This article is aimed mainly at medical aesthetic practitioners but we hope that you find it interesting if you read to the end. This article details the differences between male and female rejuvenation approaches. If you have any feedback or questions on the article please contact us on firstname.lastname@example.org
In current non-surgical aesthetic practice we are seeing a steady increase in the number of male patients presenting for aesthetic rejuvenation treatments. The number of men in the United States seeking botulinum toxin injections increased by 268% between 2008 and 2011 . There have been a number of suggested explanations for this rise, including a growing desire for men to appear more youthful and therefore competitive in the workplace and an increasing social acceptability for such procedures. Whilst the trend is ongoing, the majority of patients in aesthetic practice are still female. This means that busy practitioners who frequently see large numbers of aesthetic patients become very familiar with the female aesthetic, whilst remaining less familiar with the male aesthetic. Unfortunately this shift in skill to the female side means that the male patients are often receiving substandard or inappropriate treatments, as it is clear that the male form differs from the female, and accordingly an approach to female rejuvenation and beautification will not result in a satisfactory outcome when applied to a male face.
In todays competitive aesthetic market, where practitioners find themselves competing with less trained and non-medical service providers delivering the same treatments over and over again it is vital that the expert stands above the rest and differentiates his or her practice on superior quality, by offering expert techniques that deliver outstanding results based on superior knowledge.
In order to develop the skills required to provide outstanding aesthetic rejuvenation treatments in both men and women, an understanding of sexual diamorphism is required, coupled with a profound appreciation of both male and female beauty. This article aims to outline the differences between male and female facial anatomy, and their relevance to aesthetic rejuvenation procedures. This is intended as a guide rather than a set of instructions, to allow the reader to subtly alter their approach between male and female patients, and modify their techniques accordingly. We split the article into segments detailing specific areas, which when taken as a whole will allow a holistic appreciation of the subtle differences in anatomy and accordingly treatment.
Often the last approached area in non-surgical facial rejuvenation, the forehead, is actually one of the most important areas where marked differences are seen between the sexes. Anthropologists studying skulls use the skeletal structure of the forehead as a significant indicator as to the sex of the skeleton The forehead begins at the supraorbital ridge inferiorly and runs superiorly to the hair line. The female skeleton characteristically has a flat supraorbital ridge with a smooth convexity running up to the hairline, the male skeleton however has a prominent and more projected supraorbital ridge, above which is a concavity before it flattens out and becomes concave again. This convexity gives rise to the appearance of supraorbital bossing in males. The prominent supraorbital ridge is medially continuous with the glabella giving rise to a more pronounced and projected glabella region in males.  This skeletal difference gives rise to three important sexually defining characteristics, the prominent glabella and supraorbital bossing as described, but also the skeletal structure influences the overlying soft tissues and thereby the postition of the eyebrows. The male eyebrow sits along the supraorbital ridge and is generally flat , whereby the female brow starts medially in the same position, but arches superiorly at an angle of between 10 and 20 degrees with the tail more superior to the head.
The goal of aesthetic medicine is to restore a youthful and importantly natural appearance, So the techniques that we apply to a female patient, such as forehead revolumisation or brow lifting with neuromodulation and revolumisation may result in a feminized and unnatural appearance if used injudiciously on a male patient. Our guide when approaching the male forehead is to elevate a ptotic brow with neuromodulation and fillers if required, but endeavour to lift no more than the supraorbital ridge. An extensively bossed forehead is an indicator of volume loss and should be corrected, but there should remain a small element of bossing that corresponds to a natural contour. The female brows are more amenable to lifting techniques, and the forehead should be revolumised, when required, to acheive a smooth and natural looking convexity to the hair line.
The cheek is an extensively covered area with regards to aesthetic rejuvenation and the literature is awash with descriptions of the female contour and the female rejuvenation process, however very little is said of the male cheek. Even with the availability of literature and advice on female cheek rejuvenation we all frequently see poor treatment outcomes, seemingly from the repetition of the same cheek inflation treatment over and over again, with a consequent deformed and overinflated appearance. The cheek from an injectable perspective is largely a soft tissue structure, overlying the maxillae medially, the zygoma laterally and the deep fat and buccinator muscle inferiorly. Whilst some maxillary and zygomatic resorption does occur with age, more so in males than females , it is the overlying soft tissue contours that give rise to the characteristic differences surface contours between the male and female cheek. Overall the ideal female cheek is believed to be rounder and fuller, whereas a male cheek is flatter and more angular . A pair of studies using MRI to quantify the differences in subcutaneous facial fat in men and women and their changes with age [8,9] showed that overall the male face has a thinner layer of subcutaneous fat, but also that whilst the distribution of fat in the male cheek is uniform, the female cheek has a thicker fat compartment in the medial area as compared to the lateral area, with a ratio of 1.5 to 1. This uneven distribution explains why the female cheek is rounder and fatter, and the male cheek is flatter, conforming more to the contours of the underling structures.
The anatomic approach to a natural rejuvenation should respect the relative anatomy and thus for a male the subcutaneous should be filled uniformly, replacing the lost volume and maintaining the flatter and more angular cheek contour. For a female rejuvenation the volume replacement technique should be the same, but the volume of product used should vary, with more placement medially to mimic the naturally slightly thicker fat in this area and provide a feminine rounded appearance. Arthur Swift and Kent Remington have beautifully described the ideal contour and surface landmarks for identifying the cheek area, based on the mathematical concept of PHI . The techniques utilise a triangle drawn on the face with points at the lateral canthus, ipsilateral oral commisure, and ipsilateral tragus, and drawing an oval with three points contacting the lines of the triangle tangentially. This generally corresponds to an ideal cheek position for soft tissue volumisation in both the male and female face, the significant difference being only the point of greatest projection.
The nose is one of the areas of the face where subtle differences occur between the sexes. There are many angles and measurements to define an ideal nose shape, position and proportion , however for the purposes of the sexually diamorphic traits that can be effected, we will discuss two main angles. The nasolabial angle is the angle between a line drawn from the lip border to the base of the collumela, and a line drawn from the base of the collumella to the nasal tip. This angle describes the degree of rotation of the nasal tip. The ideal male angle has been described as 97 degrees and the ideal female angle as 105.9 degrees  The same study identifies different preferences in different ethnicities, with native americans and african americans preferring a more acute angle. A similar more acute nasolabial angle preference was found in a study in the asian patient population . It is important to bear in mind therefore the cultural preferences of the patient being treated, the general rule however is that the angle should be more obtuse in a female patient in general, and slightly upturned in a female caucasian. The other angle of significance is the naso-frontal angle. This is the angle of the radix, the lowest point on the nasal bridge and is formed by a line running from the radix to the glabella, and from the radix along the dorsum on the nose. The angle is greater in females than males, one study identifying an average female angle of 138 degrees and a male angle of 130 degrees The postition of the radix is also of importance, in the female it should be at the level of the lash line, in the male it tends to be higher, at the level of the tarsal fold, and more confluent with the glabella. When performing rhinomodulation with toxins or fillers it is important to respect these angles, as beautification does not involve masculinazation of a female feature or vice-versa.
The Jawline and Chin
The consensus of what constitutes an attractive jaw line in both males and females tends to vary with ethnicity and in todays multicultural society the practitioner must not just be aware of the local norms, but also be open to their patients expectations from treatment. The gonial angle is the angle formed by the mandibular line (a line running tangentially to the two lowest points on the anterior and posterior mandible) and the ramus line ( a line running through the two most distal points on the ramus). This angle has been shown to be lower in males than in females. Additionally the male mandible is wider at the gonion, due to eversion of the bone caused by masseteric attachement, and the bulk of a larger masseter muscle. The male chin is larger than a female chin, with a more widely set trigon. The underlying anatomy matches the Hollywood ideal of a male having a wide, sharply defined jaw, sharply angled and with a wide flat chin. The female counterpart has a narrower softer chin, gently sloping from auricle to a narrower more pointed chin. We can employ both masculinasation and feminisation techniques to the jawine and chin, using toxins to narrow down the masseter or curve a chin, and fillers to widen a jawline, increase definition, add a sharper gonial angle or flatten and enlarge a chin.
Perioral rejuvenation is a very common patent request amongst females but not so much in the male population. After appropriate lip rejuvenation there is often not much else required in a male patient, but female patients tend to suffer more from perioral smokers lines, as well as much more severe perioral wrinkling that may require resurfacing treatments in addition to toxins and fillers. The underlying reasons for this difference are not clearly understood, but it is thought to be related to the male skin being thicker and more seborhheic, with thinner underlying fat and a greater vascularity. Interestingly one study has shown that the female obicularis oris attaches 1.5 times closer to the skin in female subjects than in male subjects, which provides a reasonable explanation for the greater tenancy to smokers lines in females. Where it would be common to address a perioral female case with toxins, fillers and CO2 pulsed laser a similar approach to the male perioral area may result in feminisation of the skin and should be performed with caution.
In June 2015 we delivered a live demonstration of the differences in the assessment and injection techniques for male and female rejuvenation at FACE. Our male patient was 40 years old and had previously had mid facial volumisation with Radiesse and upper face toxin treatments 2 years previous. The female patient was 45 years old and had previously had mid facial hyaluronic fillers and upper face toxin more than 2 years previous.
We discussed the outcomes desired by each patient. The male wanted a result that was not obvious to his peers, made him look less tired and younger whilst maintaining his masculine rugged appearance. The female was less specific but wanted to look fresher and more attractive.
A comprehensive assessment of the male face identified global volume loss, particularly evident at the temples causing an hourglass deformity with loss of the tail of the eyebrow. There was moderate bossing of the central forehead and significant mid facial cheek sagging. The lips where both thinned, and the upper lip inverted causing a lengthening of the philtum. The jawline was fairly strong but had slight softening curve along from the gonion to the chin.(fig 1.) The temple was treated with superperiosteal depots of Belotero Volume, 0.8cc each side placed approximately one centimeter superiolateral to the superiolateral bony rim of the orbit (fig 2.). Further treatments in this area would be repeated at intervals until sufficient revolumsation is achieved. The central forehead bossing was softened but not completely corrected with superperiosteal deposits of Belotero Balance. The cheek was volumised with superperiosteal Volume anteriorly in a single deposit of 0.5 cc with a needle, then a uniform deposition of Volume 0.5cc in the subcutaneous fat of the anterior cheek area using a 25G microcannula. the lips both volumised and the upper lip everted with Belotero Intense 1cc using a 25G cannula and the jaw line was sharpened with subcutaneous threads of Radiesse injected with a 27G needle.
For the female patient a full assessment highlighted signs of ageing as a result of loss of volume associated with the temples, checks, jaw, maxilla and chin. The temples we augmented using the same technique as the male with 0.4ml of volume. The female temple remained concave, but helped blend the contour of the forehead smoothly into the lateral cheek prominence. The apex of the cheek is located at the intersection of the alar tragal line and a vertical line dropped vertically from the putter canthus of each eye. A bonus of 0.2 ml of volume was injected supraperiosteally at this point with a 30G 0.5mm needle to widen the bizygomal distance. Small boluses of volume were deposited across the lateral and mid cheek to lift and project the midface. Finally, lateral check contouring was defined as described by Swift and Remmington using a 25G 1.5 inch cannula subcutaneouly, depositing more filler medially. The lower third of the face showed the most marked signs of ageing. Perioral rejuvenation included restructuring the vermillion boarder by injecting Belotero Balance intradermally along the vermillion boarder. The White lip was also injected directly intradermally using a blanching technique described by Patrick Micheels. The chin was injected supraperiosteally with several boluses of standard dilution Radiesse at the pogonion to lengthen and project the chin. Radiesse was also injected in the menton area to reduce the mental crease and smooth the contour between the lower lip and the chin.
Aesthetic medicine is still a new and evolving field of medicine. In order to achieve excellence it is not enough to simply keep on top of the evolving products and techniques. If we truly want to acheive excellence we also need to stay ahead of the changing markets. With the increasing number of males presenting for rejuvenation treatments it is imperative that the expert practitioner extends his or her expertise to the matter of male rejuvenation. What constitutes a beautiful female face, and the techniques to non-surgically make a female face beautiful will not translate onto the male patient. An understanding of the different anatomical characteristics as well as the different expectations for treatment will.
Drs Emma and Simon Ravichandran are recognised and respected experts in the aesthetic medicine field who offer a multitude of training courses. To find out more about training courses visit www.clinetixtrainingacademy.co.uk or contact email@example.com
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