Dr Raul Cetto discusses the ageing process of the male lower face and possible treatment approaches.
The number of men who are interested in and who are seeking aesthetic treatments has been on the rise over recent years.1 As life expectancy increases, our expectation and demands of ourselves in our mature years have drastically changed. Certainly, we now expect to continue to be competitive in our work as well as active in our social and family lives for longer than our parents and grandparents. Improvements in the quality of non-surgical treatments with more developed techniques, scope and minimal downtime mean that we really can choose to stay looking and feeling youthful for longer. Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment.2
Facial bone structure influences how others perceive us; more specifically, our physical ability. Recent studies carried out on male patients suggest that a thinner facial structure with a shorter bi-zygomatic distance can make one appear less trustworthy; conversely, a wider bi-zygomatic distance indicates higher competence.3,4
Commonly, male patients seek aesthetic treatments to not only look younger or less tired, but also to improve their competitiveness in their work environment.5 A chiselled jawline and strong chin are characteristic and classically preferable male features. Male patients typically seek non-surgical treatments in order to enhance and restore these features as they become less defined during the ageing process. It is important to recognise that while their range of motivations to seek treatments and treatment indications will be similar, male and female patients require very different treatment protocols to restore the correct desirable features.5
In the developmental stage, both male and female faces are essentially the same. The male face later develops its characteristic features due to multiple peaks of testosterone.
The aesthetically ideal male lower face is characterised by a square projected chin and well-defined jawline. The chin-neck angle (submental-neck line) of <130 degrees is considered optimal for a man.6,7 While female attractiveness 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.7 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.7
When treating all genders, it is important to be cognisant of the five layers: skin, superficial fat, superficial musculo-aponeurotic system (SMAS), deep fat and bone. An in-depth knowledge of the pertinent structures is crucial to understanding the process of ageing and the development of a successful treatment strategy.
Both male and female patients have the same anatomy and go through the same steps during the ageing process, which are described below. Interestingly, female patients can appear masculinised as part of the ageing process as the soft tissues around the mandible prolapse and give the appearance of a square face.
Anatomy of the chin
The mandibular septum plays an important role in the formation of melomental folds and jowls. It is a membranous structure that separates the two compartments located over the edge of the submandibular fat compartment.8
Fibres of the platysma mix with the mandibular septum and are inserted in the anterior border of the mandible behind the depressor anguli oris (DAO) muscle.9
The mental area musculature is comprised of three muscles: DAO, depressor labii inferioris (DLI) and mentalis muscle. These three muscles are in relation to the orbicularis oris muscle (OO) sharing fibres along the lips. The OO muscle closes and pouts the lips and plays an important role in the formation of perioral rhytides.10,11
Anatomy of the jawline
The masseter muscle has a square shape, which comprises deep and superficial parts. Its superficial component is the largest and its insertion is located at the angle of the mandible and its inferior portion.12 There are four fat compartments in the mandibular region, two deep compartments over the inferior mandibular border and one large superficial component covering the parotid-masseteric fascia.13
The mandible has an inferior portion called the body of the mandible and two perpendicular parts, which are the mandibular rami.13
The facial artery is located 3cm in front of the angle of the jaw, anterior to the border of the masseter muscle. It is easy to feel the anterior border of the masseter when an individual is clenching their teeth, and we can palpate the pulse of the facial artery here. At the level of the mandible, the artery is deep – on the surface of bone – and then runs to become more superficial superiorly, but still underneath muscle, to the modiolus: 2cm lateral to the oral commissure. From here it gives rise to several branches, including the superior labial artery, mental and inferior labial, which become superficial to muscle at different times.13
The ageing process of the lower face will follow this sequence: atrophy of deep and superficial fat, dehiscence of the mandibular septum, resulting in the downward migration of both fat compartments towards the neck.9
There is a progressive loss of definition of the jawline as bone is resorbed and remodelled.9 Around the age of 35, bone resorption begins to take place in the mandible. This results in a loss of mandibular height and length, leading to a more obtuse mandibular angle, chin retrusion and an accentuated pre-jowl sulcus.14
The jowl and melomental folds only develop with ageing. Laxity develops in the roof of the pre-masseter space with laxity of the anterior and inferior boundaries; however, the major retaining ligaments remain strong with the superficial fascia staying firmly attached to the deep fascia. As the buccal fat descends within the buccal space, the weaker masseteric ligaments at the anterior border of the lower pre-masseter space distends downward – this gives the melomental fold. The jowl develops by the distension of the roof of the lower pre-masseter space, which causes tissue to hang below the body of the mandible.14
The ageing process results in the symptoms that often bring our patients to seek treatments. These symptoms are commonly: melomental folds, labiomental crease, double chin, jowls and poorly defined jawlines. Our understanding of this multi-layered ageing process will allow us to deliver targeted treatments.14,15
Melomental folds, also commonly referred to as marionette lines, are a crease formed between the oral commissures beside the chin. This is characterised by a sharp transition between the cheek and chin, medial to the mandibular ligament. Inferior to the melomental folds, jowling can occur, which is a disruption of the mandibular line with sagging of the soft tissues. Medial to the jowl a sharp depression can also be noted, which is the pre-jowl sulcus.14,15
The labiomental crease is caused by an upwards rotation of the mentalis muscle due to hyperactivity. The mentalis muscle becomes hyperactive due to repositioning of the surrounding tissues and loss of bony support.14,15
Along the lateral aspect of the lower face, the jawline will lose definition as the sequence of ageing continues. An uninterrupted mandibular line will no longer be present due to jowling and loss of definition of the gonial angle.14,15
To develop a successful treatment strategy, a consultation and detailed assessment should be carried out. After establishing what the patient’s aesthetic wishes are, a comprehensive facial assessment must take place. Anterior, lateral and dynamic assessment of the lower face should be performed.
For men, we pay particular attention to chin projection, chin line and lateral mandibular projection from the anterior view. The male chin, as discussed, is broader and flat distally. The chin’s width will usually correspond to the width of the mouth. From the same anterior perspective, we evaluate the lateral projection of the mandible, which in the male patient is also broader, and when compared to the mid-face, a vertical line can be drawn from the point of maximum lateral projection of the zygoma to the mandible, giving the male face a squared appearance, responsible for the characteristic chiselled male ideal.7 In a lateral view, we assess the gonial angle, which is sharper in a male patient (<130) and the mandibular line towards the chin, which should be uninterrupted. The pogonium should be within 0.5mm from a vertical line drawn from the nasion (the most anterior point of the frontal-nasal suture) perpendicular to the Frankfurt plane.16 Restoration of mandibular and chin projection is essential when treating age-related changes of the male lower face. In my experience, this is best achieved by layering soft tissue dermal fillers deep in the supra periosteal plane and at the level of the superficial fat.7 Mandibular remodelling can be restored at several points: gonial angle, prejowl sulcus, pogonium, gnathion and menton. Volume loss of the fat pads can be restored at the level of the superficial fat.
Jawline projection can be achieved by placing soft tissue dermal fillers at the level of the latero-temporal superficial fat pad. The superficial fat pad planes of the chin can also be used to restore projection and camouflage a melomental fold or jowl. Hypertonic or hypertrophic muscles can be relaxed by using neuromodulators; however, this should be performed after adequate volume restoration with dermal fillers as the position of the lower face musculature can be influenced by loss of volume in the underlying and overlying tissues that occurs during ageing.9,17 When treating male patients, I use the trademarked ‘MascuLook’ concept, which was developed by German-based cosmetic surgeon Dr Sina Djalaei. This approach aims to highlight and restore masculine features. In particular: anterior mid-face projection, lateralise and define the jawline. It also defines and gives anterior projection of the chin and chin line.
Bony and fat volume restoration should be the first step in treating age-related changes in the male face and this can be achieved with soft tissue dermal fillers using a targeted layered approach. The second step is to use neuromodulators to relax hypertonic or hypertrophic muscles, if required. Treatment of the lower third of the face can be challenging and requires in-depth knowledge of facial anatomy. This allows the practitioner to avoid danger zones and perform effective, safe treatments. The chin is a critical component to the perception of facial attractiveness and a defining characteristic of the male patient and therefore reshaping the jawline can provide a significant improvement to facial ageing. An uninterrupted jawline with adequate mandibular and chin projection is a sign of youthfulness and of particular importance when treating age-related changes of the male face.
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