Special Feature: Injecting the Male Periorbital Area

“I look tired” is a common concern that aesthetic practitioners will hear at least once a day, with patients continually dissatisfied with their dark and sunken eyes. This is a particular area of insecurity for men, with the Men’s Maximum Difference study in 2015 by Allergan revealing that tear troughs, as well as lateral canthal lines, were the top features identified by male participants as being their problem areas. In addition, 80% of them said that they were most likely to get the eye-area treated before anything else.¹

With more men seeking treatments² and the periorbital area standing out as a key concern, Aesthetics spoke to ophthalmologist Dr Tahera Bhojani-Lynch, consultant ophthalmologist, oculoplastic, aesthetic and reconstructive surgeon Miss Rachna Murthy and aesthetic practitioner Dr Nina Bal, to gain insights about how to successfully treat the male under-eye area and how practitioners should differentiate this approach from female patients.

Eye concerns and the pandemic

Miss Murthy has noticed a rise in popularity for male treatments, particularly in the periorbital area, and attributes this to the ongoing pandemic. She comments, “Not only have men had more than a whole year at home staring at their faces on Zoom, but it has also caused an increased strain on the eyes. Similarly, the constant mask wearing has brought a lot more attention to the area as it’s the only part of the face we can see!”

Dr Bal agrees, noting that over the past year she’s seen a shift in the reasons that men present to her clinic. “The most common reason I used to see male patients for was forehead lines,” she says, adding, “But thanks to the Zoom Boom this has been replaced by concerns of looking tired and having dark circles, so the under-eye is now my most popular treatment area for men. This is why it’s more important than ever that practitioners know how to correctly address concerns in this area.”

Consulting male patients

According to Dr Bhojani-Lynch men tend to express similar concerns to women, but they come in at a later stage in life and are unsure what can actually be done. She comments, “Men experience the same issues women do; they complain about crow’s feet, tired looking eyes and dark circles. However, I find that men always come into the clinic when they’re a bit older. I don’t think this is because men don’t notice these issues at the same time as women, but more that they don’t voice them. Women talk to women about what they don’t like about their faces and bodies, and it’s much more open and normalised for them to get treatments. Men don’t talk to other men in the same way, and if they do it’s often turned into a bit of a joke.”

This is what makes the initial consultation so key, she says, explaining that men feel vulnerable talking about the fact they have any insecurity. She adds, “This means my consultation style has to be completely different with men and women. What I’ve found helpful is using different terminology that attracts them to procedures and makes them feel more comfortable. Firstly, I don’t ask ‘what bothers you’, as they don’t often want to admit that anything bothers them! Also, rather than saying that a certain procedure will help them look younger, I’ll talk about how the treatment can make them look more attractive. This is very appealing to men.”

In Dr Bal’s experience, men often need reassurance when they come to her clinic. She says, “I find that men are always so worried about being judged for having or considering treatments. So, when I first see them, I let them know straight away that this is a non-judgmental space, and I mention that I have lots of other men present to me with aesthetic concerns.” Dr Bal finds that after this, men feel more comfortable to openly express what’s bothering them without holding back. “It’s also a comfort to let them know that you treat other men for whatever concern they have,” she adds.

Although Miss Murthy keeps her consultation approach similar for both men and women, she has found that the addition of 3D imaging has made men more trusting of the process. She states, “We use the Vectra H2 3D imaging system for all consultations, but I think our male patients appreciate it a lot more. They tend to have more analytical brains, so they want to see what they’re getting and what the outcomes could be. By showing them 3D images and helping them to monitor their treatments and the possible outcomes, they’re reassured they won’t leave the room looking feminised or over-filled.” 

Pre-treatment considerations

Miss Murthy emphasises the importance of assessing a patient’s eye health prior to any treatment around the periorbital area. She says, “You should never go straight into a periorbital treatment without knowing everything about the patient’s periorbital area – you need to do a full eye examination. For example, you should ask what their vision is like, whether they have dry eyes or any underlying oedema in the morning. If this is the case, non-invasive treatments may not be the right option, and they could be better suited to other interventions like surgery. The most important thing to bear in mind when treating all genders is to ensure the procedure is as safe and beneficial to the patient as possible.”

In regards to pricing, Dr Bhojani-Lynch suggests practitioners start by quoting the price based on the area rather than by syringe. She comments, “The main thing I advise all practitioners is to not overfill the under eye! Less is always more, and when you think you’re almost done, trust me you are done. But if a patient is paying by the syringe, they’ll try and get you to use all the product so that they get their money’s worth, even if they don’t need it. So, even if your patient asks you to continue injecting, you need to master the power of saying no – remember you can always add more but you can’t take it away as easily!”

Ageing in the male under-eye area

Before constructing a treatment plan, Miss Murthy emphasises the importance of practitioners understanding the underlying ageing processes of the periorbital area, as well as the fundamental differences between men and women. She explains, “It’s the first area to age in both genders because we have thinner skin around the eye, typically less than a millimetre. Underneath the skin, we have lots of different muscles which are working all the time, and because there’s no fat under the skin here, you can see loss of plumpness and lines much more quickly. Men are more prone to deeper wrinkles caused by repeated facial expression. Also, collagen loss happens steadily and more quickly in men than women throughout their lives, whereas women lose more after menopause. Because males have bulkier facial muscles and flatter cheekbones, this combined with subcutaneous fat and connective tissue loss in the mid-face with age, men tend to develop sagging lower eyelids and hollows below the eyeballs earlier and more severely than in women, making it a key area of concern.”

 “The main thing I advise all practitioners is to not overfill the eye! Less is always more, and when you think you’re almost done, trust me you are done”

Miss Murthy adds that the brow and the cheek positions are completely different for men compared to women and age differently. “The glabellar and frontonasal suture are more pronounced in males and the eyebrows are flatter, lying below the orbital rim, whereas for women they tend to be subtler, more curved and sit above the orbital rim,” she says, adding, “Because of this, men tend to have more deep-set eyes.”

All three practitioners note that it’s important to avoid any feminisation of the periorbital area (unless of course this is what the patient is requesting) by considering these anatomical differences. Dr Bhojani-Lynch says, “One reason why many men are scared to come into an aesthetic clinic is because they are worried they’ll come out looking feminine. This can be the case if they are treated by unqualified or inexperienced practitioners, and of course I’ve seen some bad results. But, if the practitioner is aware of the differences between male and female anatomy and structure, and is able to treat accordingly, the patient can end up with very natural and subtle results. This is why anatomy is absolutely key to pay attention to.”

Techniques for the tear-trough

Because a loss of support from the cheek area can worsen the appearance of the tear trough, Dr Bhojani-Lynch chooses to address volume in this area first. She notes that a common adverse effect when treating the male mid-face is over-filling, resulting in puffiness. She comments, “If you give a woman a fuller mid-face they look prettier, but if you give a man a fuller mid-face, they look feminised. Therefore, although we still have to start with this area in order to provide the under-eye with some support, we aren’t giving men the same curves we would with women.” Less product should also be used, Dr Bhojani-Lynch advises. “We need to keep the facial layers flat, and we can’t afford to give the area too much anterior projection as this will make it appear less masculine! I use a 30 or 27 gauge needle for this area because I find that it gives me a bit more precision.”

After injecting the mid-face, Dr Bhojani-Lynch treats the tear trough directly; she prefers to use a 25 gauge cannula. This is because it can help to keep a straight edge running across the cheekbone and is less likely to cause a vascular occlusion.³ She comments, “I make my entry point from the lateral aspect of the cheek and manoeuvre the cannula straight along the face to the tear trough and into the muscle to try and flatten out the dip that goes into the mid-face.”

Dr Bal also uses a 25 gauge cannula for her treatment approach, noting that she finds it a safer method for this particular area in both genders. She comments, “I sometimes use a 22 gauge, but the problem with this is that it’s easier to deposit too much product which is exactly what we want to avoid in this area. I normally go from the lateral side of the zygomatic arch, so the entry point will be on the bone, and I inject underneath the muscle, sliding the cannula across to the inner corner of the eye.”

She reminds practitioners not to go too superficial with their injections in this area. “It can feel safer sometimes to inject more superficially, but actually this can cause really persistent swelling,” she says, adding, “To make yourself more confident when injecting deeper, I recommend placing your finger in the ridge of the orbit, firmly below the lower lid, in order to be aware of where your cannula is and where it will end up.”

Miss Murthy uses her own adaption of Dr Mauricio de Maio’s MD Codes system in order to help determine her injection sites.⁴ She explains, “The first thing I do is to support the ligaments that are sagging laterally then replace deficient volume medially in the cheek – I would never treat the tear trough as a stand-alone. This means starting at point CK1 – the outer part of the zygomatic arch – and injecting straight down to the periosteum of the bone. I then move on to treat site CK3 (medial SOOF) using a fanning action. Here I tend to only use 0.5ml of product on each side to prevent overtreating. The final part of the procedure is to treat the tear trough itself.”

She starts at injection point TT1-3 (the lower lid–cheek junction) going down to the orbital rim. “Here I inject 0.1-0.5ml worth of product which has to be injected deeply, or it will sit on the muscle and cause late onset oedema,” she says, adding, “I also use a cannula here because in my hands, I find it minimises bruising and there is less risk of being in a vessel and causing a vascular occlusion.” Other complications in this area can include the Tyndall effect, asymmetry, post-inflammatory hyperpigmentation, migraines and nodules, Miss Murthy explains. “These can mostly be avoided by having an in-depth knowledge of the anatomy,” she adds.

Product selection

All practitioners voice the importance of appropriate dermal filler selection for successful outcomes. Dr Bhojani-Lynch comments, “In my opinion, Teosyal Redensity 2 is perfect for treating the under-eye because the hyaluronic acid is created in a way that does not attract as much water as other products I have used. This means there is less expansion of the product, therefore avoiding puffiness which, as mentioned, you want to avoid in this area for all patients, especially for men as it can cause feminisation. For the mid-face I use Teosyal RHA 4.”

Teosyal Redensity 2 is also a product Dr Bal will consider for the tear trough, but she also uses Juvéderm Volbella. She comments, “I find that both of these products provide good velocity and give a nice lift without causing any lumps. When addressing volume loss in the mid-face, I like to use Belotero Volume because I’ve found that it never gives the area too much swelling and won’t leave the face with any lumpiness or crepiness.”

Miss Murthy explains that she uses a combination of treatments and products for optimal results in the periorbital area, dealing with each consequence of ageing in the different layers. She comments, “To start, I’ll typically use a skinbooster. This is normally Juvéderm Volite, which I find works better on darker skin types than others I have used, so it depends on the patient. Then, when I go onto injectable treatments, I’ll use Juvéderm Voluma for restoring volume in the cheek because it’s long-lasting and gives a natural finish, and then Volbella or Volift in tiny microaliquots on the bone in the tear trough, building up over two sessions if needed.”

As well as injectable treatments, practitioners note that it is a good idea to get male patients on board to use topical skincare to maximise the results. Miss Murthy notes, “I advise them to have a daily skincare routine that can help improve the area, such as vitamin C serums, SPF factor 50 which they should apply all the way up to the lashes, and then a very light retinol at night to improve collagen production.”

Treat conservatively

All practitioners emphasise the importance of not over-treating the male under-eye area, recommending a less is more approach. Practitioners should be well-versed in periorbital anatomy and the differences between the female and male facial structures for successful results. While treating the tear trough can help to reduce the appearance of tired and ageing eyes, practitioners can also consider using other treatments in conjunction with dermal fillers to tackle concerns in the whole periorbital area, for example botulinum toxin, skin tightening treatments, topical recommendations and surgery.