As prevailing attitudes about aging and appearance have shifted, more men are seeking facial rejuvenation procedures. As a result, it’s more important than ever that aesthetic surgeons understand the nuances that impact male facelift procedures, according to Timothy Marten, M.D., of the Marten Clinic of Plastic Surgery in San Francisco, Calif.
Dr. Marten, who has authored over 20 textbook chapters on facelift surgery and related topics, presented “Facelift for the male patient—is there really a difference?” during the 2017 Vegas Cosmetic Surgery and Aesthetic Dermatology meeting, in Las Vegas.
“… plastic surgeons have recognized that a diminished margin for error arguably exists in male patients, due to the fact that men have fewer options to conceal their scars or a mediocre result,” Dr. Marten says. “Plastic surgeons have also come to recognize that, in most cultures, male facial aesthetics differ from those thought desirable in females and attractive masculinity is not as closely equated with youth and beauty as is femininity. As a result, men generally seek a somewhat different outcome from facial rejuvenation surgery, and this has led to a rethinking of techniques that have evolved mainly to treat facial aging in women.”
New approaches and a rethinking of aesthetic goals now allow for an effective rejuvenation of the male face, while preserving a natural, masculine appearance, he says.
Aesthetic goals, treatment strategies differ
It’s not appropriate to arbitrarily apply concepts and techniques that evolved for treating the female face to that of a man, according to Dr. Marten.
“The male face is arguably more nuanced than that of a woman, whom we have come to accept as having a more contrived and made-up appearance. And certain aspects of male facial aging are often regarded as signs of experience, wisdom and power that many men wish not to lose,” he says.
Men are arguably more concerned about a natural appearance, free of signs that a surgical procedure has been performed, according to Dr. Marten.
“If we see a man with an overdone or unnatural appearance, or telltale signs that surgery has been performed, we are often more judgmental and disapproving,” he says. “Women, who typically wear longer hairstyles and make-up, also have more ways to hide signs that surgery has been performed than a man does. In this sense, there is perhaps less room for error, both technically and artistically, when a male facelift is performed.”
Gender differences in perceived attractiveness
Today’s culture typically correlates female attractiveness with smooth skin, a wrinkleless forehead, an arched eyebrow, a stylized eye appearance, a high cheek profile, a tight jawline and overall inverted oval facial shape, Dr. Marten says.
“Male attractiveness, on the other hand, rests more in a bottom heavy rectangular facial shape, a heavier and bolder jawline, a good neck line, a lower and more horizontal eyebrow, a flatter cheek profile and less meticulously maintained skin,” he says.
Men typically want a bold, athletic neck and jawline, with more subtle and less dramatic changes on other facial areas.
Recipe for success
The surgeon who can deliver a good result in the neck and jawline, provide well-concealed scars, and exercise restraint when operating on the forehead, eyes and mouth, is likely to be successful when treating male patients, according to Dr. Marten.
“In contrast, surgeons who over treat the orbital area, don’t provide well-concealed scars and don’t deliver a good result in the neck are likely to have unhappy male patients,” he says.
Surgeons should also consider nuances in some male patients, including a short hairstyle, receding hairline or a bald or shaved head. Many surgeons consider these hair issues a significant challenge to facelift outcomes, or issues that preclude facelift surgery, but that doesn’t have to be the case, according to Dr. Marten.
“Even sparse, short hair provides good cover for the temple and occipital scars, if incisions are properly planned — as the short hair worn by most men falls over them and conceals them,” he says. “This is the case even in the man who wears a military-style haircut. In these patients, the basic facelift incision plan need not be specifically modified.”
It’s often possible to perform endoscopic foreheadplasty in male patients, even if they have receding hairlines or bald heads. In these cases, the incisions can be made on the temple scalp and at the superior most spot that hair is present, according to Dr. Marten.
“Alternatively, a forehead lift can be performed by excising forehead skin along a transverse forehead crease or by using a supraciliary incision along the superior margin of the eyebrow,” he says. “Both these strategies result in inconspicuous scars and represent a worthwhile trade-off in most men in the facelift age group.”
Men with shaved heads also are good facelift surgery candidates, if a thoughtful surgical plan is employed.
“In treating the man with the shaved head, one can exploit the fact that a key and quintessential feature of an attractive, athletic appearing man is a good neckline,” he says.
While women’s optimal appearances are more closely tied to youth, an inverted oval facial shape, high cheek contour and a tight jawline, the male face is more tolerant of a rectangular shape, a lower cheek profile and a lax jawline.
As a result, a “short scar” neck lift, performed through a submental incision only, in conjunction with ancillary procedures, such as fat grafting, superciliary eyebrow lift, nasolabial fold excision and conservative eyelid surgery, can result in improvement that is satisfactory to many men. That’s without the need for a full facelift and peri-auricular scars, he says.
Dr. Marten recommends that in a short scar neck lift, surgeons use only a submental incision to improve neck contour by modifying the deep layer neck structures, without excising neck skin.
“These modifications include subplatysmal lipectomy, submandibular gland reduction, partial digastric myectomy and platysmaplasty,” he says.
The skin is then allowed to re-drape and redistribute itself over the deeper and geometrically longer concave surface created by the aforementioned deep layer surgical maneuvers—in effect, absorbing loose neck skin without actually removing it.
The short scar neck lift can be a good option for men into their sixties, in most cases, he says.
“If a man with a shaved head feels excess skin … needs to be removed, an extended neck lift incision plan can be used,” Dr. Marten says.
This is typically a peri-auricular facelift incision, with no temporal portion, modified by shortening or eliminating the occipital portion of the incision. The approach is often desired by men in the 60s and 70s, when the presence of a pre-auricular scar is less of an issue than with younger men, he says.
The ‘facelift-phobic man’
Many men are put off by the term facelift.
“Often it seems that they want the improvement afforded by the facelift but just can’t get past the name of the procedure,” Dr. Marten says. “In such cases, an accord can usually be struck by simply calling the procedure an ‘extended neck lift’ and modifying the facelift incision plan slightly….”
Surgeons performing the extended neck lift would typically use a peri-auricular facelift incision, without the incision’s temporal portion. The resulting scar will be in well-concealed location, instead of one that’s potentially less well concealed in the temporal area, according to Dr. Marten.
The incision plan allows for a limited low cheek SMAS flap to be elevated, which provides improvement in the lower face and along the jawline that would not otherwise not result from an isolated neck lift only. It also allows the surgeon to excise significant skin from the lower face, jawline and neck, which would not otherwise be removed if only a short scar neck lift was performed, he says.
“It should be noted that the extended neck lift encompasses certain compromises, however, including the fact that no upper cheek or mid-face improvement is obtained,” Dr. Marten says. “While this is usually an unacceptable compromise when operating on the female face, it can be a very acceptable trade-off in the male patient.”
Surgeons can combine the extended neck lift with fat grafting to offset some limitations and obtain improvement on the upper face. Conservatively performed forehead and eyelid surgery, and other previously mentioned ancillary procedures, can further enhance outcomes, according to Dr. Marten.