Cosmetic surgery in men - Trends in Urology & Men's Health
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● Surgery
Cosmetic surgery in men
Nakul Kain, Plastic Reconstructive and Aesthetic Surgeon;1 Olivier Amar, Plastic Reconstructive and Aesthetic Surgeon1
1. Cadogan Clinic, 120 Sloan Street, London
Social pressure to look good
is part of the reason almost
1 in 10 cosmetic surgery
procedures in the UK are
performed in men. However,
they are not without risk. Here
the authors consider what is
on offer to men as well as the
dangers to be aware of.
C osmetic surgery in men accounts
for over 8% of all cosmetic
surgeries performed in the UK and the
USA, which has remained consistent
Botulinum toxin type A (Botox) is the most widely used cosmetic treatment in
over the last 10 years.1,2 Current trends the world. Current trends in societal pressures mean that more men than ever
in society and social media place a are seeking medical advice on cosmetic procedures, such as Botox
high emphasis on men looking young,
fit and well-proportioned and, as with quicker recovery and the scarless names. Cosmetically, botulinum toxin
cosmetic surgery for women, the approaches they permit.3 type A is used to target different facial/
array of cosmetic surgery available to In men, physiological and neck muscles for the removal of
men is broad. This rise of cosmetic anatomical differences mean that the wrinkles by temporarily paralysing
surgery in men means that clinicians, ageing face can manifest differently muscles. Common targets can include
especially GPs, are seeing more male compared with females.4 In men, the horizontal lines on the forehead, the
patients in regard to cosmetic surgery. changes in skin and subcutaneous vertical frown furrows that give the
The aim of this article is to provide an tissue occur gradually over time, ‘angry’ look, and the ‘crow’s feet’ (seen
overview of the current trends, what whereas in females the menopause as lateral surfaces of the eyes when
procedures involve, and the pitfalls and can drive a more sudden propensity squinting). The effects of botulinum
red flags to be aware of. for ageing effects.5,6 Often, men also toxin type A can be visibly seen within
tend to focus on specific areas, such 1–2 weeks and can be topped up if
Cosmetic surgery as their nose, rather than overall requested by the patient.
Cosmetic procedures can be ageing appearance.7 Men have a greater facial muscle
considered non-surgical or surgical. mass and facial vasculature than
According to the American Society of Non-surgical procedures women. This means they require larger
Plastic Surgeons (ASPS), the top five Botulinum toxin type A doses of toxin to produce similar
non-surgical procedures chosen by Botulinum toxin type A is the most effects, and they can have a greater
men include botulinum toxin A, laser widely used cosmetic treatment in the tendency to bleed/bruise, compared
hair removal, microdermabrasion, world. Derived from Clostridium with women.8 Although botulinum toxin
chemical peels and soft tissue fillers. botulinum, the neurotoxin comes in type A is a relatively safe drug, improper
These non-surgical ‘tweaks’ have three main brand names – Botox, technique can lead to facial drooping,
become increasingly popular among Dysport and Xeomin – that are used asymmetry and ptosis of the eyes.9,10
men, with an overall 72% increase predominantly off-licence for facial
compared with 2000.1 The growth of aesthetics. Laser hair removal
non-surgical procedures over surgical The products differ in their biological As the desire to have a hairless body
procedures in men is often due to the activity and are marketed under various has increased over time, the popularity
22 ❙ Trends in Urology & Men’s Health ❘ July/August 2020 trendsinmenshealth.com
Surgery ●
of laser hair removal has concurrently may be: superficial, (for example, a b
risen.11,12 Melanin is the target Jessner’s solution, hydroxy acids) to
chromophore in the hair follicle, and treat minor photoaging, superficial
the different types of lasers include hyperpigmentation, surface
Nd:YAG, intense pulsed light (IPL), irregularities; medium, (for example,
diode, long-pulsed ruby and long- 20–35% trichloroacetic acid) to
pulsed alexandrite.13 address superficial rhytides, minor
Treatment produces the greatest scarring and actinic keratoses; or deep,
visible change in dark haired, fair- (for example, 45% trichloroacetic acid,
Figure 1. Photos of the right brow/forehead
skinned individuals, as the melanin phenol) to treat deep rhytides and
before (1a) and six weeks after (1b) treatment
pigment is the target chromophore for deeper dermal scarring.15 with hyaluronic acid filler. The filler has helped
the laser and pigmentation changes Although the deeper peels to reduce scar tether. Patient consent obtained
are low risk in fair-skinned individuals. penetrate the skin more than
Treatments need to be repeated to superficial peels, the recovery period requires repeat injections as
target the anagen phase of hair growth. from erythema becomes more absorption occurs over six to nine
The ND:YAG laser is associated with significant, and the complication rate months. Common brand examples
the fewest side-effects, and is useful in also escalates – which can include include Perlane, Juvederm, Restylane
darker skin types as the risk of pigmentation changes, infections and and Belotero.
dyspigmentation is lower. scarring.16 To avoid pigmentation The popular target areas for filler
changes, patients must avoid sun treatment in men can often differ from
Dermabrasion and exposure and smoking, and they women. For example, women tend to
microdermabrasion require a pre-treatment course of have more lateral cheek than men.4
Dermabrasion is the mechanical topical tretinoin (+/- antiviral Therefore, care must be taken in men
removal of superficial layers of the skin medication) that is stopped one week to avoid injecting filler too laterally. In
using a rotatory device. prior to peel treatment. men, non-surgical rhinoplasty with
Microdermabrasion can achieve Although most men prefer more fillers is a popular alternative to
the same effect as dermabrasion but superficial peels due to the quicker surgery for those who require subtle
by using a handheld device containing recovery, their anatomy of thicker, changes in contour or who want to
particles such as aluminium oxide or more sebaceous skin with greater avoid surgery. Fillers can also be used
sodium chloride in a close-looped density of hair follicles and deeper to mask scars (see Figure 1).
negative pressure system. This wrinkle lines compared with women A prominent jawline is another
procedure stimulates fibroblast mean that deeper peels are often common filler target for men.7 Patients
proliferation and generation of new required to produce the desired effect need to be aware that hyaluronic acid
collagen, and is often requested by on their skin.16 expands over time due to absorption
individuals with rough skin, acne of water, so that swelling occurs 3–5
scarring, mottled pigmentation and Injectable fillers days after treatment. Permanent fillers
mild rhinophyma.14 The use of soft tissue fillers has can also be used and are formed from
As with any treatment that increased 101% since 2000.1 Cosmetic different synthetic compounds.
breaches the skin surface, signs of fillers are often used to address facial Although longer-lasting, adverse
active infection such as impetigo or skin volume loss and soft tissue events such as nodules, oedema and
herpes simplex virus must be augmentation. Filler properties vary granuloma formation are more
eradicated prior to any such treatments. greatly but can be classified broadly as common and necessitate a more
In most cases, repeated treatments temporary or permanent, synthetic or vigilant follow up.17
and aftercare are required, especially biological. The depth of injection within
in darker-skinned individuals due to the skin is specific to the type and the Surgical procedures
unwanted pigmentation changes. brand name of the filler. If this product Although non-surgical treatments in
information is not respected, visible men have increased in popularity,
Chemical peels lumps and/or a bluish discolouration there is a limit as to what can be
Facial rejuvenation can also be (Tyndall effect) may develop if injected achieved. Surgical treatments, though
performed with chemical peels, which too superficially. with greater risk, can produce more
act by inflicting a controlled chemical Hyaluronic acid (HA), which is a permanent results. Currently, the most
burn to a set depth in the skin, glycosaminoglycan found in the common procedures are rhinoplasty,
stimulating cellular activity and ground substance within the dermis, ear correction surgery, eyelid surgery,
collagen production. Chemical peels is by far the most popular filler but liposuction and male breast reduction.
trendsinmenshealth.com Trends in Urology & Men’s Health ❘ July/August 2020 ❙ 23
● Surgery
a b Surgery can be performed under
general or local anaesthetic. The
procedure involves incisions behind
the ear and manipulation of the
cartilage via scoring, sutures, excision
or a combination of all three. A
headband is usually required to
support the cartilage after surgery.
Figure 2. Photos of a male patient before (2a) and six weeks after (2b) an
upper eyelid blepharoplasty. In the preoperative photo there is ‘hooding’ of the As with any bilateral procedure,
upper eyelid skin that was sitting on top of the eyelashes, which was causing asymmetry can be a unintended
an unpleasant sensation for the patient. The postoperative result demonstrates consequence. Other complications
functional improvement with reduced upper eyelid skin. The early scars will include extrusion of internal sutures
mature and become inconspicuous over time. Patient consent obtained and recurrence of the prominent ear(s).
Rhinoplasty men is more difficult to achieve.18 As Blepharoplasty
Male rhinoplasty has remained one of previously mentioned, men can fixate Eyelid surgery or blepharoplasty was
the most popular cosmetic surgeries on certain elements of their nose that the third most common cosmetic
that men undergo both in the UK and may or may not be addressed by the surgery in men and women in 2018.1
the USA.1,2 In men, rhinoplasty is more surgeon, which may be a result of Men can sometimes complain of the
difficult due to objective and subjective body dysmorphic disorder (BDD). ‘tired’ look, which may be from excess
differences. Physiologically, men have Naturally, a significant proportion of skin and protruding fat pads in the
more sebaceous skin, which makes these patients with BDD present for upper eyelid, or the appearance of
reshaping the nose challenging. cosmetic surgery and may need bags under the eyes.20
Subjectively, patient satisfaction in referral for psychological assessment Upper blepharoplasty involves
– otherwise surgery may perpetuate excision of excess skin, and this may
a b their condition and patient satisfaction include removing a strip of orbicularis
is unlikely to be achieved. muscle and/or fat pad(s) (see Figure 2).
Open and closed rhinoplasty For the lower eyelid, fat pads are
techniques are available and differ by removed, with or without skin
the presence of an incision across the excision. Prior to surgery, patients
columella that allows direct must not be taking any form of
visualisation of the nasal anatomy. anticoagulation (the time required is
Surgery may differ from a simple dictated by the half-life of the
primary dorsal hump reduction to a medication) as the rare complication of
c d more complex revisional surgery that retrobulbar haematoma can result in
may require cartilage grafts (taken complete loss of vision.
from nasal septum, ear concha or rib). Also, overcorrection can result in
It is important to stress to the patient problems with eyelid closure and dry
that it can take up to one year, if not eyes, while undercorrection can lead
longer, to see the final result. to a dissatisfied patient.
Otoplasty Liposuction
Ear surgery or otoplasty in men forms Body contouring with liposuction is
Figure 3. Photos of a male patient before (3a, nearly 50% of the total number of very popular with men as it can
3c) and six weeks after (3b, 3d) two sessions of otoplasty procedures. Nearly 1 in 20 produce visible change with minimal
liposuction to the abdomen. The preoperative men and women consider their ears to scar burden. Liposuction, since its
photos with the markings demonstrate the be too prominent,19 and most of these introduction in 1974, has allowed quite
areas to be targeted, which are checked with are men seeking correction of drastic changes to body contouring
the patient. This male patient found exercise
prominent ears that have been present without the need for open surgery
difficult due to his body habitus, and two
since childhood or as a result of (see Figure 3). The process involves
sessions of liposuction were used to target
areas of fat in the flank and anterior abdominal trauma. Some feel embarrassed, infiltration of the desired target area
areas. Post-surgery, the patient felt he was able some are bullied, while others with a cannula through millimetre
to exercise more frequently and make dietary become increasingly concerned with incisions. The infiltration solution often
lifestyle changes. Patient consent obtained their appearance over time. combines saline (for hydro-dissection),
24 ❙ Trends in Urology & Men’s Health ❘ July/August 2020 trendsinmenshealth.com
Surgery ●
a c d e f
b
Figure 4. Photos of male breast reduction before (4a, 4c, 4d) and six weeks after (4b, 4d, 4f) liposuction. Preoperatively,
the markings denote the target areas, as agreed with the patient. Postoperatively, the drooping of the breast areas has
reduced (4b) and laterally there is flattening of the chest wall with a more upward facing areolar complex (4d, 4f). The
incisions are 5mm in length and are hidden in the anterior armpit creases (4d and 4f). Patient consent obtained
local anaesthetic (for intraoperative with some evidence that it results in less hormone sensitive and durable
and postoperative pain relief) and feelings of low self-esteem and social compared with the rest of the scalp.28
adrenaline (to minimise bleeding/ functioning.24 Two methods exist: follicular unit
bruising). A liposuction cannula is then However, gynaecomastia is a transplantation (FUT) and follicular unit
used to harvest the fat with suction. relatively common condition, involving extraction (FUE). In the former, a strip
Liposuction may be power benign proliferation of breast tissue in of posterior scalp is excised from
assisted, ultrasound assisted or laser men.25 Surgery may involve liposuction which 1–4 hair follicle groups are
assisted to improve efficiency, but to target the fatty and glandular separated and transplanted into pores
potential complications escalate components and/or excisional created at the intended site. This
accordingly. These can include contour methods (see Figure 4). Incisions are leaves a linear scar on the posterior
irregularities, asymmetry and bruising. usually made around the areolar but scalp, but a greater density of
However, patients may be provided may extend further if a significant transplanted hair compared with FUE.
with a compression garment to wear reduction is requested. Complications With FUE, individual punches are
that can help to reduce swelling, such as adverse scarring, asymmetry, taken from the posterior scalp that are
contour deformities and chronic contour irregularities and recurrence then transplanted to the intended
seroma formation. will need to be considered. recipient site, resulting in less scarring
Although liposuction is often but more hair transection during the
performed as a day case procedure, Hair restoration harvest process.29
significant fluid shifts from extensive Men seek treatment for hair Whichever method is used,
liposuction can lead to significant restoration far more than women.1,2 patients need to be aware of the risks
morbidity, and even death in rare Hair restoration is not only targeted for of bleeding, poor hair growth requiring
cases.21 Liposuction can also be the scalp, but can also be requested further transplantation (which is often
combined with body tightening for the beard. Scalp hair loss is often the case) and adverse scarring. Hair
procedures through the use of androgenic and can negatively impact can be washed, usually two weeks
radiofrequency; however, if there is on the self-confidence of some men. after surgery with the ‘pour’ method
skin excess then surgery is the only Sixty per cent of men with androgenic of light shampoo/warm water poured
true way of addressing this. alopecia were dissatisfied with their over the scalp without massaging.
level of hair, and 62% report being
Male breast reduction teased regarding hair loss.26,27 Regenerative surgery
Male breast reduction has received a To compensate for scalp hair loss, As the interest in cosmetic surgery
lot of attention in the media in recent some men grow their facial hair while increases, so has the desire to push
years.22,23 The presence of others change their hairstyle.26 Hair the boundaries in regenerative
gynaecomastia (sometimes referred to transplantation is possible because medicine. Platelet-rich plasma (PRP)
as ‘man boobs’) can be demoralising, hair in the posterior part of the scalp is treatment, derived from a patient’s
trendsinmenshealth.com Trends in Urology & Men’s Health ❘ July/August 2020 ❙ 25
● Surgery
own blood, can be used to enhance Gender Specific. Am J Clin Dermatol 19. British Association of Aesthetic Plastic
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