Aesthetic Dermatology

Fine-tuning the male aesthetic consultation includes consideration of gender-specific wrinkle pattern



– The first time a man walks in for an aesthetic consultation, he probably doesn’t know what to expect, according to Terrence Keaney, MD, a dermatologist in private practice in Arlington, Va. And he may not even be sure what he’s looking for.

Dr. Terrence Keaney of George Washington University, founder and director of SkinDC, Arlington, Va.

Dr. Terrence Keaney

However, he probably knows what he doesn’t like about his appearance. When men are questioned, the three areas they are most concerned about is their hairline, their eyes, and their jawline, said Dr. Keaney, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

It’s important to evaluate men differently, not just for anatomic differences from women, but also for behavioral and psychological factors unique to men as aesthetic patients, he noted.

Anatomic differences are significant and fundamentally shape treatment decisions, Dr. Keaney said. Broadly speaking, “the male face is traditionally more square, with a prominent supraorbital ridge.” Rather than emphasizing breadth across the cheeks, as in rejuvenation for women, a strong, youthful male face will have a square jaw, appropriate width across the cheeks, and a strong brow line with an arch that is flatter than what women seek.

Male cosmetic goals can be complicated by the fact that men “age poorly” and tend to look older than their stated age, he continued, referring to a study that found that men appear about one-third year older than their age, and women about a half year younger. A higher rate of smoking and excess ultraviolet light exposure among men may contribute to this discrepancy, he said.

Overall, men see steady atrophy of facial soft tissue throughout adulthood, in contrast to women who see a more rapid decline that starts at menopause. This makes sense in the context of the slow drop in circulating testosterone that men see beginning at about age 30, at which time men can expect a decrease of about 1% per year, he noted.

A common opener from men, said Dr. Keaney, is “’I look tired.’ When I hear that, I’m thinking about the eyes.” Men are more likely to develop tear troughs and a sunken appearance because of their larger orbital cavities and smaller orbital fat pads, so periocular fillers are often a treatment tool to consider.

Around mens’ eyes, “it’s not just the presence, but the pattern of wrinkles that guides treatment,” he noted. At the lateral canthi, both at rest and with maximum smile, the predominant wrinkle pattern in crows’ feet is the lower fan. The cheek elevator musculature, including the zygomaticus major, are more involved in animation around the eyes with smiling, which is important because reaching for botulinum toxin alone is probably not going to give the patient his desired effect, he added.

Other differences in the male wrinkle pattern can be found on the brow. The “U” contraction pattern between the brows is more common in men than women, at least partly because men have greater involvement of the procerus muscle, Dr. Keaney said.

Taking all of this into account, caution is the watchword when using botulinum toxin for the glabellar and brow region. “Beware of eyebrow ptosis: avoid the frontalis in patients with eyebrow ptosis,” he said. Treating the corrugators can also be an unwise move, since toxin can diffuse to the inferior fibers of the frontalis muscle, he added.

For men with jawline concerns, consider a combination approach, Dr. Keaney said. The lower face and neck can be rejuvenated by a redraping solution, such as skin tightening with high frequency ultrasound or radiofrequency ablation.

Sometimes, a clean, tight sweep of jawline can be restored with dermal fillers to the lower face, along with a noninvasive fat reduction approach, said Dr. Keaney.

Knowing men’s unique anatomy and aging patterns is only half the battle, though. “How you communicate with men and evaluate them has to take into account that you might be seeing a sweaty, nervous, treatment-naive patient,” at the initial consultation, said Dr. Keaney. “Do men care? Yes, but men display a different set of motivations.”

Plan for all of this to take time. “The initial consultation tends to be longer” for male patients, who are “less savvy” about cosmetic procedures than women, he pointed out.

A clear discussion of side effects is critical when discussing treatment options with men. “If they get a side effect, you’ll never see them again – and you won’t ever hear about it,” he added.

Though overall, women have been shown to be more sensitive to pain, in cosmetic procedures, “men are less tolerant of pain.” Plan for this, set reasonable expectations but be proactive about pain control, and still expect a need for some hand-holding, said Dr. Keaney.

“Men do not like surprises,” he added. Clearly define what expected side effects may be, what they’ll look like, and what downtime the patient should expect.

For Dr. Keaney’s part, he’s found that the best way to retain men in his cosmetic practice is to “start with a home run treatment to earn trust.” Men often appreciate a slow and steady approach to addressing concerns. “Make sure to connect the treatment plan to the primary cosmetic concern.”

Dr. Keaney reported that he has relationships with multiple pharmaceutical and cosmetic companies.

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