual HA injection aftercare, I advised the patient to avoid heat or extreme cold for 48 hours following treatment. Strenuous physical activity and massaging of the treated area should also be avoided for at least six hours.
A follow-up consultation was scheduled for 14 days post procedure, in which we discussed the patient’s recovery. He had experienced mild bruising and some pain at the middle part of the folds, which was expected with the intensive cross-hatching injection points. The patient was satisfied with the results and pleased that we did not completely eradicate the appearance of the folds, which he feared would look too feminine. The patient was advised that the results would last 12-18 months.
It is important to bear in mind that the cheeks should be targeted first when treating the nasolabial folds to maximise results. This should be done so in a very careful manner in men, especially bald men who, due to the lack of hairline, could look over feminised.
Product choice is extremely important when it comes to treating nasolabial folds or creases, as different concentrations of cross-linked HA fillers will provide the appropriate results for each. I would recommend the use of a cannula when possible to minimise bruising, particularly in men who wish to remain discreet about undergoing facial aesthetic procedures. The appropriate use of a needle is useful too, as long as it will deliver better results for the patient.
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