INJECTABLES

Ethnic and Gender Considerations in the Use

of Facial Injectables: Male Patients
Mauricio de Maio, MD,
Summary: The contemporary male look includes sharp contours of the face
ScM, PhD
with strong nose, significant malar-midface structure, and a powerful chin with
São Paulo, Brazil well-defined jawline. Neurotoxins in the upper facial lines should preserve a
lower position of the brows and flatter arch in men. Excessive lifting of the eye-
brows and full correction of forehead and periorbital lines are not desirable.
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The use of dermal fillers is fully accepted into the nasolabial. Male patients with
sagginess and hollowness related or not related to acquired lipodystrophies are
candidates for cheek correction with volumizers. Female attractiveness lies in
the cheekbones, and for men, it lies in the chin. The use of volumizers in the
chin is very much appreciated by male patients, especially when it is recessed.
A strong and masculine appearance is obtained by creating a square chin.
Men present slight thinner lips, especially the upper one. Lip reshape in male
patients is very much rejected. It requires expertise both in communication
and in technical skills to convince male patients to undergo lip treatments
with fillers. The use of injectables in male patients is growing. Neurotoxins in
the upper facial lines and the use of dermal fillers in the nasolabial folds are
widely accepted. The use of volumizers in the chin is highly appreciated. There
is clear need of volumizers in the cheek to correct sagginess and hollowness in
men. However, proper communication and technique are required. The same
applies for the lips. Cheek and lip reshape is still considered a taboo for most
patients and injectors.  (Plast. Reconstr. Surg. 136: 40S, 2015.)

M
ale attractiveness can also be described as nose, the zygomatic prominences, and the chin
an intuitive appreciation of the symme- and jawline. The second landmarks include the
try, balance, and harmony. Regardless of supraorbital ridges, the temporal contours, the
gender, all faces do exhibit imperfections in one premaxilla, and the infraorbital region. The third
or more features. However, some of those imper- aspects that contribute for creating or restoring
fections that are not desirable in women may be facial harmony and balance include perioral and
acceptable in men. nasolabial regions. Lips, eyes, and eyebrows gov-
Developmentally, all human faces begin as ern our attention in interpersonal communica-
essentially feminine—even if genetically male. The tion and are responsible for the individuality in
genetic male face gradually transforms into the male appearance (Fig. 1).
configuration through multiple exposures to testos-
terone. Dramatic contours of the face accented by
TREATMENT GUIDELINES FOR MALE
strong noses, significant malar-midface configura-
tions, and sharp, well-defined jaw lines have become PATIENTS
hallmarks of contemporary male patterns. The knowledge of differences in facial fea-
tures enables a more natural result and less risk
to feminize the male’s face. Women have more
ASSESSING THE MALE FACE prominent upper facial characteristics, with a
The 3 major landmarks of volume and mass gradual taper in facial silhouette from upper to
that dominate male facial topography include the lower. Men, however, have squarer faces and more

From the Clínica Médica Dr. Maurício de Maio Ltda. Disclosure: Dr. de Maio is a consultant and a
Received for publication April 5, 2015; accepted July 10, speaker for Allergan. He has no financial interest in
2015. any of the products, devices, or drugs mentioned in
Copyright © 2015 by the American Society of Plastic Surgeons this article.
DOI: 10.1097/PRS.0000000000001729

40S www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 5S • Ethnic/Gender Considerations in Male Patients

Fig. 2. Comparison of female and male features at 30s. Males

Fig. 1. First step of male facial assessment: nose, cheekbones, present a stronger jawline with square face. Note the domi-
chin, and jawline. The models are 30 years of difference. Note the nance of the upper third of the face in the female with arched
presence of sagginess at the level of cheeks and jawline. Second brows and rounder eyes. Hairy brows with smaller eyes are typi-
step: supraorbital ridges, temporal contours, premaxilla, and cal male features. The presence of forehead lines compensates
infraorbital area. Volume loss and deflation is noticeable. Third the low position of male brows. Male cheeks are flatter in the
step: the presence of eye-bags, prominent nasolabial folds, and anteromedial aspect. Also notice that the zygomatic arch is pro-
downturn of corners of the mouth and thin lips. nounced and stronger in men. Female cheeks are higher, fuller,
and more projected in all dimensions.
angled with larger jaws and equally balanced
upper and lower facial proportions (Fig. 2).1

THE UPPER FACE

AND PERIORBITAL AREA
Male eyebrows are usually flatter in contour and
sit along the orbital rim compared with the female
brow. The male eyebrow should have a flat radius of
curvature. The lateral brow is more prominent and
fuller, and the redundant upper eyelid gives a mas-
culine look.2 Brow ptosis is a common feature seen
in male patients not only during the aging process.
Interestingly, mild brow ptosis in male patient gives
an impression of leadership and power. In severe
cases, it is seen primarily as a sign of anger.3
The ideal female face exhibits a smooth fore-
head with arched eyebrows, whereas the ideal
male face has a muscular forehead with an over-
hanging horizontal brow. Horizontal forehead Fig. 3. The assessment of the models in a tilting-down position
lines usually appear earlier in male patients than clarifies the differences in the cheek. Female cheeks are fuller,
in female patients. Men tend to compensate the higher, and more projected in all positions. Also notice the
low brow position and upper eyelid skin excess recruitment of frontalis muscle and the horizontal lines in the
with frontalis contraction (Fig. 3). forehead to compensate the low position of the brows.

41S
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 Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 4. Male patient timeline with comparison of age decades. Note that the anteromedial compartment is totally empty in youth.
Volume replacement at this level may bring fullness but results in aged appearance that is evident after the fifth decade. Loss of
definition of the jawline and submental skin and/or fat excess is also noticeable in aging process.

The prominent supraorbital ridges, the fron- The nose is usually slightly longer and/or wider
tal bossing, result in deep-set appearing eyes in in male patients. There is a preference of a 95- to
men. The tear trough may be relatively deeper 100-degree nasolabial angle in women and approxi-
due to muscular projection at the subciliary mately 90–95 degrees in men. Volume loss within
region. Hypertrophy of the orbicularis oculi pars the mid third produces pronounced cheek hollow-
palpebralis is a common finding in male patients ing with sagging jowls. Drop of the tip of the nose
(Fig. 2). This feature is usually treated in women. also occurs. Male cheeks are always less projected
The treatment of tear-trough deformities is also and less full in the anteromedial aspect. With aging
much less frequent in men and may occur later in process, the cheek rotates from lateral to medial and
life than in women. from up to down (Fig. 4). Cheek reshape with volu-
The treatment of the upper face in male mizers in men should reinforce the lateral support.
patients with neurotoxins should preserve a lower Volume replacement in the anterior compartment
position of the brows and a flatter arch. Excessive may lead to fullness but results in aged appearance
lifting of the eyebrows and full correction of fore- of the cheek and should be avoided.
head lines are not desirable. The male forehead The use of dermal fillers is fully accepted
skin cannot be as reflective as in females after the into the nasolabial fold in male patients. How-
treatment. Male eyes are narrower or less wide ever, the use of volumizers in the cheek is still a
open and eyelids slightly closed. This is another taboo. Both patients and injectors believe that
reason to avoid excessive blocking of orbicularis cheek injections will lead to a feminine look. This
oculi when treating the periorbital lines. The use is completely nonsense if proper technique is
of neurotoxins in the upper face is getting more applied. The injection sites in male patients along
and more accepted by men. However, the use of the zygomatic arch are usually lower and with less
dermal fillers and volumizers is still rare. volume. Over projection, excessive fullness, and
height should be avoided. Male patients with sag-
giness and hollowness related or not related to
THE MIDFACE
acquired lipodystrophies are candidates for cheek
The maxilla, muscles of mastication, and correction with volumizers. In women, cheek aug-
mandible in a man are sturdier than those in a mentation is a procedure to enhance attractive-
woman of similar age. Very projected, round, and ness, as well as combating aging process. For men,
full cheekbones are considered a feminine sign. it is ultimately used for corrective reasons.
It is a misunderstanding that men have more
projected anteromedial cheeks and women have
more lateral cheeks. Shortly, female cheeks are THE LOWER FACE
fuller, higher, and more projected in all dimen- A male face is usually squarer, and the jaws are
sions (Fig. 3). stronger. Mandible projection is more acceptable in

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 Volume 136, Number 5S • Ethnic/Gender Considerations in Male Patients

Volume loss and sagginess is greatest in the

lower one third of the face at all tissue levels from
intrinsic aging. This is most apparent in the peri-
oral area, resulting in thin, atrophic lips; mario-
nette lines; and nasolabial folds and grooves. Loss
of definition of jawline and submental fat increases
dramatically after the fifth decade (Fig. 4).
Even female patients still fear lip augmentation
with fillers due to so many unnatural results. Lack
of understanding of the lip subunits and poor tech-
nique are the main reasons. Lip reshape in male
patients is really a taboo, and it is very much rejected.
It requires expertise both in communication and in
technical skills to convince male patients to undergo
lip treatments. If properly delivered, it is very much
rewarding for both patients and injectors.
Fig. 5. Assessment of female and male profile. In men, the Mauricio de Maio, MD, ScM, PhD
forehead indentation is very common due to projection of the Clínica Médica Dr. Maurício de Maio
supraorbital ridge. Nasal hump is also common in men, and Avenida Ibirapuera
No. 2907, CJ 1202
the nasolabial angle should not be as open as in women. The São Paulo, SP 04029-200, Brazil
anteromedial cheek is flatter in men and fuller in women. The mauriciodemaio@uol.com.br
chin is more projected and stronger in men.

patient consent
men than in women. Female attractiveness lies in Patients provided written consent for the use of their
the cheekbones, and for men, it lies in the chin. The images.
use of volumizers in the chin is very much appreci-
ated by male patients, especially when it is recessed.
In women, the chin lies slightly posterior to the REFERENCES
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The Male Patient in Aesthetic Medicine. Berlin Heidelberg:
jected (Fig. 5). Men have larger mouths with slight Springer-Verlag; 2009:1–18.
thinner lips, especially the upper lip.4 Some male 2. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows.
patients have a tension lip, which is characterized Plast Reconstr Surg. 1997;99:1808–1816.
by fullness at the columellar-labial angle and a thin 3. Coleman KR, Carruthers J. Combination therapy with
lip and a vermillion surface that appears retracted. BOTOX and fillers: the new rejuvnation paradigm. Dermatol
Ther. 2006;19:177–188.
There is always a tendency of the lips to become 4. Chatham DR. Special considerations for the male patient:
thinner during aging. Male patients who already things I wish I knew when I started practice. Facial Plast Surg.
have genetically thin lips will evolve worse (Fig. 4). 2005;21:232–239.

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