Only around 9% of all aesthetic procedures are performed on males in the United States according to ASPS and ASAPS 2018 data.1,2 However, the requirement for male aesthetic procedures is growing in numbers from year to year. Men seek nonsurgical procedures more commonly than they do surgical procedures and this is a particular area of market growth. The approach to the male patient is somewhat different to the female patient and must take into account general differences in structural anatomy of the face and body as well as the objectives set by males, which can differ greatly from those set by females. In general, men tend to want quick, simple procedures which have reliable, but subtle results and minimal downtime. They have a growing understanding of the availability of aesthetic procedures due to their promotion online and in the media. It is important to consider the requirements for male patients carefully. For surgeons interested in developing a practice in male aesthetics, there are many opportunities available depending on patient subgroup and procedure type they wish to offer, e.g., facial rejuvenation, breast surgery, and body contouring. Marketing style and web content should differ from clinics more focused on the female patient to ensure patients feel comfortable to seek treatments they require.3
When performing aesthetic rejuvenation procedures on the male face, it is really important to avoid any intervention that will feminize facial appearance. In order to avoid this, it is vital that the practitioner has an understanding of the differences between male and female facial structure. The male face has less fullness in the malar region and the fullness in that area tends to sit lower (caudally) in the cheek. Overzealous augmentation in this area, with fillers such as fat or hyaluronic acid, or during facelift can lead to a more feminine appearance (Fig. 124.1). Other areas that must be treated carefully to avoid causing feminization are the brow, which sits lower and more flat in males without the high arch seen in females, and the periorbital region which tends to have a longer upper lip which is thinner, deeper, and heavier nasolabial folds and a stronger, squarer chin.1–4
3. Boxall M. Changing Faces: marketing to the male customer. Available at:https://aestheticsjournal.com/feature/changing- faces-marketing-to-the-male-customer. Accessed June 10, 2021
The term “SIMON” refers to a notional patient who has some specific traits and characteristics. These are as follows: • Single • Immature • Male • Obsessive • Narcissistic Clearly any individual may possess some or all of these characteristics, but when seen collectively in a patient they are a red flag for undergoing aesthetic procedures because they are likely to have unrealistic expectations, have more difficulty describing their objectives, and have selective hearing in terms of advice offered by the clinician. This can collectively lead to patient dissatisfaction with treatment. Undergoing aesthetic surgery in any individual can heighten focus on the body part or area treated, leading to obsessive behavior where individuals repeatedly analyze the results with a mirror and photographs multiple times each day. Photographs are often taken at a range of different unusual angles and with differing lighting settings, which do not represent the appearance of the area in everyday life. Patients will then have a tendency to compare images with those found online which may not be genuine, realistic, or comparable to their own images anyway. A patient with SIMON characteristics is highly likely to experience this type of behavior postsurgery and the situation should therefore be dodged by avoiding surgery in the first place. This is not to say that all male patients who are young and single should not undergo aesthetic surgery, but rather than the operator must take the responsibility to assess and evaluate the likelihood of such events occurring before they do so, based on their intuition in the office visit. For this reason, at least two consults prior to surgery is normally recommended to build appropriate rapport and make safe, sensible, and appropriate plans for patients.1–3
Understanding the differences between the male and female nose is important in rhinoplasty to ensure that male patients are not feminized and female patients are not masculinized. The key features of the male nose are that it is larger and longer, the dorsum is wider and straighter, there is no supratip break, and there is less tip rotation (with a reduced nasolabial angle of 90–95 degrees instead of 95–105 degrees). In addition, the nasal tip is broader and more bulbous and because the male skin is thicker, there are limitations in the ability to change its shape. The chin is also stronger and more prominent; so, the balance between the nose and chin is altered. The upper lip is usually taller and the lips are thinner in the male patient. The key aims of the male rhinoplasty should, in general terms, be to create a natural appearance and avoid feminization; preserve facial balance; avoid an excessively small, tweaked, upturned, or rounded nose; and avoid a nose that is too narrow, which will also lead to airway problems. In the lateral view, a straight dorsal line is generally preferred for the male patient (Fig. 124.2).1–3
The most popular aesthetic nonsurgical procedure for males is neurotoxin therapy. This is frequently requested to improve the crow’s feet area and the brow. Care must be taken to avoid over-treatment in males, as the glabellar region and brow can be feminized if excessive neurotoxin doses are used. The brow should remain flat in males rather than the high arch appearance seen in females. A subtle weakening of the mimetic muscles involved is preferable. Remembering to under-correct is always better than over-correcting as further injection top ups can be given, and considering reversal is not possible (unlike with hyaluronic acid injections). Males tend to have more powerful muscles especially in the brow and generally require larger doses to achieve the equivalent result Fig. 124.2 Differences in the male and female nose. than females. For example, in the glabellar region, a starting dose for women is 20 to 30 units of Botox, where in men it is 30 to 40 units. Other popular procedures for males include fillers, which may be commonly used to fill specific lines or furrows including the nasolabial folds, which tend to be deeper in males. Hair removal is another popular choice, although less so in the face. Sites such as the back and chest are more commonly targeted. Chemical peels and microdermabrasion are also popular for more general facial rejuvenation.1–3
final step prior to closure when performing this procedure. There are a number of key points to consider specific to the male blepharoplasty. The key goals of lower eyelid surgery are to remove any excess skin, fat, or muscle and improve the lid–cheek junction and tear trough areas, while ensuring that the lower eyelid remains well supported such that a natural shape is maintained and ectropion is avoided. Pitfalls that surgeons can run into include overly aggressive skin and or muscle resection without sufficient internal canthal support leading to poor results, and ongoing challenges in their subsequent correction. In order to avoid removing excess skin, this must be done conservatively in the lower eyelid, and AFTER the other components have been completed, including canthal suspension in the form of a canthoplasty or canthopexy where necessary. The difference between the two is that in a “pexy,” the canthal tendon remains in continuity, where in a “plasty,” it is divided and repaired during the tightening procedure. In general, skin removal in the lower eyelid should be no more than a few mm, in contrast to the upper lid where 10 to 15 mm may often be taken. The approach to lower eyelid blepharoplasty may be with skin/orbicularis flap elevation to access the orbital septum and pre- and postseptal fat compartments. In this more invasive approach, many elements of the eyelid can be manipulated under direct vision. Alternatively, a pinch blepharoplasty approach may be preferred in younger patients who require only subtle changes and have good lower eyelid support. This is something that tends to be paired with procedures like a facelift where the malar tissues have been supported in a different manner.1–3
patient? Hair transplant has advanced in recent years and the gold standard now is to use a follicular unit extraction technique with single follicles containing between one and four hairs each. As with all aesthetic procedures, it is vital to discuss things in detail with the patient beforehand, to ensure patients are well informed and have realistic expectations. Hair loss will continue to progress with time and patients must be aware of this. Of course, it is particularly true in younger patients undergoing hair transplant. Setting a hairline too low in these individuals must be avoided, as it will create problems in the future with an unnatural appearance. The hairline needs to look natural as the patient ages. Pretreatment with PRP or finasteride can be helpful in hair loss patients, as can posttreatment with minoxidil. The posterior strip excision is virtually obsolete and leaves a transverse scar in the posterior hair-bearing scalp.1,2 1116 Part VII ■ Aesthetic Surgery
Following hair transplant, it is normal for the transplanted hair to fall out at around 2 weeks. New hair growth begins around 12 weeks. It is vital to explain this to patients preoperatively and remind them postoperatively to avoid unnecessary anxiety as has occurred in this case. The usual posttreatment regimen includes oral antibiotics for a few days, and liposomal adenosine triphosphate (ATP) spray should be used every few hours throughout the day and a light covering used on the head for a few days. The ATP is thought to help graft growth by returning ATP levels to normal (ATP is presumed to be depleted because the hairs are deprived of blood and oxygen for a period of time), yet is important in hair growth. Normal washing may begin at day 5 and minoxidil or laser light therapy can begin around 3 weeks as adjunctive therapy. Usually 90% of follicles will grow. Intraoperatively, grafts should be placed snuggly and oriented with angulation flat in forward and lateral directions. Density of graft placement should increase moving posteriorly to help create a natural appearance. Triangulation involves random distribution of smaller and larger units.1,2
Surgery for correction of gynecomastia (development of a female-shape breast in a male) is one of the most commonly performed aesthetic surgical procedures for males. Gynecomastia affects a large proportion of men at some point in their life, although most will not require surgery for it. Causes include certain medications, tumors, Muscular anatomical landmarks Fig. 124.3 Etching details for males undergoing abdominal liposuction. weight gain, and hormone imbalances. Gynecomastia can be glandular or fatty with or without excess skin and accompanying ptosis. The male chest should ideally have the nipple areola complex (NAC) at least 1 to 2 cm above the inframammary fold (IMF) and it should normally be less than 2 cm in diameter. The IMF should be fairly indistinct with no breast ptosis. When it is well defined, this gives the breast a more feminine appearance. A larger IMF-to-NAC distance and a larger diameter NAC are both feminizing features of the breast. Upper and medial pectoralis major fullness is desirable in the male chest and any outer chest and axillary fullness should be corrected if surgery is performed, as this is less desirable. Surgery should be aimed at resetting the chest to a male appearance with minimal tell-tale signs. If the consistency of the excess soft tissue is fatty, then liposuction is helpful, whereas if it is glandular, then formal surgical resection will be required. Skin excision will incur visible scars and the length of these is usually determined by the amount of skin excess. Trying to place these inconspicuously is a key factor in achieving a natural result and avoiding highlighting that breast surgery has been performed.1–4