Facial Soft Tissue Augmentation in Males: An Anatomical

and Practical Approach

Anthony M. Rossi, MD,*† Rebecca Fitzgerald, MD,‡ and Shannon Humphrey, MDx

BACKGROUND Soft tissue augmentation is increasingly being performed to treat male facial aging.

OBJECTIVE To review anatomical consideration specific for the male face and define an approach to male
soft tissue augmentation that creates harmonious and natural results.

CONCLUSION Addressing aesthetic concerns in the upper face, midface, and lower face should be per-
formed in concert with a combinatorial and pan facial approach. Correct filler placement at different areas of
concern is important to achieve desired and natural results. Dermal and subcutaneous fillers can be used
successfully in the male patient to enhance facial features, correct volume loss, and improve features of aging.

A. M. Rossi cites the NIH/NCI Cancer Center Support Grant P30 CA008748. A. M. Rossi is a consultant for
Allergan; R. Fitzgerald serves as speaker, trainer advisory board member for Allergan, Galderma, and Merz;
S. Humphrey serves as speaker and/or consultant for Allergan, Galderma, and Merz.

in 2015.1 The use of soft-tissue fillers—the fifth most

S oft tissue augmentation in men represents
a balance between anatomy and aesthetic goals. A
hormonal cascade that culminates in puberty forms
common nonsurgical cosmetic treatment—increased by
6% from the previous year. However, motivations,
the characteristic and prominent features that expectations, procedures, and recovery may differ for
differentiate the male face from its female counterpart. men compared to women. Jadego and colleagues1 polled
This sexual dimorphism is evident in nasal shape, chin aesthetically oriented but treatment-naive men and
projection and width, mandibular angle, and the found that the facial areas of most concern included the
zygomatic–maxilla ratio. Additionally, the supraor- tear troughs, crow’s feet, forehead lines, and submental
bital ridge, forehead slope, and temporal sulcus all fat, with tear troughs and crow’s feet most likely to be
contribute to differences in the male face, although treated first. The authors concluded that males were
individual and ethnic variations do exist and should be most motivated to consider cosmetic injectable proce-
considered during aesthetic assessment. dures to look “good for their age” and “youthful.”

Dermal and subcutaneous fillers can be used success- A thorough preprocedural consultation is necessary.
fully in the male patient to enhance facial features, Frank discussion between the patient and treating
correct volume loss, and improve features of aging. physician is paramount to discuss individual realistic
The number of male patients seeking cosmetic treat- goals and expectations, recovery time, maintenance,
ment continues to rise. According to the American and to address any preconceived notions or mis-
Society for Plastic Surgery, nose reshaping, eyelid conceptions about the cosmetic use of fillers in the
surgery, male breast reduction, liposuction, and face- male face, such as distortion or feminization of fea-
lift constituted the most requested surgical procedures tures. Moreover, the consultation provides an ideal

*Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York; †Department of Dermatology,
Weill Cornell Medicine, New York, New York; ‡Department of Dermatology, UCLA Medical Center, Los Angles,
California; xDepartment of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia,
Canada

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· ·
ISSN: 1076-0512 Dermatol Surg 2017;0:1–9 DOI: 10.1097/DSS.0000000000001315

© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 FACIAL SOFT TISSUE AUGMENTATION IN MALES

opportunity to raise important issues relating to

TABLE 1. Masculine Facial Features
overall skin care, such as sun protection and skin
cancer awareness; with poor sun-protective behavior, Upper face features
young men account for 40% of melanoma cases2 and Larger forehead area with backward slope greater
than that of females
are more susceptible to extrinsic photoaging that Prominent supraorbital ridge with eyebrows that sit
contributes to rhytid formation, loss of elasticity, and flat and straight
pigmentary alterations. Midface features
Wider glabellar area
Wider nasal bridge along with a higher nasal radix
Facial Anatomy in Relation to Soft
Straight sloped nasal dorsum
Tissue Augmentation
Even ratio of medial to lateral cheek projection
Thorough knowledge of facial anatomy—bony land- Lower face features
Wider mandible and chin with more forward
marks, retaining ligament insertions, vascular and projection
nerve bundles, and anatomical variations—is essential Sharper and defined mandibular angle
when using soft-tissue fillers in men and women alike.
However, sexual dimorphism in areas requiring aug-
mentation is an important consideration that directs
leading into a wider and larger chin area that has more
the creation of a tailored treatment plan.
forward projection compared to women (Table 1).6

Male Facial Anatomy

Soft Tissue Augmentation
Facial anatomy in adult men differs considerably from
that of women. The overall thickness of male skin— Adult male skin differs from female skin in hormone
including the epidermis and dermis—is greater at all metabolism, hair pattern, sweat rate, sebum gland
anatomical locations, whereas subcutaneous fat is less size, and skin thickness. Men tend to age on a steady
prominent.3 The female skull is approximately four- but gradual timeline corresponding to a linear
fifths the size of the male skull and different in skeletal decrease in total and free testosterone.2 Moreover,
proportion and overall facial shape.4 decreased muscle mass and bone mineral density—
known consequences of decreased testosterone—may
As a whole—aside from ethnic variations—the male affect intrinsic skin aging.3 Skin thickness steadily
face is more square in shape compared to the heart- declines, in contrast to women, for whom thickness
shaped face of a woman. In the upper third of the face, remains constant until the onset of menopause or
men have greater forehead height and width, with around the fifth decade. Volume loss, not always
a prominent supraorbital ridge that slopes backward apparent to the patient, is largely responsible for aging
toward the hairline, giving men a more angled and in the male face and can be seen in the medial cheek
sharper upper face. The pronounced supraorbital and infraorbital hollow. Volume loss, combined with
ridge establishes the position of the male eyebrow, extrinsic photoaging, can cause a ptotic appearance in
which tends to sit flat and straight along the orbital rim the male face. When approaching soft tissue aug-
compared to the arched brow of a woman. mentation in men, a global approach and combina-
torial approach is endorsed. Taking into account the
The male midface is notably different than that of upper face, midface, and lower face will help to keep
a woman, for whom the ideal cheek is rounder and balance and harmony among the facial features. When
fuller, with a laterally based apex and 3 mm more choosing dermal fillers, the same guiding principles
subcutaneous tissue in the medial malar area; in men, apply to men and women; however, it is important to
the medial to lateral cheek projection is more even.5 note the variations in skin quality and cutaneous
The lower face is marked by a sharper and more thickness in men. The overall thickness of male skin,
defined mandibular angle—a singularly masculine both epidermis and dermis, is greater for males when,
attribute—that corresponds to a more defined jawline however, the subcutaneous fat is less prominent in

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 ROSSI ET AL

males. Therefore, when augmenting certain anatomi- as loss of osseous support and soft tissue may all
cal locations, the choice of a higher G9 filler may help contribute to tear trough deformity. Therefore, soft-
to lift the thicker skin in men. Moreover, due to poorer tissue correction of this area is best accomplished via
sun-protective behaviors, extrinsic photoaging may be depots along the orbital rim for support and small
more prominent in men and contribute to rhytid for- aliquots of filler deposited in the true tear trough
mation and loss of elasticity. Dermal fillers have area, followed by gentle blending of the filler into the
evolved substantially in regards to integration into lateral and inferior cheek. The use of a cannula can
tissue and longevity. With increasing understanding of also be used in this area with an access point that is
rheology of hyaluronic acid (HA), physicians are lateral and inferior to the lid–cheek junction. This
better equipped to augment and improve different will allow access to fill the infraorbital tear trough
anatomical areas. G9 is the primary determinant of and the medial and lateral cheek if needed. There are
a tissue’s projection because it signifies stiffness/ multiple fillers that can be used in this area but
hardness and resistance to compression. Another understanding the relatively thin epidermal thick-
important rheologic property, cohesivity describes the ness and potential for Tyndall effect is important.
product’s affinity between the gel molecules and leads Using a “thinner” HA or newer more integrative
to increased tissue expansion rather than projection. HA types will help prevent uneven contour irregu-
Restylane and Lyft (Galderma, Fort Worth, TX) both larities in this area. Also for areas needing support,
have high G9 and low cohesivity and therefore provide depots onto periosteum as aforementioned will
more tissue projection. Belotero Balance (Merz, ameliorate this. Fillers that are less hydrophilic may
Geneva, Switzerland) possesses a low G9 and high also be more appealing in this area as there is a lesser
cohesivity impart a greater tissue expansion. Juved ́ erm degree of postinjection swelling and water
Voluma, Ultra Plus, and Ultra (Allergan, Irvine, CA) accumulation.
have a G9 and cohesivity between the aforementioned
products and will provide an intermediate balance of Cheek
tissue projection and tissue expansion. Newer prod-
Because the infraorbital hollow naturally transitions
ucts such as Juvederm Vollure have cross-linking
to the medial and lateral cheek, it is usually best to
technology that has been approved with longer filler
approach these areas in conjunction (Figure 1). In
durations.
men, an even distribution between the medial and
lateral cheek is more appropriate (ratio of 1:1). The
Radiesse (Merz), made of calcium hydroxylapatite
cheek apex sits more medially compared to the female
(CaHa) micropsheres suspended in an aqueous gel of
face, with a wider-based malar prominence. Over-
sodium carboxymethylcellulose and water, and
correction may lead to a more feminine appearance.
Sculptra (poly-L-lactic acid, PLLA) (Galderma, Sweden)
are both biostimulatory fillers shown to stimulate
The malar eminence can be located using Hinderer
new collagen production. These may not be suitable
method or Wilkinson method.7 The Hinderer line defines
for the thinner infraorbital skin.
the anteromedial border of the cheek mound and is
composed of one line drawn from the lateral commissure
Infraorbital Hollow
toward the ipsilateral lateral iris and another line from
The lower eyelid–cheek junction can progressively the ala to the ipsilateral infratragal notch. The intersec-
shift downward in appearance as men age and may tion of these 2 lines denotes the apex of the malar emi-
be exacerbated by festoon formation or fat pad nence. Wilkinson method consists of a vertical line
herniation.4 The tear trough includes the boundaries drawn from the lateral canthus to the edge of the man-
of the medial lower eyelid, lateral to the anterior dible; the malar eminence is located about one-third
lacrimal crest and superior to the inferior orbital rim down this line.8 In addition to the location of the
and blends inferiorly with the maxilla.5 Orbital fat malar eminence, it is important to appreciate the anterior
herniation above the orbitomalar ligament, as well projection of the cheek. In men, the ogee cuve—the

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 FACIAL SOFT TISSUE AUGMENTATION IN MALES

Figure 1. A male in his 30s: infraorbital, malar, and chin atrophy before (A) and after (B) soft tissue augmentation with 4 mL
of 20 mg/mL smooth cohesive HA filler over 2 sessions. Photos courtesy of R. Fitzgerald.

S-shaped curve from the cheekbone to the mid-cheek Depending on where the volume loss has occurred, one
hollow—tends to be flatter in its lower concavity can inject laterally or medially, aiming for an even
(Figures 2 and 4). ratio. Often times, when starting the injections

Figure 2. A male in his 40s: three quarter view of patient with infraorbital filler, before (A) and after (C)—note the
enhancement and blending of the infraorbital tear trough deformity with the malar and lateral cheek without excessive
anterior projection. (C) Progression over 5 years of fillers and neurotoxins: Year 1—1 mL of 20 mg/mL particulate HA filler in
tear troughs; Year 2—2 mL of 20 mg/mL particulate HA filler in forehead and 50 units of onabotulinumtoxin A toxin to
masseters; Year 3—1 vial PLLA to bilateral zygomatic arch, 50 units of onabotulinumtoxin A toxin to masseter; Year 4—1 mL
of 20 mg/mL smooth cohesive HA filler to tear troughs and chin; Year 5—2 mL of 24 mg/mL cohesive HA filler in temples;
Year 6—50 units of onabotulinumtoxin A toxin to masseter. Photos courtesy of S. Humphrey.

4 DERMATOLOGIC SURGERY

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 ROSSI ET AL

laterally, the lift that is provided allows for less prod- Wysong and colleagues10 noted that the temple is the
uct needed medially. Periosteal depots of fillers in the location of the second greatest loss of subcutaneous
lateral cheek can provide correction without excessive tissue (23%) in the aging male face. Filler can be used
volume of product. In areas lacking in bony support, to correct this concavity that leads to a sunken in
a cross-hatching technique can be used. A cannula may appearance of the upper face. In this area, the
be used in the medial cheek to avoid accidental superficial temporal artery runs along the superficial
injection of vasculature. Asking the patient to animate temporal fascia, whereas the temporal nerve is
will help identify any uneven contours. Both found just deep to the superficial fascia. Before
CaHA and thicker HA concentration fillers can be commencing injection, anatomical landmarks can
used to augment the malar and zygomatic areas. be marked. It is important to palpate and mark the
For severe volume loss, choosing a series of PLLA superficial temporal artery to avoid it. The temporal
(Sculptra, Galderma, Sweden) injections over fusion line can be marked and will create the
multiple months can help restore volume to this superior-medial boundary. Identifying the zygo-
area. matic arch and drawing a line about 1.5 cm above
this will create the inferior boundary and help to
Temple—Brow Area avoid the middle temporal vein. The injections will
be inferior and lateral to the temporal fusion line.
The upper face can readily show signs of aging; both
This should identify the area of concavity that can be
intrinsic volume loss in the temples and descent of the
augmented with filler deposited directly onto the
brow, as well as extrinsic photoaging and rhytid
periosteum using a needle or cannula. The injection
formation.
should be done in a slow manner without much
force. Higher G9 HA fillers like Lyft (Galderma
The male eyebrow sits horizontally and straighter than
Inc., Lausanne, Switzerland), Juvéderm Voluma,
in women and it also sits lower on the orbital rim. With
Radiesse, or Sculptra (PLLA) (multiple sessions)
aging further brow ptosis and eyelid ptosis can give
can be used in a depot method onto the periosteum
a tired, aged appearance. A brow that hangs too low
(Figure 6).
can also give an aggressive appearance and interfere
with function.
Nasal Augmentation—Anatomical and
Approach Considerations
Eyebrow placement can be modulated with the use of
neurotoxins to the depressor muscles of the brow, such Surgical rhinoplasty remains a popular procedure in
as corrugators, procerus, depressor supercilli, and men. Soft tissue augmentation of the nose is
lateral fibers of the orbicularis oculi. This neuro- becoming more commonly performed for correction
modulation allows the unopposed frontalis to lift the of contour irregularities due to dorsal nasal humps
brow. or for augmentation of the radix in certain
ethnicities. Understanding the vascular anatomy
Filler can also be used to support the lateral brow and tissue planes is crucial for correct filler place-
that has become ptotic and correct volume loss in the ment and avoiding complications, such as vascular
temporal area. The temple width should ideally line occlusion. The off-label injection of filler into the
up with the lateral zygoma, which can also fall in line nose usually requires very small amounts as larger
with the projection of the mandible. This recreates boluses of soft tissue filler can also lead to pressure-
the “squared” facial appearance that has been con- induced necrosis. The radix height, slope of the nose,
sidered an ideal masculine feature. The Carruthers and the nasofrontal angle should be assessed before
have described their injection of a diluted HA gel augmentation, as these areas can be augmented. The
filler into the subgaleal space of the lateral brow nasofrontal angle is defined by the radix of the nose,
and glabellar area to augment these areas9 with a more masculine radix starting more superior
(Figure 5). around the superior tarsal fold and blending into the

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 FACIAL SOFT TISSUE AUGMENTATION IN MALES

glabellar region. Injecting this area will give more precisely where it is desired. A cannula may also
anterior projection of the radix; a filler with the be used along the supraperosteal plane for filler
appropriate G9 will resist deformity. CaHA or placement along the dorsum; however, there is some
higher G9 HA products have been used in this area. thought that this could cause a potential plane or
Although both the aforementioned products are “dead space” for filler to spread. A staged approach
used, the choice of a HA filler may be preferred for its to nasal augmentation can sometimes be helpful and
reversibility in the case of an occlusive event or prevent overcorrection. Injection at the base of the
contour irregularities. For first-time patients, a HA columella and nasal tip can performed to add nasal
filler may also be preferred as it is reversible if out- tip lift. A bolus of filler can be deposited in the ret-
comes are not desirable. rocolumellar plane on the nasal spine (pre-septa)
and at the nasal tip between the alar cartilages,
The dorsum slope is another important measurement both at 90° angles and retrograde injection
in nasal augmentation. A more masculine appearance (Figure 3).
corresponds to a slope that approaches a straight line
drawn from the radix to nasal tip, whereas in females it The use of soft tissue fillers in nose has been compli-
will be slightly under sloping. The dorsal injection can cated by vascular occlusion resulting in necrosis and
also be used to camouflage any dorsal nasal bone even blindness from retrograde flow of filler into the
protrusion (hump) by augmenting superiorly and ophthalmic artery. The dorsal nasal artery and lateral
inferiorly to it. For wider-based noses, the addition of nasal arteries are important vascular considerations
filler to the dorsum creates a narrowing visual effect as and injection onto the periosteal or perichondiral
well. planes is necessary to help avoid these.11 Apart from
intravascular occlusion, necrosis can also occur due to
One injection technique used is to stay in the midline excessive volume leading to pressure necrosis. Since
and to inject onto the supraperiosteal and supra- these are potential complications, the choice of an HA
cartilaginous plane using a 30-gauge needle. Slow filler is also warranted because of the ability to dissolve
injections and small volumes (approximately 0.1 mL the filler with hyaluronidase. In addition, overfilling
depots or less) are preferred. This places the product the radix may give an unnatural convexity. A depot

Figure 3. A male in his 30s: global facial soft tissue augmentation including infraorbital hollows, cheek, nose, chin, and lip
augmentation, before (A) and after (B). One milliliter of 20 mg/mL particulate HA filler to tear trough; 0.5 mL of 20 mg/mL
particulate HA filler to upper and lower lip; 2 mL of 24 mg/mL of cohesive HA filler to malar and zygomatic cheeks; 1.5 mL of
CaHa to chin and mandible area. Photos courtesy of A. M. Rossi.

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 ROSSI ET AL

Figure 4. A male in his 50s: global facial soft tissue augmentation and neurotoxin; before (A) and 14 days after (B) treat-
ment: 8 mL of 20 mg/mL smooth cohesive HA filler to midface and lower face; 0.5 mL of 15 mg/mL smooth cohesive HA
filler to glabella: 110 units of onabotulinumtoxin A to upper facial lines (glabella, forehead, and lateral canthal lines). Photos
courtesy of S. Humphrey.

injection can be placed in this area using small aliquots stop and withdraw the needle to ensure proper
at a time. Aspiration before injection can be helpful to placement.
prevent inadvertent injection into a vessel; if there is
any resistance felt to injection, the physician should Lower Face: Mandible, Chin, and Lip

The lower face can often be an area of concern for

men. An angled jawline and chin can create defini-
tion of the lower face and are features of traditional
masculinity. Although lip augmentation may not
always be considered for the male patient, it is
important to keep all these features in proportion. A
proportionate chin will balance the wider mandible
area appreciated in men. Achieving proper balance
in the proportions of the upper lip, lower lip, and
chin is the goal in reconstructing and augmenting the
lower face. To help establish proportionality, ana-
lyzing the Riedel plane is helpful.12 This is a straight
line from the anterior projection of the chin that will
tangentially touch the anterior points of the upper
and lower lip. With this as a reference, filler can be
added to the corresponding structures to approach
this plane (Figures 3 and 6).

When approaching the lower face to define the angle

of the jaw, mandible, and chin complex, the use of
appropriate fillers is important. To recreate
a squared lower face that is a classically appreciated
Figure 5. A male in his 50s treated with 1 mL of 20 mg/mL masculine feature, it is appropriate to use the ante-
particulate HA filler under brow (noneuromodulater)
before and 1 year after. Notice the natural appearance with
rior chin projection and angle of the mandible
movement. Photos courtesy of R. Fitzgerald. (gonial angle, where the body meets the ramus) as

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 FACIAL SOFT TISSUE AUGMENTATION IN MALES

Figure 6. A male in his 30s with soft tissue augmentation to the temples, brow, zygoma/malar areas, and chin over multiple
sessions. Two milliliter of 20 mg/mL smooth cohesive HA filler to zygoma and malar regions and temples in first session
and then 3 mL of CaHa to the temples/brows bilaterally, zygoma bilaterally, and chin in the next session. Before and after.
Photos courtesy of A. M. Rossi.

“anchoring points.” The chin’s anterior projection in skeletal anatomy, skin thickness, muscula-
should be in proportion to the lip projection and ture, and fat distribution—plays a key role in
nasal tip projection (Ridel plane), whereas the lat- a successful treatment plan that produces natural but
eral projection of the jaw should be in proportion to appreciable results. As the number of male patients
lateral zygoma projection (recreating a more continues to grow, it is important to recognize the
squared face in men). To augment both of these differences between men and women with respect to
anchoring points, using a robust higher G9 filler with anatomy, cosmetic goals, and likely outcomes. An
periosteal depots (needle works well) will help pro- open dialogue will help highlight the role of soft-tissue
ject both of these points in the desired direction fillers in the face and assuage concerns before the
(Thicker HA, CaHA). Volumes of around 1 mL or procedure.
more may be needed and can be done in stages for
full correction. After these 2 points are augmented, References
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© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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4. van den Bosch WA, Leenders I, Mulder P. Topographic anatomy of the 10. Wysong A, Kim D, Joseph T, MacFarlane DF, et al. Quantifying soft
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8. Wilkinson TS. Complications in aesthetic malar augmentation. Plast Address correspondence and reprint requests to: Anthony
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M. Rossi, MD, Dermatology Service, Memorial Sloan
9. Carruthers J, Carruthers A. Three-dimensional forehead reflation. Kettering Cancer Center, 16 East 60th Street, 4th Floor,
Dermatol Surg 2015;41(Suppl 1):S321–4. New York, NY 10022, or e-mail: [email protected]

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