Male Facial Revolumisation with Dermal Fillers

By Dr Pamela Benito and Dr Vincent Wong / 09 Jan 2018

Dr Vincent Wong and Dr Pamela Benito present a step-by-step guide to rejuvenating the male face after volume loss

]Sexual dimorphism – the phenotypic differences between the sexes of the same species – in some ways may be less obvious when it comes to facial structure. However, the approach to male aesthetics is different from that of a female. As more men come forward for non-surgical enhancements, it is important that we understand sexual dimorphism and have a profound appreciation of both male and female beauty. This would prevent unwanted feminisation of the male face, which, from our experience, remains one of the main concerns amongst male patients seeking aesthetic treatment.

In this article, we detail the step-by-step treatment of a 40-year-old male patient who presented to us with facial volume loss after losing weight. Due to his job as a personal trainer and fitness model, his body weight fluctuates frequently. 

Upon presentation, he had lost 1.5 stone through intensive exercise and was worried about the ‘sunken appearance’ of his visage. The patient had never had any dermal filler procedures before the treatment. At the first consultation, we had a long and thorough discussion with the patient to identify his concerns, needs, worries and expectations. Benefits, risks and side effects, were also discussed, and alternative treatments including surgery were explored. The upper, middle, and lower thirds of the patient’s face were analysed for volume loss and the estimated volume of dermal filler required was also discussed. The patient was given a cooling-off period of two weeks before the procedure and was advised to carefully consider all the options. Photographs were taken before and after treatment, and consent forms were signed.

Facial analysis: male vs. female

Facial attractiveness is characterised by a combination of factors that involve symmetry and proportions that are deemed aesthetically pleasing, according to a number of sources listed in the table below. Before performing any facial enhancing procedures with dermal fillers, it is vital to analyse the patient’s face so that we:

  1. Correctly identify the areas that need volumising
  2. Respect the symmetry and proportions of the face

Step by step guide

Our experience in treating male patients has led to the development of the ‘23XY Lift’, which describes the injection techniques of dermal fillers into the seven zones of the male face, where volume deficiencies are commonly found. 23XY is the genetic makeup of a male human (X and Y chromosome on chromosome number 23). This technique comprises seven single techniques, one for each zone, which are:

  1. Temple
  2. Cheek
  3. Infraorbital region
  4. Alar base
  5. Corner of mouth
  6. Chin
  7. Angle of the jaw

When it comes to male facial aesthetics, the 23XY Lift can help enhance the masculinity of the visage, and in our experience of performing 25 treatments using this technique, it also minimises the risks of complications and feminisation of the face. Here, we discuss the seven regions of the male face that can be treated using a step-by-step approach. These techniques are used widely within the aesthetics specialty and are considered safe. However, it is important to bear in mind that this is purely a guide, and there are various other techniques available for the same regions. The patient was treated using the following guide: 

Upper third ideals


Men

Women

Forehead

  • Greater height and width1,2
  • Extensive supraorbital bossing (physical prominence of the supraorbital rim)3
  • Flat area above bossing, before the convex curvature of upper forehead4
  • Shorter and narrower forehead1,4
  • Less or absent bossing4
  • Entire forehead is a continuous mild curvature4

Eyebrows

  • Sit along orbital rim3
  • Flat in contour3

  • Sit above orbital rim3
  • Arched at an angle of 10 to 20 degrees – peak in the lateral third3

Glabella

  • Pronounced and projected1
  • Less pronounced and less projected1

Middle third ideals


Men

Women

Eyes

  • Proportionally smaller in relation to skull size2
  • Low eyelid crease5
  • Upper eyelids are fuller and more redundant5
  • Proportionally bigger in relation to skull size2
  • Higher eyelid crease5
  • Less upper eyelid tissue5

Nose

  • Wide and straight
  • Straight contour from radix to tip5
  • Radix position: at the level of tarsal fold5
  • Nasofrontal angle: approximately 130 degrees1
  • Nasolabial angle: 90 to 95 degrees1
  • Narrow and laterally concave
  • Subtle 2mm concavity along contour of nose5
  • Radix position: at the level of lash line5
  • Presence of supra tip break (inflection point before the tip starts to elevate)5
  • Nasofrontal angle: approximately 138 degrees1
  • Nasolabial angle: 95 to 100 degrees, resulting in upward rotation of the tip1

Cheeks

  • Flatter and more angular1,5
  • Uniform distribution of subcutaneous fat6
  • Apex is low, more medial and subtly defined6
  • Rounder and fuller1,5
  • Thicker subcutaneous fat compartment medially at a ratio of 1.5:17
  • Apex is located higher on the mid-face, below and lateral to the lateral canthus and well defined7

Lower third ideals


Men

Women

Lips

  • More volume loss in the lower lip than upper lip with age5
  • More volume loss in upper lip than lower lip with age5

Chin

  • Larger and more protruding with well-developed lateral tubercles1
  • Smaller, narrower and more pointed with less prominent lateral tubercles1

Jawline

  • Wide and well-defined (square appearance) with large masseter muscle
  • Prominent angulation of the mandibular ramis5
  • Lower gonial angle1
  • Narrower and less prominent (V-shape)
  • Less prominent angulation of the mandibular ramis5
  • Higher gonial angle1
  1. Palpate the superior medial quadrant of the temple for any vessels and identify a vessel-free area as the needle insertion point.
  2. Insert the needle perpendicularly to reach the periosteum.
  3. Aspirate to ensure that the needle tip is not in a vessel.
  4. Slowly inject a bolus of 0.5-0.6ml.
  5. Upon completion of the injection, apply firm pressure to the area to distribute the product evenly.
  6. Further treatments in this area should be repeated until sufficient revolumisation is achieved. 

Note

The inferior half of the temporal fossa has a higher vascular density, hence a higher vascular risk, compared to the upper half. Practitioners must note that the superficial temporal artery runs in the lateral third of the temporal fossa in the subcutaneous/ superficial muscular aponeurotic system (SMAS) layer. They should also be aware, that the anterior and posterior deep temporal arteries lie in the periosteal and muscular layers respectively in the inferior medial quadrant.8 

  1. Draw a triangle connecting the lateral canthus, ipsilateral oral commissure and ipsilateral tragus (Figure 1).
  2. Within the triangle, draw an oval with three points contacting the lines of the triangle tangentially.
  3. Divide the oval into lateral, middle and medial thirds.
  4. In the lateral third of the oval, pull the lateral cheek taut along the zygoma. While maintaining the tissue in taut position, inject a single depot of 0.2ml supraperiosteally using a needle (perpendicular approach).
  5. Apply pressure on the depot post injection to distribute it evenly.
  6. Further injections should be repeated in the middle and medial third of the oval until sufficient revolumisation in the lateral cheek is achieved.
Figure 1: Marking for lateral cheek enhancement in a male face.


  1. At the intersection of the alar-tragal line and the line dropping vertically down from the lateral canthus, insert a 25G cannula into the subcutaneous layer and inject the medial cheek in a fan-shaped retrograde manner until sufficient revolumisation is achieved (on average 0.2-0.3ml per side in a male face).

Note

Whereas the female cheek has a thicker fat compartment in the medial cheek, the male cheek is flatter, with a uniform distribution of fat and hence conforming more to the underlying structures. Therefore, the subcutaneous should be filled uniformly in a male face, replacing lost volume and maintaining the flatter and more angular cheek contour at the same time. Filling of the cheek also provides structural support to the tear trough and palpebral malar groove.

  1. Palpate and mark out the orbital rim. Injections in this area are safe as long as they are below the orbital rim.
  2. Locate and mark the infraorbital foramen by applying pressure using a cotton bud at a point 6-8mm below the orbital rim, slightly medial to the mid-pupillary line. The patient will feel a discomfort when the right spot is located. Avoid injecting into this high-risk area.
  3. Identify the first injection site by placing the needle along the tear trough so that the tip of the needle is below the medial canthus.
  4. Insert the needle perpendicularly to reach the periosteum and advance the needle along the tear trough on the orbital rim.
  5. Aspirate to ensure that the needle tip is not in a vessel.
  6. Inject slowly along the tear tough using a retrograde technique (approximately 0.1ml per injection) supraperiosteally.
  7. Upon completion of the injection, apply gentle pressure to the area to distribute the product evenly.
  8. Further injections should be repeated over the palpebral malar groove and the lateral lid-cheek junction.

Note

The infraorbital foramen marks the location of the emergence of the infraorbital neurovascular bundle. Also, injections around the eye area have to be done supraperiosteally to prevent damage to the lymphatic drainage system.8 

  1. Insert needle perpendicularly onto the periosteum immediately lateral to the base of the nostril.
  2. Aspirate to ensure that the needle tip is not in a vessel.
  3. Slowly, inject a bolus of approximately 0.2ml.
  4. Post injection, mould the depot accordingly.

Note

The piriform becomes wider as the nose ages and alar base treatment will help define and restore a youthful appearance. Note that the facial artery usually lies lateral to the buccal-maxillary ligament, and hence it is important to position the needle correctly, in the right depth and to aspirate before injection.8 Injections in the alar base come with a risk of vascular compression.8 Patients should be made aware of this and report any skin changes to the nose after the procedure. Also, filling of the nasolabial lines can be carried out in the same session if required. 

  1. Identify a point 5mm lateral to the corner of the mouth.
  2. Insert the needle superficially into the deep dermis/superficial subcutaneous layer, running parallel to the vermillion border.
  3. Inject in a retrograde fan-shaped manner (approximately 0.1- 0.15ml per side).
  4. Mould the product accordingly.

Note

Superficial injections in this region will help support the structure and skin texture of the corners of the mouth. This treatment can be supported with deeper injections inferiorly towards the chin if required; dermal fillers should be injected medial to the mandibular retaining ligament. 

  1. Identify the area of weakness in the lateral border of the chin by pinching it horizontally.
  2. Insert needle perpendicularly onto the periosteum, medial to the mandibular retaining ligament.
  3. Aspirate to ensure that the needle tip is not in a vessel.
  4. Slowly, inject a bolus of approximately 0.2ml per side.
  5. Mould the depot accordingly post injection.
  6. Repeat until sufficient revolumisation is achieved.
  7. Stress the chin to identify the point of weakness in the pogonion (Riedel line) by pinching the chin horizontally.
  8. Insert the needle perpendicularly onto the periosteum.
  9. Aspirate to ensure that the needle tip is not in a vessel.
  10. Slowly, inject a bolus of approximately 0.2ml.
  11. Mould the depot accordingly post injection. This treatment will increase anterior projection of the chin.
  12. Repeat until sufficient revolumisation is achieved.
  13. To elongate the chin, inject a slow depot of 0.2ml supraperiosteally at the most inferior point of the chin on each side using an inferior perpendicular approach (aspirate before injecting). Further injections should be repeated until the desired result is achieved.

Note

In a male, the lateral border of the chin should correlate with a vertical line dropped from the corner of the mouth.9 For men with a chin cleft requesting anterior projection/elongation, fillers should be injected lateral to the cleft in order to preserve it. Increasing the forward projection of the chin will also tighten the skin around the jawline area. 

Treatment of the lateral borders of the chin alone will result in a squarer chin, as well as a sharper and well-defined jawline. A line connecting the most prominent portion of the upper and lower lip should touch the pogonion.9 The lower lip should be 2-3mm posterior to the upper lip and the pogonion should never project beyond this line; if this was disrupted, the overall facial harmony would be disrupted too. Treatment of the mental crease can also be carried out in the same session (superficial injections). 

  1. Pinch the angle of the jaw and lift the tissue with the thumb and index finger of the non-injecting hand.
  2. Insert needle perpendicularly onto the periosteum.
  3. Aspirate to ensure that the needle tip is not in a vessel.
  4. Slowly, inject a bolus of approximately 0.3ml per side.
  5. Mould the depot accordingly post injection.
  6. Further injections should be repeated until the desired result is achieved.

Note

Most males are blunt at the angle of the jaw, partially due to thinning of the temporal-buccal fat pad, and this treatment will project the jaw laterally and strengthen the jawline, resulting in a square jaw, which is usually desirable in a man. Dermal fillers must be injected supraperiosteally to avoid damage to important structures (e.g. parotid gland and ducts).

Results

The patient was seen three times in total – consultation, treatment, and review at three-weeks post treatment. He was quite swollen and bruised, but that resolved spontaneously without any interventions. As seen in Figure 2, the patient’s results were immediately visible. Significant improvements to his concerns were observed. He looked more youthful, energetic and well-rested after treatment. To further optimise his results, skin resurfacing treatments were recommended, for example skin peels and laser treatments. 

Figure 2: The patient before and after treatment using the 23XY Lift with dermal fillers.


Conclusion

The aesthetic approach to treating a male face differs significantly to that of a female face. As aesthetic medicine predominantly focuses on the female face, characteristics of the male face must be fully understood and appreciated before being applied in our practice. This case study demonstrated that the male face can be successfully rejuvenated without risk of feminisation.

References

  1. Ravichandran E, Ravichandran S. Male vs. Female Facial Rejuvenation. Aesthetics Journal 2015;2(11)
  2. Snow CC, Gatliff BP, McWilliams KR. Reconstruction of facial features from the skull: An evaluation of its usefulness in forensic anthropology. American Journal of Physical Anthropology 1970;33(2):221-7.
  3. Goldstein SM, Katowitz JA. The male eyebrow: A topographic anatomic analysis. Ophthalmic Plastic & Reconstructive Surgery 2005;21(4):285-91.
  4. Ousterhout DK. Feminization of the forehead: Contour changing to improve female aesthetics. Plast Reconstr Surg 1987, May;79(5):701-13.
  5. Farhadian JA, Bloom BS, Brauer JA. Male aesthetics: A review of facial anatomy and pertinent clinical implications. Journal of Drugs in Dermatology: JDD 2015;14(9):1029-34.
  6. Wysong A, Kim D, Joseph T, MacFarlane DF, Tang JY, Gladstone HB. Quantifying soft tissue loss in the aging male face using magnetic resonance imaging. Dermatologic Surgery 2014;40(7):786-93.
  7. Wysong A, Joseph T, Kim D, Tang JY, Gladstone HB. Quantifying soft tissue loss in facial aging: A study in women using magnetic resonance imaging. Dermatol Surg 2013, Dec;39(12):1895-902.
  8. Andre, P. and Garcia, P. (2012). Anatomy and volumising injections. [UK]: E2e Medical Pub.
  9. Marquardt Beauty Analysis, Face Variations by Sex (2014) <http://www.beautyanalysis.com/ beauty-and-you/face-variations/face-variations-sex/> 

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