Refining male injectables in aesthetics.

The number of men interested in nonsurgical cosmetic procedures has been increasing in recent years. Given the gender differences in cutaneous biology and anatomy, the aesthetic treatment of men requires certain nuances and modifications from the more frequently completed procedures in women. In addition, photoaging and sun protective practices can vary between gender, which may be a consequence of the stigma that surrounds skin care and its relation to traditional gender roles. We have reviewed pertinent biologic, anatomic, and behavioral aspects of men as they relate to cosmetic injectable treatments. Men may require higher doses of injectable neuromodulators due to their larger and stronger facial mimetic muscles. Injectable soft-tissue fillers should also accentuate the ideal facial shape of men, which includes a squared jawline and inferomedial projection of the cheeks. The approach to injectable treatments differs between men and women in the aesthetic setting, and this should be addressed by practitioners.

Best Clinical Practices with ATX-101 for Submental Fat Reduction: Patient-related Factors and Physician Considerations.

BACKGROUND: Submental fat can be reduced with ATX-101 (deoxycholic acid injection), a customizable and minimally invasive alternative to liposuction. In the years since its approval, the treatment patterns of ATX-101 have evolved. METHODS: A panel of experienced physicians from the United States gathered to generate best practices for the use of ATX-101 in submental contouring. RESULTS: The expert panel provided their insights on appropriate patient selection, managing patient expectations of ATX-101 treatment outcomes, and adverse events, and guidance on ATX-101 administration for optimal outcomes are presented here. CONCLUSION: These best clinical practices on the use of ATX-101 for the reduction of submental fat should enable physicians to enhance the patient treatment experience and outcomes.

Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals.

There is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodeling and transformation. These procedures may increase transgender individuals' satisfaction with their appearance and allow them to more effectively harmonize their physical appearance with their perception of self. There is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. In this report, the authors provide experience-based treatment considerations and recommendations for use of minimally invasive facial aesthetic procedures in transgender patients, including case studies illustrating the use of these procedures for both male-to-female and female-to-male transitioning patients. This report highlights the success of minimally invasive methods for assisting transgender patients in achieving their facial remodeling goals. Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process. When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients' self-perception and overall quality of life.

Efficacy, Patient-Reported Outcomes, and Safety in Male Subjects Treated With OnabotulinumtoxinA for Improvement of Moderate to Severe Horizontal Forehead Lines.

BACKGROUND: Men represent a growing segment of the facial aesthetic market. OBJECTIVE: To evaluate investigator-assessed efficacy, patient-reported outcomes, and safety after onabotulinumtoxinA treatment of forehead lines (FHL) in men. METHODS: Subjects with moderate to severe FHL received onabotulinumtoxinA (frontalis: 20 U; glabellar complex: 20 U, with/without 24 U in crow's feet regions) or placebo in 6-month, double-blind periods of 2 pivotal trials. Results for men were pooled. RESULTS: Men comprised 12% (140/1,178) of subjects. Day 30 male responder rates for achieving at least 1-grade Facial Wrinkle Scale (FWS) improvement at maximum eyebrow elevation and at rest were 98.2% and 93.3%, respectively; a significant difference in responder rates was maintained versus placebo (p < .05) through Day 150. Despite men having proportionately more severe FHL at baseline, 81.8% and 79.8% achieved Day 30 FWS ratings of none or mild at maximum eyebrow elevation and at rest, respectively (p < .05); significance versus placebo was maintained through Day 120. Men reported high satisfaction rates and improved psychological impacts. No new safety signals were detected. CONCLUSION: Standard dosing and administration of onabotulinumtoxinA significantly improved static and dynamic FHL appearance, despite men having proportionately more severe FHL at baseline. Men reported high satisfaction and appearance-related psychological impact improvements.

Eskata (40% Hydrogen Peroxide Solution) for the Treatment of Seborrheic Keratoses

"Barnacles", "liverspots", "age spots": Seborrheic keratoses (SKs) have many different names, sizes, and clinical presentations in our patients. The only commonality among SKs is that patients despise them. While patients are initially concerned about their malignant potential, once they are reassured, most patients quickly transition from relief to request: "Can you get rid of them?" An observational study conducted across multiple dermatology practices found that SKs have a significant impact on quality of life, causing patients to adopt strategies to cover them and seek treatment for asymptomatic lesions.1 Given their benign potential, the only reason to remove an asymptomatic raised SK is cosmetic. When doing a cosmetic procedure, the acceptable risk is often lower given that the benefit for treatment is aesthetic. Ideally, a cosmetic intervention would have a wealth of evidence-based data and a favorable side effect profile. Eskata 40% hydrogen peroxide topical solution, the only FDA-approved drug for the treatment of raised SKs, strikes the perfect balance between efficacy and side effect profile.

Systematic review of platelet-rich plasma (PRP) preparation and composition for the treatment of androgenetic alopecia.

BACKGROUND: Platelet-rich plasma (PRP) injections have gained popularity in dermatology practice as a treatment for hair loss. As an autologous blood product, PRP is categorized as a minimally manipulated tissue by the U.S. Food and Drug Administration (FDA) and thus evades extensive regulation. As a result, there is a lack of standardization of its preparation and final composition. OBJECTIVE: This study aims to provide a systematic review of the various PRP preparation protocols and PRP compositions utilized in clinical trials for the treatment of hair loss. METHODS & MATERIALS: A review of the literature was performed using PubMed and Ovid/Medline in November 2017 using the search terms "Platelet-Rich Plasma" and ("Alopecia" or "Hair Loss"), including all publication dates. Human clinical trials in the English language were included. RESULTS: Nineteen studies (in 15 articles) met the inclusion criteria for analysis. Only 21% of these studies reported all PRP preparation factors analyzed, and only 32% of the protocols reported the platelet count for both the initial whole blood and final PRP product. CONCLUSION: The current reporting of PRP preparation methodology and final composition is inconsistent and insufficient to enable comparison between studies and determination of efficacy for particular treatment applications.

The Male Aesthetic Patient: Facial Anatomy, Concepts of Attractiveness, and Treatment Patterns.

BACKGROUND: The number of nonsurgical aesthetic procedures performed in men is growing rapidly. However, there are limited data on treatment principles and goals for the male aesthetic patient.

OBJECTIVE: To review the objective data available on male aging and aesthetics and to synthesize with expert opinion on treatment considerations specific to male patients.

METHODS: Expert advisors met to discuss anatomical differences in male versus female facial anatomy related to aging, facial treatment preferences in aesthetically oriented men, and current dosing data for facial injectable treatments in male versus female patients.

RESULTS: Symmetry, averageness, sexual dimorphism, and youthfulness are generally accepted as factors that contribute to the perception of attractiveness. There are differences between men and women in facial anatomy, concepts of attractiveness in the context of masculinity and femininity, and treatment objectives. A communication gap exists for men, as evidenced by the lack of information available online or by word of mouth about injectable treatments.

CONCLUSIONS: Approaches to aesthetic consultation and treatment should differ between men and women based on the fundamental dissimilarities between the sexes. Educating men about available aesthetic treatments and about the safety and side effects associated with each treatment, as well as addressing concerns about their treatment results looking natural, are key considerations.

J Drugs Dermatol. 2018;17(1):19-28.

Aesthetic Treatment With Botulinum Toxin: Approaches Specific to Men.

BACKGROUND: Men are increasingly seeking aesthetic treatment with neuromodulators. OBJECTIVE: To successfully treat the male patient, it is imperative to understand anatomical and dosing differences from his, perhaps more familiar, female counterpart. CONCLUSION: After reading this review including male-specific botulinum toxin technique tips derived from their own practices, the authors hope injectors are able to approach their male patients with increased confidence to deliver superior outcomes.

Signs of Facial Aging in Men in a Diverse, Multinational Study: Timing and Preventive Behaviors.

BACKGROUND: Men are a growing patient population in aesthetic medicine and are increasingly seeking minimally invasive cosmetic procedures. OBJECTIVE: To examine differences in the timing of facial aging and in the prevalence of preventive facial aging behaviors in men by race/ethnicity. METHODS: Men aged 18 to 75 years in the United States, Canada, United Kingdom, and Australia rated their features using photonumeric rating scales for 10 facial aging characteristics. Impact of race/ethnicity (Caucasian, black, Asian, Hispanic) on severity of each feature was assessed. Subjects also reported the frequency of dermatologic facial product use. RESULTS: The study included 819 men. Glabellar lines, crow's feet lines, and nasolabial folds showed the greatest change with age. Caucasian men reported more severe signs of aging and earlier onset, by 10 to 20 years, compared with Asian, Hispanic, and, particularly, black men. In all racial/ethnic groups, most men did not regularly engage in basic, antiaging preventive behaviors, such as use of sunscreen. CONCLUSION: Findings from this study conducted in a globally diverse sample may guide clinical discussions with men about the prevention and treatment of signs of facial aging, to help men of all races/ethnicities achieve their desired aesthetic outcomes.

"Man-some": A Review of Male Facial Aging and Beauty.

Gender plays a significant role in determining facial anatomy and behavior, both of which are key factors in the aging process. Understanding the pattern of male facial aging is critical when planning aesthetic treatments on men. Men develop more severe rhytides in a unique pattern, show increased periocular aging changes, and are more prone to hair loss. What also needs to be considered when planning a treatment is what makes men beautiful or "man-some". Male beauty strikes a balance between masculine and feminine facial features. A hypermasculine face can have negative associations. Men also exhibit different cosmetic concerns. Men tend to focus on three areas of the face - hairline, periocular area, and jawline. A comprehensive understanding of the male patient including anatomy, facial aging, cosmetic concerns, and beauty are needed for successful cosmetic outcomes.

J Drugs Dermatol. 2017;16(6 Suppl):s91-93.

Laser Treatment of Professional Tattoos With a 1064/532-nm Dual-Wavelength Picosecond Laser.

BACKGROUND: Picosecond-domain laser pulses improve the photomechanical disruption of tattoos. OBJECTIVE: This study evaluates the efficacy and safety of a novel, dual-wavelength, 1,064/532-nm, picosecond-domain laser for tattoo clearance. MATERIALS AND METHODS: This was a prospective, self-controlled, clinical study of 34 subjects with 39 tattoos treated at 2 sites with an interval of 4.8 ± 1.6 weeks and up to 10 treatments (mean, 7.5). Blinded evaluation and investigator assessment of serial digital images was performed to evaluate treatment efficacy in the 36 tattoos that received at least 3 treatments. Investigators also assessed efficacy before each treatment visit up to 10 treatments. Safety and tolerability was evaluated for all 39 tattoos that underwent at least 1 treatment. RESULTS: Blinded evaluation demonstrated that lightening of tattoos was achieved in all subjects, with 86% (31 of 36 tattoos) showing at least a 50% clearance after 3 treatments. Adverse events were few and transient in nature. Patient satisfaction and treatment tolerability were high. CONCLUSION: Treatment of single-colored and multicolored tattoos with this novel 1,064/532-nm picosecond laser is highly safe and effective.

Facial Treatment Preferences Among Aesthetically Oriented Men.

BACKGROUND: There is a paucity of data describing male attitudes toward age-related changes to their facial features and associated preferences for prioritizing treatment. METHODS: Injectable-naive but aesthetically oriented men aged 30 to 65 participated in an online study (N = 600). Respondents indicated how concerned they were by the appearance of 15 age-related facial features, and the Maximum Difference scaling system was used to explore which features were most likely to be prioritized for treatment. The correlation between the features of most concern and the areas of treatment priority was assessed. Other aspects regarding the male perspective on aesthetic procedures, such as awareness, motivating factors, and barriers, also were explored. RESULTS: Crow's feet and tear troughs were rated as the most likely to be treated first (80% of first preferences) followed by forehead lines (74%), double chin (70%), and glabellar lines (60%). The areas of most concern in order were tear troughs, double chin, crow's feet, and forehead lines. There was a strong correlation between the features of most concern and the areas of treatment priority (r = 0.81). CONCLUSION: The periorbital areas, in particular crow's feet and tear troughs, are of most concern and likely to be prioritized for treatment among aesthetically oriented men.

Men at risk for paradoxical adipose hyperplasia after cryolipolysis.

Cryolipolysis, an aesthetic procedure that reduces adipose tissue by exposure to cold temperature, is generally well tolerated with mild side effects including temporary numbness, erythema, and tenderness. However, as cryolipolysis is gaining popularity and more treatments are being performed, reports of rare adverse events including delayed onset pain and paradoxical adipose hyperplasia (PAH) have been described. Recent studies have suggested that PAH can be more common than expected and have a predilection for males, as a disproportionate number of the cases reported in the literature have occurred in men despite the fact that fewer men are likely to be treated with cryolipolysis. Sexual dimorphism in adipose anatomy may provide insight into the increased susceptibility of men to PAH. Careful patient selection avoiding men with visceral abdominal adipose and firm, nondistensible, fibrous fat may be important to minimize the risk of PAH.

Aging in the Male Face: Intrinsic and Extrinsic Factors.

BACKGROUND: Gender is one of the most significant factors that influence facial anatomy and behavior, both key factors in the aging process. OBJECTIVE: To review male facial anatomy, physiology, and behavior and how it contributes to sexual dimorphism in facial aging. METHODS: A MEDLINE search was performed for publications on gender differences in facial anatomy, aging, cutaneous physiology, and behavior. RESULTS: There are differences in both intrinsic and extrinsic aging factors in men. Men have a thicker epidermis and dermis with more active cutaneous appendages including hair growth. Male skin has a reduced antioxidant capacity and increased ultraviolet-induced immunosuppression. The male face is larger and has a unique square shape with less subcutaneous soft tissue, especially at the medial cheek. Men are also more prone to smoking and exhibiting poor sun-protective behavior. The differences in intrinsic and extrinsic aging factors contribute to poor facial aging in men. Men develop more severe rhytides in a unique pattern, show increased periocular aging changes, and are more prone to hair loss. CONCLUSION: This review provides insight into the factors contributing to accelerated male facial aging. Understanding gender differences in aging will help physicians tailor cosmetic treatments for men and minimize extrinsic aging factors.

Efficacy and Safety of Minoxidil 5% Foam in Combination With a Botanical Hair Solution in Men With Androgenic Alopecia.

Androgenic alopecia (AGA) is the most common type of hair loss in men, characterized by hair miniaturization, hairline recession, and vertex balding. It affects approximately 50% of men, negatively affecting self-esteem and sociability. Topical minoxidil formulations are approved up to a 5% concentration for men, but patient adherence to treatment is challenged by gradual results that may be perceived as a lack of initial benefit. Herbal extracts, which are also believed to promote healthier-looking hair, have a long history of use in hair care formulations. The safety and efficacy of a twice-daily regimen of 5% minoxidil foam used in combination with a novel botanical hair solution was evaluated in a 12-week, multicenter, single-arm, open label study in 56 subjects with mild to moderate AGA. Assessments included investigator ratings of improvement and subject self-ratings of satisfaction. Investigator ratings indicated significant improvement in scalp hair coverage and perception of overall treatment benefit in as early as 4 weeks (P<.001). Subject self-ratings were significant for improved hair growth and hair appearance in as few as 4 weeks (P<.05). The regimen was well tolerated, and subjects indicated a high degree of satisfaction. Investigator and subject-assessed efficacy and subject satisfaction with this novel regimen provide clinicians with an effective treatment option for AGA that also provides a high level of patient satisfaction, which may help promote patient adherence to long-term treatment.

Comparison of 532 nm Potassium Titanyl Phosphate Laser and 595 nm Pulsed Dye Laser in the Treatment of Erythematous Surgical Scars: A Randomized, Controlled, Open-Label Study.

BACKGROUND: The pulsed dye laser (PDL) has long been used for treatment of erythematous and hypertrophic scars. Its effectiveness has been attributed in large part to its vascular-specificity. The vascular-specific potassium titanyl phosphate (KTP) laser has also been reported to be clinically effective for scars, but has not been compared to the PDL. OBJECTIVE: To compare the safety and clinical efficacy of a 532-nm KTP laser versus a 595-nm PDL in improving the appearance of erythematous surgical scars. METHODS: Twenty patients with matched bilateral erythematous surgical scars or a single linear erythematous scar measuring longer than 5 cm were enrolled in the study. Single scars were divided into equal halves with each half randomized to receive 3 successive treatments at 6-week intervals with either a 532-nm KTP laser (Excel V; Brisbane, CA) or a 595-nm PDL (Cynergy; Cynosure Inc., Chelmsford, MA) at equivalent laser parameters. Bilateral matched scars were similarly randomized to receive three 532-nm KTP or 595-nm PDL treatments. Clinical efficacy was evaluated 12 weeks after the third (final) laser treatment by independent, blinded photographic scar assessments. Secondary evaluations included final investigator and subject treatment/satisfaction assessments, Vancouver scar scale (VSS) scores, subject scar symptoms, intraoperative pain scores, and incidence of side effects. RESULTS: Clinical improvement of erythematous surgical scars was observed with both 532-nm KTP and 595-nm PDL systems. No statistically significant differences between the 2 treatment arms were noted in the independent, blinded photographic scar assessments, investigator and subject treatment/satisfaction assessments, subject scar symptoms, and intraoperative pain scores. The KTP arm produced statistically significant improvement for the vascularity component of the VSS only. Side effects were limited to mild treatment discomfort and minimal transient post-treatment erythema and purpura. No vesiculation, infection, scarring or other adverse events were experienced. Subject satisfaction surveys mirrored the observed clinical effects. CONCLUSION: The-532 nm KTP laser is comparable in efficacy and safety to the 595-nm PDL laser in the treatment of erythematous surgical scars.

Prevention and treatment of nonfacial scars.

Hypertrophy in nonfacial scars can be caused by mechanical stress created by large core muscles and joint movement and by increased pressure and shear over sites with boney prominences. Careful surgical planning and technique to minimize wound tension, followed by tension off-loading, can help minimize scar hypertrophy. Both surgical and nonsurgical techniques can be utilized for non-facial scar revision. The adoption of a combination therapy with multiple treatment modalities may be required to improve the appearance of nonfacial scars.

Delayed Onset Pain Associated With Cryolipolysis Treatment: A Retrospective Study With Treatment Recommendations.

BACKGROUND: Cryolipolysis has become a popular treatment for noninvasive destruction of unwanted subcutaneous fat. It is a generally well-tolerated treatment with mild transient side effects. Delayed posttreatment pain has been sporadically reported, but its incidence, etiology, and treatment have not been elucidated in a large series of patients. METHODS: A retrospective review of 125 patients who received 554 cryolipolysis procedures over a 1-year period was conducted. Demographic data were obtained to determine specific variables that influenced development of delayed posttreatment pain. RESULTS: Young women (mean age, 39 years) undergoing abdominal cryolipolysis were at greatest risk of experiencing delayed posttreatment pain. The pain was self-limited (duration, 3-11 days) and resolved completely without long-term sequelae. The number of treatment cycles did not impact the development of this side effect. CONCLUSION: Delayed posttreatment pain is a not uncommon adverse effect after cryolipolysis. Patients should be counseled on the possibility of its occurrence, and timely intervention should be instituted to reduce its impact.

Emerging Therapies for Androgenetic Alopecia.

Androgenetic alopecia is the progressive miniaturization of the scalp's terminal follicles in aging men. Over 40% of Caucasian men develop hair loss by the age of 40. Despite its prevalence, there are only two FDA approved medications to treat the condition. Recognizing the unmet need, new medical, procedural, and surgical treatments are being adopted to combat progressive hair loss. This review examines emerging hair loss treatments including medical therapies that the target prostaglandins, low level light therapy, platelet rich plasma injections, and robotic hair transplantation.

Male Body Contouring.

Men are increasingly turning to dermatologists and plastic surgeons to request procedures that correct or enhance physical features. With the advent of this emerging new patient population, alterations in preexisting aesthetic techniques, gender-specific uses of existing devices and overall approaches need to be revisited and adapted to obtain results that are suitable for the male patient. Recently, body contouring has become one of the most sought out procedures by men. Although the majority of clinical studies involving body contouring esthetics are performed with female patients, gains from such studies can be extrapolated to men. Body contouring can be broadly classified as non-invasive or invasive, depending on the modality used. Non-invasive contouring is most frequently performed with devices that target subcutaneous adipose with focused electrical or thermal energy, including low-level laser, cryolipolysis, ultrasonography, and radiofrequency. Invasive body contouring modalities useful for male body contouring include liposuction, pectoral and abdominal wall etching, jawline fillers, synthetic deoxycholic acid injections, and solid silicone implants. The purpose of this review is to bring attention to the unique aspects, strategies, and modalities used in aesthetic body contouring for the male patient.