Radiesse® is another option for the nasolabial fold. It should be placed in deep dermis or subcutaneous tissue via a retrograde tunneling technique.9 In addition to nasolabial folds, Radiesse® can be used for marionette lines and elevating the corner of the lips.
Jawline
Many men desire a wide mandible with a prominent flexure, unlike the narrow and rounded lower face of a female. With age, men can develop masseter hypertrophy, loss of the angular shape of the jawline, and sagging of the pre-jowl sulcus.
Masseter hypertrophy in men can lead to irregular contour of the lower face and an aggressive appearance. Off-label botulinum toxin injections into the muscle can reduce masseter hypertrophy. Xie et al. classified five different bulging types of a contracted masseter: minimal, mono, double, triple, and excessive by using ultrasound studies and cadaver dissections.43 The muscle is comprised of three different muscle layers which contract in different directions. Each layer in innervated by separate nerve branches that originate from the nervus massetericus. They found that the most prominent part of the masseter bulge corresponds to the distribution region of the nervus massetericus. Thus, identifying and injecting the most prominent bulge can allow for a reduced injection dosage and limited dispersion (Figure 5).
In the study, the authors found the minimal dose of onabotulinumtoxinA used was 20 units with the highest amount being 40 units. The greatest reduction of masseter hypertrophy occurred at 3 months. While the overall complication rate was 9.1%, it was 60% among patients who received higher doses. Therefore, a safe approach would be to start off with fewer units and supplement with further injections at a follow up visit.
Filler can be used to restore angularity and definition to the jawline and soften jowls. Here, thicker hyaluronic acid products like by Perlane® or Juvéderm® Ultra Plus, Ultra Plus XC, and Voluma are more useful. The filler can be placed against the mandible and molded along the jaw line.
Sculptra®, initially approved in the United States for AIDS-related lipoatrophy, may be a useful filler in correcting jowls and enhancing the jawline. The polymerized lactic acid stimulates macrophages and fibroblasts, leading to new collagen deposition.44 Monheit et al. note that 3-5 treatments every few months can last 1-2 years.1 The authors recommend diluting the filler in 5 or more cc of water for at least 3 hours to allow the material to hydrate. The filler can then be injected in aliquots of 0.01-0.02 cc in a grid-like pattern, followed by vigorous massage to avoid nodule formation.
Chin
Like the mandible, the male chin is wide and projects anteriorly. Loss of bone and soft tissue in the chin and medial cheek can cause decreased projection of the chin and downward displacement of the mid face over the melomental folds, causing downward displacement of the oral commissures and marionette lines.
Here, injection of botulinum toxin type A into the depressor angularis oris (DAO) decreases the pull on the corners of the mouth, elevating the oral commissure and softening marionette lines. Neurotoxin can also be used to soften the chin clefts, which can make men look aggressive. Flynn recommends 10 units of botulinum toxin type A to the mentalis.33
When augmenting the chin, it is helpful to assess the Riedel plane, which connects the relationship between the upper lip, lower lip, and chin.45 A straight line drawn from the anterior projection of the chin should touch the lower and upper lip. This relationship can be used to assess where volume will be most beneficial. As in the jaw, fillers can be injected along the mandible and molded. For marionette lines, filler is best injected in the deep dermis in a cross hatching or fanning technique.
A more cross linked hyaluronic acid filler such as Perlane® or Juvéderm® Ultra Plus, Ultra Plus XC, and Voluma is recommended. Sculptra® and Radiesse® are also useful for the chin and rest of the jawline, as mentioned before.
Submental Fat
Submental fat, caused by aging, diet, lifestyle, and genetics, decreases the angularity and definition of the jawline.46 This fat accumulates subcutaneously superior to the plastysma.
Male patients wishing to avoid surgical procedures may be interested in injectable deoxycholic acid, which disrupts the cell
