Exploring the Male Face with Threads

We are seeing more men than ever seeking to enhance their appearance and reduce the signs of ageing by harnessing the effectiveness of non-surgical clinical treatments.¹ 

At our clinic, around 10% of our patients are male, and this number is growing year on year. Typically, we find that male patients are seeking treatments which ensure they are ‘naturally’ enhanced and importantly, do not feminise their appearance in any way. Subtlety is key, and like our female patients, they are very reticent to have any treatment that leaves them looking like they have had ‘work done’. Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment.² Procedures like dermal fillers and toxins have paved the way for thread lifts, which are thought of as the next ‘step up’ for lifting, contouring, and defining an ageing male face.

It’s well known that a chiselled jawline and strong chin are characteristic and classically preferable male features. It is important to recognise that while a man’s indications and motivations to seek treatments will be similar, male and female patients require very different treatment protocols to restore the correct desirable features.³

Threads are particularly suitable for enhancing facial definition by addressing sagging skin, and they are effective for treating male jowling, marionette lines and nasolabial folds, as well as addressing facial asymmetry.⁴ We always educate our patients that facial rejuvenation is a combination approach to volume, skin laxity, and skin texture and we frequently use a two-phased approach of filler and threads to give men the maximum results possible for a lift through the mid-face.

In our experience, thread treatments are particularly popular with our male patients who are typically aged between 40-55 years old. Most attend the clinic actively requesting thread lift treatment, having undertaken their own, in-depth research online.

Anatomical and physiological considerations when treating male patients with threads

There are a number of factors that must be considered before embarking on thread treatment for men. Male skin is thicker than female skin, resulting in a deeper dermis, and a greater volume of subcutaneous, fibrous tissue.⁵ Therefore, as when treating both genders, it is paramount to be aware of the five layers: skin, superficial fat, the superficial muscular aponeurotic system (SMAS), deep fat and bone. With threads, we are addressing the superficial fat layer. Knowledge of these layers is important to understand the ageing process and the development of a successful treatment strategy.⁵

The thickness of the male skin and the fact that biologically male faces are larger than female faces means that the tissue to be repositioned and lifted by the threads is heavier. As a result, the depth of thread placement is typically deeper than that of female patients.⁵ In general, thread placement in females is about 5mm to reach the subcutaneous layer, and in males this is about 8mm.⁵ Besides facial hair, there are structural differences between the skin of men and women. Androgen stimulation causes an increase in skin thickness, which accounts for why a man’s skin is about 25% thicker than a woman’s.⁵ In addition to being thicker, a man’s skin texture is tougher.⁵

While female beauty mostly lies in the cheekbones, male attractiveness is thought to be in the chin and a stronger masculine appearance can be achieved by creating a square chin.⁶ Mandible projection is more acceptable in men; the chin is flatter and wider and has the same width of the mouth.

In female patients, the width of the chin is the same as that of the nose and it also corresponds to where most of the volume of the lips is.⁶

Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment

Treatment strategy for the male lower face

To develop a successful treatment plan, a consultation and detailed medical assessment should be carried out. Practitioners should ensure there are no contraindications to treatment, such as a history of autoimmune disease, blood thinner medication, unrealistic expectations for example.⁷ After exploring the patient’s aesthetic ideas, concerns and expectations, a comprehensive facial analysis must take place. Anterior, lateral and dynamic assessment of the lower face should be performed, including assessment of vectors, fat pad distribution and degree of skin laxity.

It is important to keep in mind how the male face will specifically age when deciding on treatment. Understanding the ageing process of the male lower face tends to follow a sequence of events:⁸

1. Atrophy of deep and superficial fat
2. Dehiscence of the mandibular septum, resulting in the ptosis of both fat compartments
3. Gradual loss of definition of the jawline as bone is resorbed and remodelled, starting around 35 years, leading to loss of height and length and a more obtuse mandibular angle, chin retraction and more appearance of pre-jowl sulcus

As clinicians, it is important that we consider the forces that individual threads will be placed under and ensure that the weight is correctly distributed. We find that male patients typically benefit from more threads per treatment than females to ensure the correct force distribution, and more thread cones to enable a greater area of skin and fat pad to be lifted. For my male patients, we prefer to use threads with 12 cones, as opposed to our female patients, where we typically use eight cone threads. The larger male face allows the longer thread to be used without extruding cones on tightening of the thread.

Clinicians must always be mindful that when injected correctly, thread treatment does not feminise the face, unless this is the desired effect. In our male patients, we typically insert threads lower, near the jawline and more vertically in the mid-face than we do for our female patients to ensure maximum lift through the mid-face via perpendicular vectors to improve jawline definition.

Combining treatments

We often recommend male patients combine thread lifts with other non-surgical treatments to maximise and enhance the result. Restoration of mandibular and chin projection is essential when treating age-related changes of the male lower face. In our experience, this is best achieved by layering dermal fillers deep in the supraperiosteal plane and at the level of the superficial fat, in addition to placing threads in the subcutaneous layer.⁹

We pay particular attention to chin projection, and lateral mandibular projection from the anterior view. The male chin, as discussed, is wider, with the width usually corresponding to the width of the mouth.¹⁰

For example, to address marionette lines and nasolabial folds, and have associated volume loss in the buccal hollows, we administer filler (typically Ellansé which is also a biostimulator) to the area two weeks before thread treatment. In our experience, this ensures the depth of the thread insertion can be maintained for the subsequent repositioning of the tissue. For treatments to restructure the chin and jawline (a particular area of interest to our male patients) threads are placed in phase one of the treatment to reposition tissues which have migrated south as part of the ageing process. This is then followed by the use of collagen stimulating fillers to create the chiselled definition along the jawline and add lost volume.

Clinicians must always be mindful that when injected correctly, thread treatment does not feminise the face, unless this is the desired effect

Side effects and guidance

Common short-term side effects including bruising, swelling, dimpling, temporary skin contour irregularities, and puckering.⁷ While post-treatment care is the same for both sexes, male patients tend to find it more of a challenge not to touch their faces or perform large movements, including exaggerated yawning, and exercise posttreatment than female patients. Patients should be reminded frequently during and after treatment what protocols they should undertake post-treatment, particularly stressing the importance of hand hygiene to ensure the entry and exit points of the needle do not become infected.

It is important to ensure that patients have realistic expectations of treatment results and longevity. They are advised thread treatment will last 15-18 months, which of course depends on the products chosen; however, like a car’s yearly service, if patients are keen to maintain results for as long as possible, repeat treatments are necessary.¹¹

A growing interest in threads

Interest and demand for male thread treatments continue to grow, as male patients embrace the growing evidence for the effectiveness of the treatment to treat their ageing concerns. Clinicians should be mindful of the physiological differences male patients present with, paying particular care to depth of thread placement, force distribution on each thread and the desired result of defined, masculine features that male patients require.