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

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

© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
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
overall skin care, such as sun protection and skin
cancer awareness; with poor sun-protective behavior,
young men account for 40% of melanoma cases2 and
are more susceptible to extrinsic photoaging that
contributes to rhytid formation, loss of elasticity, and
pigmentary alterations.
Facial Anatomy in Relation to Soft
Tissue Augmentation
Thorough knowledge of facial anatomy—bony land-
marks, retaining ligament insertions, vascular and
nerve bundles, and anatomical variations—is essential
when using soft-tissue fillers in men and women alike.
However, sexual dimorphism in areas requiring aug-
mentation is an important consideration that directs
the creation of a tailored treatment plan.
Male Facial Anatomy
Facial anatomy in adult men differs considerably from
that of women. The overall thickness of male skin—
including the epidermis and dermis—is greater at all
anatomical locations, whereas subcutaneous fat is less
prominent.3 The female skull is approximately four-
fifths the size of the male skull and different in skeletal
proportion and overall facial shape.4
As a whole—aside from ethnic variations—the male
face is more square in shape compared to the heart-
shaped face of a woman. In the upper third of the face,
men have greater forehead height and width, with
a prominent supraorbital ridge that slopes backward
toward the hairline, giving men a more angled and
sharper upper face. The pronounced supraorbital
ridge establishes the position of the male eyebrow,
which tends to sit flat and straight along the orbital rim
compared to the arched brow of a woman.
The male midface is notably different than that of
a woman, for whom the ideal cheek is rounder and
fuller, with a laterally based apex and 3 mm more
subcutaneous tissue in the medial malar area; in men,
the medial to lateral cheek projection is more even.5
The lower face is marked by a sharper and more
defined mandibular angle—a singularly masculine
attribute—that corresponds to a more defined jawline
2 DERMATOLOGIC SURGERY
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TABLE 1. Masculine Facial Features
Upper face features
Larger forehead area with backward slope greater
than that of females
Prominent supraorbital ridge with eyebrows that sit
flat and straight
Midface features
Wider glabellar area
Wider nasal bridge along with a higher nasal radix
Straight sloped nasal dorsum
Even ratio of medial to lateral cheek projection
Lower face features
Wider mandible and chin with more forward
projection
Sharper and defined mandibular angle
leading into a wider and larger chin area that has more
forward projection compared to women (Table 1).6
Soft Tissue Augmentation
Adult male skin differs from female skin in hormone
metabolism, hair pattern, sweat rate, sebum gland
size, and skin thickness. Men tend to age on a steady
but gradual timeline corresponding to a linear
decrease in total and free testosterone.2 Moreover,
decreased muscle mass and bone mineral density—
known consequences of decreased testosterone—may
affect intrinsic skin aging.3 Skin thickness steadily
declines, in contrast to women, for whom thickness
remains constant until the onset of menopause or
around the fifth decade. Volume loss, not always
apparent to the patient, is largely responsible for aging
in the male face and can be seen in the medial cheek
and infraorbital hollow. Volume loss, combined with
extrinsic photoaging, can cause a ptotic appearance in
the male face. When approaching soft tissue aug-
mentation in men, a global approach and combina-
torial approach is endorsed. Taking into account the
upper face, midface, and lower face will help to keep
balance and harmony among the facial features. When
choosing dermal fillers, the same guiding principles
apply to men and women; however, it is important to
note the variations in skin quality and cutaneous
thickness in men. The overall thickness of male skin,
both epidermis and dermis, is greater for males when,
however, the subcutaneous fat is less prominent in

males. Therefore, when augmenting certain anatomi-
cal locations, the choice of a higher G9 filler may help
to lift the thicker skin in men. Moreover, due to poorer
sun-protective behaviors, extrinsic photoaging may be
more prominent in men and contribute to rhytid for-
mation and loss of elasticity. Dermal fillers have
evolved substantially in regards to integration into
tissue and longevity. With increasing understanding of
rheology of hyaluronic acid (HA), physicians are
better equipped to augment and improve different
anatomical areas. G9 is the primary determinant of
a tissue’s projection because it signifies stiffness/
hardness and resistance to compression. Another
important rheologic property, cohesivity describes the
product’s affinity between the gel molecules and leads
to increased tissue expansion rather than projection.
Restylane and Lyft (Galderma, Fort Worth, TX) both
have high G9 and low cohesivity and therefore provide
more tissue projection. Belotero Balance (Merz,
Geneva, Switzerland) possesses a low G9 and high
cohesivity impart a greater tissue expansion. Juved ́ erm
Voluma, Ultra Plus, and Ultra (Allergan, Irvine, CA)
have a G9 and cohesivity between the aforementioned
products and will provide an intermediate balance of
tissue projection and tissue expansion. Newer prod-
ucts such as Juvederm Vollure have cross-linking
technology that has been approved with longer filler
durations.
Radiesse (Merz), made of calcium hydroxylapatite
(CaHa) micropsheres suspended in an aqueous gel of
sodium carboxymethylcellulose and water, and
Sculptra (poly-L-lactic acid, PLLA) (Galderma, Sweden)
are both biostimulatory fillers shown to stimulate
new collagen production. These may not be suitable
for the thinner infraorbital skin.
Infraorbital Hollow
The lower eyelid–cheek junction can progressively
shift downward in appearance as men age and may
be exacerbated by festoon formation or fat pad
herniation.4 The tear trough includes the boundaries
of the medial lower eyelid, lateral to the anterior
lacrimal crest and superior to the inferior orbital rim
and blends inferiorly with the maxilla.5 Orbital fat
herniation above the orbitomalar ligament, as well
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ROSSI ET AL
as loss of osseous support and soft tissue may all
contribute to tear trough deformity. Therefore, soft-
tissue correction of this area is best accomplished via
depots along the orbital rim for support and small
aliquots of filler deposited in the true tear trough
area, followed by gentle blending of the filler into the
lateral and inferior cheek. The use of a cannula can
also be used in this area with an access point that is
lateral and inferior to the lid–cheek junction. This
will allow access to fill the infraorbital tear trough
and the medial and lateral cheek if needed. There are
multiple fillers that can be used in this area but
understanding the relatively thin epidermal thick-
ness and potential for Tyndall effect is important.
Using a “thinner” HA or newer more integrative
HA types will help prevent uneven contour irregu-
larities in this area. Also for areas needing support,
depots onto periosteum as aforementioned will
ameliorate this. Fillers that are less hydrophilic may
also be more appealing in this area as there is a lesser
degree of postinjection swelling and water
accumulation.
Cheek
Because the infraorbital hollow naturally transitions
to the medial and lateral cheek, it is usually best to
approach these areas in conjunction (Figure 1). In
men, an even distribution between the medial and
lateral cheek is more appropriate (ratio of 1:1). The
cheek apex sits more medially compared to the female
face, with a wider-based malar prominence. Over-
correction may lead to a more feminine appearance.
The malar eminence can be located using Hinderer
method or Wilkinson method.7 The Hinderer line defines
the anteromedial border of the cheek mound and is
composed of one line drawn from the lateral commissure
toward the ipsilateral lateral iris and another line from
the ala to the ipsilateral infratragal notch. The intersec-
tion of these 2 lines denotes the apex of the malar emi-
nence. Wilkinson method consists of a vertical line
drawn from the lateral canthus to the edge of the man-
dible; the malar eminence is located about one-third
down this line.8 In addition to the location of the
malar eminence, it is important to appreciate the anterior
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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laterally, the lift that is provided allows for less prod-
uct needed medially. Periosteal depots of fillers in the
lateral cheek can provide correction without excessive
volume of product. In areas lacking in bony support,
a cross-hatching technique can be used. A cannula may
be used in the medial cheek to avoid accidental
injection of vasculature. Asking the patient to animate
will help identify any uneven contours. Both
CaHA and thicker HA concentration fillers can be
used to augment the malar and zygomatic areas.
For severe volume loss, choosing a series of PLLA
(Sculptra, Galderma, Sweden) injections over
multiple months can help restore volume to this
area.
Temple—Brow Area
The upper face can readily show signs of aging; both
intrinsic volume loss in the temples and descent of the
brow, as well as extrinsic photoaging and rhytid
formation.
The male eyebrow sits horizontally and straighter than
in women and it also sits lower on the orbital rim. With
aging further brow ptosis and eyelid ptosis can give
a tired, aged appearance. A brow that hangs too low
can also give an aggressive appearance and interfere
with function.
Eyebrow placement can be modulated with the use of
neurotoxins to the depressor muscles of the brow, such
as corrugators, procerus, depressor supercilli, and
lateral fibers of the orbicularis oculi. This neuro-
modulation allows the unopposed frontalis to lift the
brow.
Filler can also be used to support the lateral brow
that has become ptotic and correct volume loss in the
temporal area. The temple width should ideally line
up with the lateral zygoma, which can also fall in line
with the projection of the mandible. This recreates
the “squared” facial appearance that has been con-
sidered an ideal masculine feature. The Carruthers
have described their injection of a diluted HA gel
filler into the subgaleal space of the lateral brow
and glabellar area to augment these areas9
(Figure 5).
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ROSSI ET AL
Wysong and colleagues10 noted that the temple is the
location of the second greatest loss of subcutaneous
tissue (23%) in the aging male face. Filler can be used
to correct this concavity that leads to a sunken in
appearance of the upper face. In this area, the
superficial temporal artery runs along the superficial
temporal fascia, whereas the temporal nerve is
found just deep to the superficial fascia. Before
commencing injection, anatomical landmarks can
be marked. It is important to palpate and mark the
superficial temporal artery to avoid it. The temporal
fusion line can be marked and will create the
superior-medial boundary. Identifying the zygo-
matic arch and drawing a line about 1.5 cm above
this will create the inferior boundary and help to
avoid the middle temporal vein. The injections will
be inferior and lateral to the temporal fusion line.
This should identify the area of concavity that can be
augmented with filler deposited directly onto the
periosteum using a needle or cannula. The injection
should be done in a slow manner without much
force. Higher G9 HA fillers like Lyft (Galderma
Inc., Lausanne, Switzerland), Juvéderm Voluma,
Radiesse, or Sculptra (PLLA) (multiple sessions)
can be used in a depot method onto the periosteum
(Figure 6).
Nasal Augmentation—Anatomical and
Approach Considerations
Surgical rhinoplasty remains a popular procedure in
men. Soft tissue augmentation of the nose is
becoming more commonly performed for correction
of contour irregularities due to dorsal nasal humps
or for augmentation of the radix in certain
ethnicities. Understanding the vascular anatomy
and tissue planes is crucial for correct filler place-
ment and avoiding complications, such as vascular
occlusion. The off-label injection of filler into the
nose usually requires very small amounts as larger
boluses of soft tissue filler can also lead to pressure-
induced necrosis. The radix height, slope of the nose,
and the nasofrontal angle should be assessed before
augmentation, as these areas can be augmented. The
nasofrontal angle is defined by the radix of the nose,
with a more masculine radix starting more superior
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
anterior projection of the radix; a filler with the
appropriate G9 will resist deformity. CaHA or
higher G9 HA products have been used in this area.
Although both the aforementioned products are
used, the choice of a HA filler may be preferred for its
reversibility in the case of an occlusive event or
contour irregularities. For first-time patients, a HA
filler may also be preferred as it is reversible if out-
comes are not desirable.
The dorsum slope is another important measurement
in nasal augmentation. A more masculine appearance
corresponds to a slope that approaches a straight line
drawn from the radix to nasal tip, whereas in females it
will be slightly under sloping. The dorsal injection can
also be used to camouflage any dorsal nasal bone
protrusion (hump) by augmenting superiorly and
inferiorly to it. For wider-based noses, the addition of
filler to the dorsum creates a narrowing visual effect as
well.
One injection technique used is to stay in the midline
and to inject onto the supraperiosteal and supra-
cartilaginous plane using a 30-gauge needle. Slow
injections and small volumes (approximately 0.1 mL
depots or less) are preferred. This places the product
precisely where it is desired. A cannula may also
be used along the supraperosteal plane for filler
placement along the dorsum; however, there is some
thought that this could cause a potential plane or
“dead space” for filler to spread. A staged approach
to nasal augmentation can sometimes be helpful and
prevent overcorrection. Injection at the base of the
columella and nasal tip can performed to add nasal
tip lift. A bolus of filler can be deposited in the ret-
rocolumellar plane on the nasal spine (pre-septa)
and at the nasal tip between the alar cartilages,
both at 90° angles and retrograde injection
(Figure 3).
The use of soft tissue fillers in nose has been compli-
cated by vascular occlusion resulting in necrosis and
even blindness from retrograde flow of filler into the
ophthalmic artery. The dorsal nasal artery and lateral
nasal arteries are important vascular considerations
and injection onto the periosteal or perichondiral
planes is necessary to help avoid these.11 Apart from
intravascular occlusion, necrosis can also occur due to
excessive volume leading to pressure necrosis. Since
these are potential complications, the choice of an HA
filler is also warranted because of the ability to dissolve
the filler with hyaluronidase. In addition, overfilling
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.

6 DERMATOLOGIC SURGERY

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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

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

0:0:MONTH 2017 7

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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
should be in proportion to the lip projection and
nasal tip projection (Ridel plane), whereas the lat-
eral projection of the jaw should be in proportion to
lateral zygoma projection (recreating a more
squared face in men). To augment both of these
anchoring points, using a robust higher G9 filler with
periosteal depots (needle works well) will help pro-
ject both of these points in the desired direction
(Thicker HA, CaHA). Volumes of around 1 mL or
more may be needed and can be done in stages for
full correction. After these 2 points are augmented,
a cannula can be a practical approach to add filler to
the body of the mandible to “connect” these 2 points
and define the plane.
Conclusion
Soft tissue augmentation is an important tool for facial
enhancement in men. Sexual dimorphism—differences
in skeletal anatomy, skin thickness, muscula-
ture, and fat distribution—plays a key role in
a successful treatment plan that produces natural but
appreciable results. As the number of male patients
continues to grow, it is important to recognize the
differences between men and women with respect to
anatomy, cosmetic goals, and likely outcomes. An
open dialogue will help highlight the role of soft-tissue
fillers in the face and assuage concerns before the
procedure.
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ROSSI ET AL
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Address correspondence and reprint requests to: Anthony
M. Rossi, MD, Dermatology Service, Memorial Sloan
Kettering Cancer Center, 16 East 60th Street, 4th Floor,
New York, NY 10022, or e-mail: RossiA@mskcc.org
0:0:MONTH 2017 9