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Higher doses of botulinum toxin combined with fillers maximize male aesthetics

Article-Higher doses of botulinum toxin combined with fillers maximize male aesthetics

"The two most popular treatments in men, by far, are botulinum toxin and fillers — and I often combine both," Chad L. Prather, M.D., of Total Skin & Beauty Dermatology Center, Birmingham, Alabama, tells Cosmetic Surgery Times.

"As volume depletion is one of the major etiologies of the clinical appearance of the aging face in males, replacement of this loss, for instance with hyaluronic acid fillers, can help restore once-youthful characteristics."

Dr. Prather
According to Dr. Prather, different fillers are used to address the different nuances and aspects of the aging male face. Restylane or Juvederm Ultra achieve natural and biocompatible results when treating the nasolabial folds or for enhancing lip volume. Deeper grooves and wrinkles can best be treated with larger particle fillers such as Radiesse, Hylaform Plus, Juvederm Ultra Plus or Perlane. Patients with prominent nasolabial folds with out overlying flaccid, thin or porous skin (which may show the filler or encourage its migration) do well with Artefill, and demonstrate long-lasting and sometimes even permanent corrective results, he says. Dr. Prather likes to shape the male brow by deeply injecting hyaluronic fillers over the lateral orbital rim, especially in those patients with an overhanging medial brow, to offset any central prominence. Here, he notes that it's important to remember that a strong horizontal brow is the desired outcome in men — not a highly-arched, lateral brow as in women.

Dr. Flynn
FURROW-FREE One of the hotspots in treating the male cosmetic patient is forehead wrinkles due to men's anatomically lower brows. The trick here is to treat the brow area carefully so that you don't drop the brow any further, impeding vision. When performing facial rejuvenation procedures with botulinum toxin in the male cosmetic patient, one of the most important points aesthetic surgeons should remember is that men need higher doses of botulinum toxin in the same cosmetic areas of the face compared to female patients, such as in the glabellar region.

"I use the same technique and dilutions in men as in women," Dr. Prather explains, "with the major difference being that in men, higher volumes of botulinum toxin need to be injected into a given treatment area to achieve the desired cosmetic effect. This is due to a greater muscle mass in men." For the glabellar region, Dr. Prather typically begins with a starting dose of 40 units in men as opposed to the 20 to 30 units he starts with in women, using the 5-point glabellar injection pattern dosed at 8 units per site. "Males naturally have a lower, more horizontal brow, so you do have to be careful in treating the male forehead with Botox because the eyebrow can be dropped further than aesthetically desired," Dr. Prather cautions.

Timothy C. Flynn M.D., a dermatologist at the Cary Skin Center, Cary, North Carolina, has found it effective to take a phased approach to brow-smoothing.

46-year-old male patient shown (left) prior to injection and (right) 20 days post-injection with 30 units of Botox in the frontalis. (Editor's note: patient's eyes intentionally pixelated.). Photo credit: Timothy C. Flynn, M.D.
"In my male patients, I usually start with 40 units for the male glabella and then carefully work my way up," he says. "For crow´s feet, I usually start with 15 units in each male crow´s foot area as opposed to 12 units in women. If you're treating a man and the cosmetic outcome is not what you aimed for, the key is to increase the dose."

"I treat the upper two-thirds of the forehead first which preserves the lower function of the forehead," Dr. Flynn explains. "Then I follow up two to three weeks later, looking at the wrinkle pattern at the base and then trying very carefully to relax the wrinkles on the lower portion of the frontalis without dropping the brow."

45-year-old male patient (left) with residual frontalis activity after 20 units of Botox to the forehead. Patient has been undertreated and still has kinetic rhytids on the right side. Same patient (right) following injection of an additional 10 units of Botox to the right side. Patient is now adequately treated and pleased. Photo credit: Chad L. Prather, M.D.
LATERAL PLAY Dr. Flynn notes that in males, the peri-ocular muscles can run a bit more laterally due to the greater mass of the orbicularis muscle and therefore one may consider a bit more lateral of an injection point to achieve the best results. He concurs that it's critical to refrain from creating an unnaturally high lateral eyebrow in males, as this is a visual clue of a Botox procedure. Botox treatments done too medially in the glabella can result in this excessively arched eyebrow — unnatural to the male face. On the other hand, he adds, less aggressive treatments can sometimes give the patient a feeling of ineffective therapy, underscoring the importance of before and after treatment images. According to Dr. Flynn, the mid and lower face also respond well to Botox treatments, including the nasalis muscles, perioral wrinkles and the depressor anguli oris. The same is true for those men with an excessively animated mentalis muscle, resulting in a "peach pit" chin appearance. Dr. Flynn addresses this by injecting approximately 10 IU into the mentalis.

FILLER COMBO In addition to botulinum toxin treatments, Dr. Flynn agrees that men often require fillers in order to achieve the desired aesthetic result. However, he prefers to treat these patients with a combination therapy using injectable collagen, carefully flowing the filler into the glabellar lines.

"If we see that the male patient has lines at rest when considering botulinum toxin treatment, then we go ahead and treat them with the combination approach using collagen in addition to the Botox," Dr. Flynn notes.

Overall, cosmetic results seen in men and women with botulinum toxin and filler treatments have the same persistence and are usually repeated approximately every three to four months to maintain the aesthetic effect.

COMMON GOALS Both physicians agree that both genders are equally compliant when it comes to pre-and post-procedure instructions, and that their male patients appreciate the treatments just as much as their female patients. And while he has seen an increase in requests from male patients, Dr. Flynn says that, to date, they still represent the minority of patients in his practice. Though men are equally as demanding as female patients, these two cosmetic practitioners perceive that their demands differ. Male patients often come with the reason of job preservation, not with the aim of looking more handsome but instead to look more vital for their workplace. According to Dr. Prather, the most significant difference is power-based.

"The male patient wants to feel a sense of control in so far as having a large part in the decision of what procedure is done and how far it should be taken," he concludes.

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