The requirements of men with regard to aesthetics are quite different to those of females in terms of a general goal, as well as procedure. It is often the case that men are looking for a greater sex appeal with quicker, more radical treatments, while women usually aim to please themselves and desire something more preventive and less obvious. Ageing itself is also very different between men and women. The hormone testosterone influences a number of qualities of the epidermis and dermis, including thickness, vascularity, sweat and sebaceous glands, and fat and bone resorption. The beauty care applied to and by women cannot be transferred to men. It is the role of the aesthetic practitioner to adapt this to the male patient, matching precise specifications, and providing male patients with treatments that meet their expectations.
Male demand for cosmetic treatments has been rapidly increasing over the past few years. Not only do men want to look younger and more attractive, but they are also aiming to smooth over the signs of fatigue in order to appear more capable and competitive at work, for example. They seem to have understood that, in order to boost their professional career, taking care of their image is just one more necessary factor. The rush of male patients into cosmetic surgery and aesthetic medicine has, in fact, become a global trend. Indeed, when the author began her career as a cosmetic practitioner during the 1980s, men accounted for only 5% of the patient cohort, but have now grown to represent 20%.
Changing objectives and demand
At the beginning of the author’s career, male patients could be easily divided into two sub-groups. Firstly, homosexual men, whose demand for treatments resembled that of many female patients by targeting wrinkles, skin laxity, and ill-looking skin, for example. The second group encompassed heterosexual men, whose demands were rather stereotypical, covering rosacea and brown spots, for example.
At present, men account for approximately 20% of the author’s practice, but the distribution has changed. Homosexual men account for up to 80% of this patient cohort, with the remaining 20% being heterosexual. However, differences in the demands of these groups can no longer be easily distinguished; both groups want to look well, reduce the signs of fatigue, and appear more competitive. The objective seems to have shifted from an impact on private life to a desire to improve performance in the evermore demanding socio–professional world.
A more detailed analysis of the expectations of male patients reveals that those over 50 years of age seek the same improvements as those patients whom the author treated in the early years of her career. With a desire to obtain healthy-looking skin, patients will often ask for a ‘clean’ face, with the removal of ear and nose hairs, brown spots, and blood vessels visible on the nose.
On the contrary, men in the age range of 35–50 years wish to erase all signs of fatigue, such as bags under the eyes, and a sad-looking or ill-looking face; they do not want their social life to be visible on the skin when at work, but wish to look ready and accessible.
A more surprising phenomenon is the entry of the 20–35-year age range in the author’s practice. This patient group, who, years ago, would only come for treatment on very rare occasions, seem to have developed a strong interest in aesthetic medicine, so much so that their female relatives complain that they spend as much time in front of the mirror as them.
When male patients come for a consultation, they are very well informed about the treatments they require, such as those for acne scars treated with fractional C02 laser or radiofrequency. They are not only very aware of the effects of botulinum toxin and hyaluronic acid injections on wrinkles, and the prospects offered by techniques such as LED or radiofrequency for the enhancement of skin quality, but they are also ‘on top’ of
subjects such as hair growth treatments and the range of methods for handling weight issues.
It should be noted that techniques intended for female patients cannot be used in male patients. Indeed, the two genders show a number of differences with regard to their motivations for treatment, their histologic and physiologic specificity, and their psychological characteristics for example.
Motivations for treatment
The majority of men will begin their journey toward cosmetic treatments by exercising and taking a healthy diet1. According to Fried2, their motivation comes from a combination of fear of age, and a desire for sexual intimacy, money, power and prestige, through which they can enhance their success. In practice, it should be noted that men want to erase any sign of fatigue and appear more competitive and dynamic. The aspiration to look younger or more attractive does not seem to be their first motivation; most importantly, men want to please themselves.
Whenever possible, male patients generally prefer ‘one shot’ treatments that do not require repetition: the main requirement is discretion. These gentlemen want to be presentable from the moment of leaving the clinic, and are often ready to cancel the entire process when the risk of bruising is high, for example.
With regard to pain, men are well known to be more sensitive than women, are less tolerant to discomfort, and do not have as strong a will to reach their goals. Men are also often less satisfied after a treatment compared with women.
In the author’s experience, these gentlemen are more fearful of pain, but seem to have the same pain threshold as the ‘weaker’ sex.
In men, the epidermis is 10% thicker and the stratum corneum has a less efficient barrier function (sexual/gonadal steroids have an impact on permeability)3. Furthermore, the hydrolipidic film is thicker and the pH lower (4.5 vs 5.3 for women)4. It is well known that the skin’s pH can influence the barrier function of the stratum corneum and the flora living on it5. Therefore, men have a more abundant and varied aerobic flora than women, hence the importance of beard and acne folliculitis6. As
a result, men have a significantly greater potential for skin infection6.
The average thickness of the dermis in a man is 2.3 mm, compared with 1.8 mm in women. A strong collagen density as a result of the impregnation of testosterone induces this difference. With age, the dermo–epidermic junction flattens3.
The sebaceous glands are bigger and more numerous in men. The sudoriparous glands secrete more sweat, which is also more acidic as well as more odorous. When exercising, men sweat earlier and more abundantly compared with women7, 8.
The vascularity of the face is sufficiently more developed among men, and can be linked to the significant levels of hairiness among this gender. Many studies have shown that the higher vascular flow in men is caused by the greater number of microvessels, resulting in a greater risk of rhinophyma9.
The arch of the eyebrow, the zygomatic arch and the chin area of the jaw are more prominent in men than in women.
The frontalis, occipitofrontalis muscle and the masseters weigh more and have a higher tensing power compared with that in women. The consequences can be seen in treatments such as botulinum toxin, for which the doses used must be double that for women.
Correct facial proportions
According to Mommaerts10, the ideal proportions for the face should see the height of the lower third of the face at approximately 48% of the overall height, and the cheeks to be rather long. The upper lip and the philtrum are generally larger in men11.
The cutaneous receptors to androgens are closely linked to eccrine and apocrine secretions. A decrease in testosterone levels with age will induce less seborrhoea, a poorer hydrolipidic film and therefore, poorer protection against stresses affecting the skin. However, it should not be forgotten that excessive weight causes a significant quantity of oestrogen and a feminisation of the skin through the aromatisation of testosterone12.
On average, the testosterone level drops by 1–2% every year after the age of 40 years13, but the usual values are in such a wide range that some authors even claim that 80% of men still have a normal testosterone level at the age of 60 years14. This has led many to believe that in a few years, an early testosterone test (e.g. at 35 years of age) could be developed in order to determine each individual’s physiological levels and supplement when necessary.
The instructions on the substitutive treatment of male menopause (i.e. andropause) will be evaluated not only against a biological check-up, but also with regard to symptoms based on the ADAM (Androgen Deficiency in Ageing Males) test and a clinical examination (Table 1).
- The positive effects of androgen supplementation are15–17:
- An increase in muscle mass by 1–3 kg
- A decrease in fat by up to 2%
- Enhanced bone mineralisation
- A decrease in total cholesterol
- Improved cognitive function and mood.
It is now well known that low levels of testosterone are linked to a higher risk of prostate cancer and that, conversely, high levels of testosterone reduce this risk. This is the reason why knowledge of men’s levels of testosterone — before they become mature and as carried out with the thyroid — and supplementing when needed could be beneficial. The link between testosterone substitution treatments and the risk of prostate cancer are not currently known, however18.
DHEA (dehydroepiandrosterone) is a prohormone that also has an androgenic action. It metabolises into hormones such a testosterone, estradiol and cortisol and, depending on the individual’s enzymatic heritage, one of them will be prevailing. At present, we are unable to determine what transformation will take place; therefore a biological inventory of the different hormones at T0 and 6 weeks after DHEA supplementation should be carried out. This supplementation will be continued only if a rise in the testosterone levels has been noted (as detected by blood test DHEA-S).
It should not be forgotten that testosterone is more likely to be converted into estradiol when the male individual is overweight as this aromatisation takes place in body fat. It is also important to note the DHEA : cortisol ratio that influences our capacity of resistance to psychological stresses. This capacity is reduced with age and as a result, the stresses of life have a greater impact. DHEA itself also diminishes with age, while our cortisol levels increase; this ratio is therefore reduced by a factor of 10 between the ages of 20 and 50 years.
Supplementation through DHEA allows a prevention of this weaker stress resistance induced by the years.
The most common cosmetic treatments for men
In the US, figures with regard to treatments on men for 2011 can be found in Table 2. With regard to common cosmetic procedures for men in France, the author offers her own opinions as solid statistics are unavailable in the literature:
- Laser hair removal. Among young men (i.e. under 45 years of age), demand seems to focus on the shape of the beard, or ‘tidying’ of the shoulders and back. Mature men are more concerned about tidying the inside of the ears and nose
- Periorbital circles. A significant demand concerns the reduction of signs of fatigue. Fillers containing hyaluronic acid to the tear trough or carboxytherapy on purple or dark circles of the eyes are very popular
- Lifting Bone Structure. Dermal filler volumisers are more suited to men than simple fillers (for the tear trough and cheek bones). Men usually desire a restructuring treatments than simply filling wrinkles
- Botulinum toxin. This treatment methodology corresponds well with the desires of male patients when seeking aesthetic treatments — one-shot and without frequent maintenance — and corrects unpleasant facial expressions, such as signs of anxiety or dissatisfaction. Wrinkles are not usually the first concern of male patients
- Rosacea. This condition has a negative impact on public image as it is often associated with alcoholism. Men cannot stand to leave even a few vascular signs on the face, but want perfectly clear skin.
The characteristics of treatment methodologies for men
The eyebrow shape in men is usually more rectilinear and lower on the arch of the brow line. Therefore, relaxation of the forehead muscle should not result in an excessive lowering of the eyebrow or a change in its shape. Physicians should also remain vigilant of a feminisation of the facial shape19. In fact, Carruthers and Carruthers even suggested that ‘real men’ have brow ptosis, with the corrugator supercilii inserted more laterally11, 21. Flynn20 recommends treating male patients over two sessions, with the first session treating the upper part of frontalis and the lower part treated in the second session, 14 days later.
A double dose to the forehead is required as men’s muscular power is much greater compared with women. Carruthers and Carruthers recommend treating the glabella with 80 UI Vistabel (Allergan) compared with 40 UI21. Blitzer22 recommends that men need between 25% and 100% of supplementary doses for all muscles in cosmetic procedures. The author of the current article, however, believes that this is correct for the upper face but not for the lower face. Early alopecia may also compel the physician to treat the upper part of the frontalis.
In the lower face, the depressor anguli oris is not as necessary to treat as the mouth has less tendency to fall (doses will be a maximum of 5 UI). The platysma is usually treated from the age of 65 years in men, while treatment to this area begins at approximately 55 years for women (a dose of 5–8 UI administered to each side of platysma).
The reduction of axillary hyperhidrosis — through treatment with botulinum toxin — is also of significant demand as men will often sweat more than women, and which will generally be more acidic and therefore more odorous. The sweating response to heat appears to be lower in women than in men, and females demonstrate a higher threshold to the onset of exercise-related sweating
Men now desire increasingly clean and healthy-looking skin, with a fresh complexion. For this purpose, the younger generation are willing to accept recurring sessions of treatments such as LED, radiofrequency or chemical peels, which are still often rejected by older patients.
The younger generation are also more likely to request cleaner-shaven skin than the more mature generation, targeting areas such as the shoulders, back, and nape of
the neck, as well as the hands and the abdomen. Following the trend for stubble, men want their beard outline to be redrawn by erasing hairs on the cheekbones and the neck. Of course, the older generation will focus hair removal on the nose and ears.
At a time when life expectancy is constantly increasing, both genders will only benefit from a good appearance. However, women are not only more accustomed to the embellishing technique, but are also the main target for cosmetic treatments. This is perhaps the reason why, in just a few decades, women have learnt how to grow old gracefully. A woman over 50 years of age can still be very attractive, and when she reaches older age, she is often more lively and dynamic than her male counterpart.
It is now men’s turn to reach this stage. The author hopes that cosmetic and anti-ageing medicine will help them to enhance their vitality, following the example of their spouses. While the beauty care applied to and by women cannot be transferred to men, it is the role of the physician to adapt this, to match male specifications and supply men with treatments that meet their expectations.