membrane of adipocytes, leading to mild inflammation and
phagocytosis by macrophages. 47
More recently, a synthetically derived, purified formation of
deoxycholic acid, or ATX-101, has undergone phase III trials
for treatment of submental fat. McDiarmid et al. examined
the pooled data of two European randomized phase 3 trials
of ATX-101, which included 716 patients with a moderate or
severe submental convexity and prominent to marked localized
submental fat.48
ATX-101 (1 or 2 mg/cm2) was given in up to four treatment
sessions separated by approximately 28 days.48 At each session,
patients received up to 0.2 ml at 1 cm intervals to the
preplastysmal submental fat. Patients received a maximum
of 50 injections and 10mL per session. Patients were then
followed 4 and 12 weeks after the completion of treatment.
ATX-101 was effective based on clinician-rated efficacy
outcomes, a subjective self-rating scale, and caliper measurements.
Adverse events included pain, edema, bruising,
bleeding, numbness, erythema, and induration. These adverse
events resulted in discontinuation in 7 and 10% of
patients treated with ATX-101 1 and 2 mg/cm2, respectively.
Five cases of injection-site nerve injury occurred with the
higher ATX-101 dose; none of the cases resulted in permanent
symptoms.48
Males comprised 26% of treated patients. It is important to note
that male patients only achieved statistical significance compared
to placebo with the 2 mg/cm2 concentration of ATX-101.
Additionally, the authors found that although male patients age
18-30 experienced improvement, it was not statistically significant
when compared to placebo. There may not have been
enough power to show significance in this subgroup.48
Lips
With age, men experience thinning of the lip, blunting of the
vermillion border and philthral columns, and downward projection
of the angle of mouth. Perioral lines tend to be less
severe than in women, thought to be secondary to smaller
pilosebaceous units.49
The goals of lip restoration must be fully discussed with the
patient. Under-correction is the safest approach to avoid a
feminine lip. Overall, the volume ratio of the upper to lower lip
should be one-third to two-thirds, and the upper lip should protrude
1 to 2 mm anteriorly compared to the lower lip. Ethnicity
and cultural differences must be kept in mind, as patients of
African descent tend to have fuller lips.50
Less viscous HA products are preferable, like Restylane® ,
Juvéderm® Ultra and Ultra XC, and Restylane® Silk. The patient
should be warned about post-procedural edema, as
HA fillers absorb water and can increase in size by 10-15%.1
Non-hyaluronic acid fillers have an increased rate of nodules
and granulomas in the lips, and thus their use is not
recommended.
Nose
With age, the male nasal tip drops, causing an elongated nose
that worsens with smiling. As rhinoplasty is the third most
common procedure in men, neurotoxin and soft tissue filler
can be used in an off-label manner to re-shape or restore nasal
structures. In males, the desirable nasolabial angle tends to be
smaller than in females (97 degrees versus 104.9).51 Therefore,
a nasal tip that is too elevated can feminize the male face. Additionally,
the male radix starts at about the superior tarsal fold,
which is higher than in females.52 Another area that should be
considered is the dorsum of the nose. In men, the dorsum of
the nose approaches a straight line drawn from the radix to the
nasal tip; females tend to have a more sloping line. Accordingly,
nasal root and dorsum augmentation has become a popular
procedure for the Asian patient, who tends to have a flatter radix
and dorsum.53 The ethnic background of the patient of the
patient must be taken into account as nasal proportions vary
greatly with ethnicity.
A hypertrophied depressor septi nasi can lead to nasal tip ptosis
and upper lip shortening. The muscle arises from the orbicularis
oris and periosteum above the central and lateral incisors,
then inserts onto the nasal septum and/or medial cura.54 Injecting
neurotoxin into this muscle can elevate the nasal tip. Small
aliquots should be placed to avoid diffusion into the orbicularis
oris, which is only 3 cm away. Another muscle that contributes to
the nasal tip is the musculus digastricus septi nasi labialis. This
muscle pulls the nasal tip downward while lifting the upper lip.
Neurotoxin injection here can further elevate the nasal tip.55
Filler can be used to adjust the nasal radix and dorsum. Since
the skin on the radix is thicker than on the nasal dorsum, a high
G’ filler with give enough lifting quality. A depot injection can
be placed in this area, using small volumes.
Filler placed into the nasal dorsum can straighten the line between
the radix and nasal tip, and can camouflage a dorsal
