hangs too low can give an aggressive appearance and interfere with function or give a heavy feeling.
Eyebrow placement is controlled by the frontalis and the corrugators. Spreading botulinum toxin injections evenly over the corrugators and frontalis, with purposeful injection of the lateral aspect of frontalis, can prevent arching of the brow. Staying 1-2 cm above the orbital rim avoids diffusion of the toxin into the muscles of the eyelid such as the levator palpebrae, which can result in ptosis and heaviness of the eyelid. For men who already have lower set eyebrows and a heavier eyelid, keeping frontalis injections higher on the forehead will help from overly depressing the brow and causing further ptosis.
Filler is best used to correct brows that have lost volume in the medial third or equally across the brow length. Lambros et al. recommends the use of hyaluronic acid (HA) filler with a gel consistency like Restylane® (Galderma Inc., Lausanne, Switzerland). The filler can be placed in a fanning technique inferior to the brow at the level of the superior orbital rim. Filler should be injected at the depth of the orbicularis muscle in order to avoid supraperiosteal arteries.31
Glabella
Men tend to have a deeper furrow in the glabella due to their anatomy. Botulinum toxin injection can soften the glabellar ridge and decrease the appearance of aggressiveness and age.
Similar to the forehead, men require a greater number of units to the glabella than women. In the study by Carruters et al., at least 40 units of onabotulinumtoxin A were recommended to the glabella, as they found 20 units of onabotulinumtoxinA was inadequate.30 Brandt et al. concluded that men need doses greater than 50 units.32 It may be challenging to predict the optimal number of units to use on the first visit, and over-correction can cause an unnatural look in men. Therefore, Flynn recommends seeing patients 2 weeks after the initial injection.33 Many patients require 10-20 additional units. Additionally, it is important to note that the corrugator supercilii extends farther laterally men. Thus, identification and injection of the lateral fibers can prevent suboptimal outcomes.
For glabellar furrows that do not respond to botulinum toxin, injectable fillers (off-label) can provide the effect desired. It is important to be aware of the higher risk for complications in this area including tissue necrosis, or product embolization (resulting in blindness) due to the anastomosis of the internal and external carotid artery systems, and many perforating arteries in this area.34 Additionally, the glabella is an unforgiving location for bumps and nodules. It is important to aspirate before injection into this area to prevent inadvertent placement of filler into a vessel. If any resistance is felt during injection, the physician should stop and withdraw the needle to ensure proper placement.
In the glabella, HA fillers with low viscosity allow spreading of the filler to prevent an irregular contour. These include Juvéderm® Ultra or Ultra XC (Allergan Inc., Irvine, CA), Restylane®, Belotero® (Merz Aesthetics, Greensboro, NC), and Prevelle® Silk (Mentor Worldwide, LLC, Santa Barbara, CA). Juvéderm® and Restylane® are both capable of causing the Tyndall effect, in which particles within the filler scatter light, causing a blue discoloration when the filler is present superficially.35 Diluting Juvéderm® and Restylane® with saline or lidocaine can reduce the particle concentration and lower the risk of Tyndall effect.36
Having the patient lying horizontally, glabellar lines can be approached from the superior aspect of the patient’s head. The injection should be placed in the mid to upper dermis via a retrograde linear threading technique. Using small initial volumes of filler is recommended to prevent lumps and compression of vessels leading to superficial skin necrosis. Further correction can be performed at a later time if needed (Figure 2).
Periocular Skin
Like women, men develop periocular rhytids with age. While many women may desire these rhytids to be completely gone, the presence of these lines in men can indicate maturity. Thus, a goal for some male patient may be to just soften these rhytids.
When injecting, the physician should keep in mind that the orbicularis oculi is broader and extends more laterally in men. Therefore, men often require a greater number of injection points in addition to a greater number of units. Flynn recommends starting with 15 units of onabotulinum toxin A per side.33
At times, the infraorbital eyelid can developed rounding after injecting neurotoxin to the periocular skin. Applying 1-2 units of onabotulinum toxin A to the inferior orbicularis oculi muscle can decrease muscle hypertrophy that contributes to this shelving. A lateral horizontal injection technique is recommended with superficial placement of neuromodulator.
Infraorbital Hollow
The infraorbital hollow is the depression under the eyes composed of the tear trough, nasojugal fold, and palpebromalar groove. Orbital fat herniation above the orbitomalar ligmanent in addition to loss of bone and soft tissue contribute to the infraorbital depression. These processes extend laterally past the tear trough, and inferiorly into the cheek. Wysong et al noted men had the greatest loss of soft tissue thickness in the tear trough (40% reduction) compared to other areas of the face.21
