Case Study: Treating the Male Profile

Case Study: Balancing the Male Profile Dr Joshua Van der Aa details a profile balancing treatment plan administered over six months to masculinise a male face The goal for most men who turn to cosmetic treatments is to look well-rested, energised and ready for business.1 In my experience, typically those aged 40 and over prefer rejuvenating tweaks for reducing signs of weathering or tiredness, such as tear trough fillers for restoring hollow under-eyes, and anti-wrinkle injections for a softer-ridged brow. Personal tastes factor highly in terms of how many expression lines are desirable. For men in their 20s and 30s, alteration is more often the quest: understated yet effective solutions, usually with fillers, for helping to achieve stronger, more defined and masculine looks. However, in recent months, I have noticed a discreet and steady shift among male patients – regardless of age or occupation – towards full-facial ‘refreshment’, as opposed to simply wanting to have ‘this or that’ done in isolation. Case study

Consultation A 33-year-old Caucasian man presented to my clinic concerned with the absence of a defined jawline, which was clearly impacting his self-esteem. He’s highly visible on social media with a significant following – in fact, most people in his close social circle are models and media personalities and as a result, his photograph is taken regularly. This was making him very conscious of how lacking in structure his facial features appeared in pictures. He had never had cosmetic treatments before and after taking a full medical history there were no lifestyle factors of relevance. I deemed his concerns to be valid and was satisfied that his expectations were realistic. I carefully assessed his face from different angles and we discussed in detail the features he found particularly bothersome, namely his lower face, taking a full-face approach and thus ensuring a balanced and proportional outcome was always in sight. I find it satisfying to analyse and interpret the different facial anatomical components together with my patients in this way and it became clear that what he was hoping to achieve was a straighter nose, more defined cheeks and, crucially, a stronger jawline supported by better chin projection. The consultation process was aided by referencing his own photographs, the clinical pictures I took from front, oblique and side angles, and the use of a handheld mirror for helping him visualise my advice. I identified and noted the dorsal hump and drooping tip of the nose, the slight frontal asymmetry with curving towards the left, and a retrognathic chin with overall small mandible, meaning the absence of a defined jawline and chin. My decided strategy was a deliberate but necessary slow progression towards the ‘goal’ through several sessions, because I find that high volume injections administered in one go don’t integrate well; there’s more control if you go slowly and steadily. I’m a firm believer in the maxim that the best results are achieved with a marathon, not a sprint. We also discussed the effects of filler in different parts of the face, the potential risks and inevitable downtime, as well as the products I would use. I explained that the downtime can be negligible but swelling between weeks one and four is possible, and if there’s any bruising, it will last about a week. The patient was encouraged to ask questions and he was invited to contact me via email or WhatsApp if he wanted to know more or to follow-up on any details. For preparation, I advised him that it’s important to avoid drinking alcohol to excess because I find this can increase the risk of bruising. I gave him the necessary aftercare advice he would need to follow, including avoiding exercise and alcohol for two days following treatments; details that I repeated before and after each phase in the plan. As I had already discussed this treatment in detail with the patient prior to this consultation they had already had sufficient time to consider the outcomes and risks. I therefore performed the treatment on the same day, but I would normally recommend a cooling-off period of a couple of weeks.

Treatment

For the first round of treatments, I decided on performing a liquid rhinoplasty and starting the injections to address the mandibular angle, jawline and chin, as these were his primary concerns. When treating, it’s vital to take into consideration the different angles, shapes and projections that must be respected so as not to feminise the male face. The angle of the mandible, for example, tends to be closer to 90-100 degrees in men, whereas in women it’s more typically between 120-130 degrees.2 Similarly, careful consideration is needed when rotating the tip of the nose in men. The angle of the tip of the nose should be at around 90 degrees to the upper lip; rotating any

Your patients have the will. You can offer them the way.

Patients achieved signifi cant and sustained weight loss, in conjunction with reduced calorie intake and increased physical activity, in 1-year and 3-year trials vs placebo 1,2*

Similar to natural glucagon-like peptide-1, Saxenda® works to decrease appetite and thereby reduce food intake3†

This is not a real patient but only an illustration.

This material only relates to adult indication only. Please refer to SmPC for full indication.

Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m2 (obesity) or ≥ 27 kg/m2 to < 30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. If you would like to request a visit from a representative please contact us on obesityuk@novonordisk.com For all product related enquiries please contact Novo Nordisk Customer Care Centre on 0800 023 2573.

†The exact mechanism of action is not entirely clear.

Prescribing Information

Please refer to the Saxenda® summary of product characteristics for full information. Saxenda® Liraglutide injection 3 mg. Saxenda® 6 mg/mL solution for injection in a pre-fi lled pen. One pre-fi lled pen contains 18mg liraglutide in 3mL. Indication: Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m² (obesity) or ≥ 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Adolescents (≥12 years): Saxenda® can be used as an adjunct to a healthy nutrition and increased physical activity for weight management in adolescent patients from the age of 12 years and above with obesity (BMI corresponding to ≥30 kg/m2 for adults by international cut-off points) and body weight above 60 kg. Posology and administration: Saxenda® is for once daily subcutaneous use only. Is administered once daily at any time, independent of meals. It is preferable that Saxenda® is injected around the same time of the day. Recommended starting dose is 0.6 mg once daily. Dose should be increased to 3.0 mg once daily in increments of 0.6 mg with at least one week intervals to improve gastro-intestinal (GI) tolerability. Treatment with Saxenda® in adults should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight. Daily doses higher than 3.0 mg are not recommended. No dose adjustment is required based on age but therapeutic experience in patients ≥75 years is limited and not recommended. No dose adjustment required for patients with mild or moderate renal impairment or mild or moderate hepatic impairment but it should be used with caution. Saxenda® for adolescents from the age of 12 to below 18 years old a similar dose escalation schedule as for adults should be applied. Treatment with Saxenda® in adolescents should be discontinued and re-evaluated if patients have not lost at least 4% of their BMI or BMI z score after 12 weeks on the 3.0mg/day or maximum tolerated dose. Saxenda® is not recommended for use in patients with severe renal impairment including endstage renal disease, or severe hepatic impairment or children below 12 years of age. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and Saxenda® is not recommended for use in these patients. It is also not recommended in patients with eating disorders or treatment with medicinal products that may cause weight gain. Use of Saxenda® is not recommended in patients with infl ammatory bowel disease and diabetic gastroparesis since it is associated with transient GI adverse reactions including nausea, diarrhoea and vomiting. Acute pancreatitis has been observed with the use of GLP-1 receptor agonists, patients should be informed of the characteristic symptoms. If pancreatitis is suspected, Saxenda® should be discontinued. If acute pancreatitis is confi rmed, Saxenda® should not be restarted. In weight management clinical trials, a higher rate of cholelithiasis and cholecystitis was observed in patients on Saxenda® than those on placebo, therefore patients should be informed of characteristic symptoms. Thyroid adverse events such as goitre have been reported in particular in patients with pre-existing thyroid disease. Saxenda® should be used with caution in patients with thyroid disease. An increased risk in heart rate was observed in clinical trials. For patients who experience a clinically relevant sustained increase in resting heart rate, treatment with Saxenda® should be discontinued. There is a risk of dehydration in relation to GI side effects associated with GLP-1 receptor agonists. Precautions should be taken to avoid fl uid depletion. Patients with type 2 diabetes mellitus receiving Saxenda® in combination with insulin and/or sulfonylurea may have an increased risk of hypoglycaemia. Episodes of clinically signifi cant hypoglycaemia have been reported in adolescents (≥12 years) treated with liraglutide. Adolescents should be informed about the characteristic symptoms of hypoglycaemia and the appropriate actions. Fertility, pregnancy and lactation: Saxenda® should not be used during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Saxenda® should be discontinued. It should not be used during breast-feeding. Undesirable effects: Very common (≥1/10); nausea, vomiting, diarrhoea, constipation. Common (≥1/100 to <1/10); hypoglycaemia, insomnia, dizziness, dysgeusia, dry mouth, dyspepsia, gastritis, gastro-oesophageal refl ux disease, abdominal pain upper, fl atulence, eructation, abdominal distension, cholelithiasis, injection site reactions, asthenia, fatigue, increased lipase, increased amylase. Uncommon (≥1/1,000 to <1/100); dehydration, tachycardia, pancreatitis, cholecystitis, urticaria, malaise, delayed gastric emptying Rare (≥1/10,000 to <1/1,000); anaphylactic reaction, acute renal failure, renal impairment. The Summary of Product Characteristics should be consulted for a full list of side effects. MA numbers and Basic NHS Price : 5 x 3 ml pre-fi lled pens £196.20 NI: EU/1/15/992/003 GB : PLGB 04668/0409 Legal category: POM. Full prescribing information can be obtained from: Novo Nordisk Limited, 3 City Place, Beehive Ring Road, Gatwick, West Sussex, RH6 0PA. Marketing Authorisation Holder: Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark. Date last revised: October 2021

* In the 1 year trial patients taking Saxenda® (n=2487) had a baseline body weight of 106.2 kg. Completers’ (n=2437) mean weight loss at week 56 of treatment was 8.4 kg. Patients taking placebo (n=1244) had a baseline body weight of 106.2 kg. Completers’ (n=1225) mean weight loss at week 56 of treatment was 2.8 kg1, p<0.001. In the 3 year trial Patients taking Saxenda® (n=1505) had a baseline body weight of 107.5 kg. Completers’ (n=1472) mean weight loss at week 160 of treatment was 6.5 kg. Patients taking placebo (n=749) had a baseline body weight of 107.9 kg. Completers’ (n=738) mean weight loss at week 160 of treatment was 2.0kg2, p<0.0001. References: 1. Pi-Sunyer X, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. A randomised, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med. 2015;373(1):11-22. 2. le Roux CW, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet. 2017;389(10077):1399-1409. 3. Saxenda® Summary of product characteristics, NI&GB. Bagsvard, Denmark: Novo Nordisk A/S.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Novo Nordisk Limited (Telephone Novo Nordisk Customer Care Centre 0800 023 2573). Calls may be monitored for training purposes.

Saxenda® is a trademark owned by Novo Nordisk A/S.

Results

Before

The patient experienced no side effects other than the expected swelling outlined above, and he was delighted with the added definition in his face. It was rewarding to see his confidence grow, something that was noticeable in his demeanour each time he arrived in clinic during the course of treatments.

As can be seen, he doesn’t look warped or unrecognisable, nor feminised or overinflated, just a more polished version of himself – a natural aesthetic that respects his individual anatomy. It was interesting to note that as the jawline looked more sculpted and defined, he chose to grow less facial hair because he was no longer subconsciously disguising a soft jawline.

Before

more than this risks a more feminine ‘sloped’ appearance, something most are typically eager to avoid.2 Once I had signed informed consent and with some additional clinical photographs taken, my patient was invited to recline on the treatment bed. Invariably, patients are positioned at a 45-degree angle, which is comfortable for them and gives me ample access to the face. I work under high lumen LED twin bar lights so I can also ensure that I’m never working in my own shadow, and because it facilitates assessment of light reflections on the face, which arguably allows for greater precision. I began by disinfecting the area using a 10x10cm square gauze and Clinisept+ Skin, and then marked the nose in white pencil as well as the face along the mandibular border and the width of the chin in line with the corners of the mouth. I carefully straightened the nose bridge by injecting Teosyal Ultra Deep over and around the rounded dorsum. Then I lifted the nose using the same product because of its G prime and projection capacity. I carefully placed injections in the tip and columella to rotate it upwards and improve the angle of the tip. For the cheek, jawline and chin areas, I also started by using Teosyal Dr Joshua Van der Aa is an injection-focused cosmetic practitioner specialising in rejuvenation of the periorbital area. He is a graduate of Leuven University’s medical school. Before opening Dr Joshua Harley Street Aesthetics in 2020, he worked in several reputable and award-winning clinics in London and Europe. Qual: Master’s Degree in Medicine, Belgium

Ultra Deep, administered using a 27 gauge needle for supraperiosteal injections, down to the bone. I prefer this method of injection for the chin as too much product injected superficially in this area can leave it looking somewhat overly rounded and obvious, making it look feminised or unnatural. Even at this early stage in the process, results could be seen straight away, something which is often quite astonishing for the patient and in this case clearly excited him in terms of what could be achieved over time. For the second and third appointments (spaced six weeks apart due to the COVID-19 lockdown), I switched from Teosyal to Radiesse because it’s less hydrophilic, and in my experience, there’s more sharpness and less ‘roundness’ and swelling. I administered this with a 27 gauge needle Figure 1: 33-year-old patient before and after three sessions treating the supraperiosteally for extra deep volume and sharper projection. My focus during these chin, jawline, lips and cheeks sittings was chin balancing, projection and widening. Afterwards I began introducing anterior jawline cannula superficially on either side. During the third sitting I also addressed the pre-jowl dip, injected supraperiosteal again and the rest was done superficially once more using a cannula. I smoothened the dorsal hump in the nose by injecting the radix and middle of the bridge and performed a tip lift to improve the nasolabial angle by injecting small aliquots of filler on top of the ala major cartilage. I also treated the lips during the second session, and a later fourth session, with 1ml of Belotero Intense, using a 27 gauge needle, targeting the lip tubercles for volume so as to optimise the eversion and side profile of the lips. Respect the anatomy With the male face, I’d argue that it’s even more important to deliver subtle and almost undetectable results because of the stigma attached to treatments. To successfully treat the male face, it’s all about respecting the sexual dimorphisms; for the female face, it’s about rounded curves but, in men, it’s all about high tight lines. The more we discuss facial anatomy with men in our clinics and explain the differences in the anatomy compared with women’s features, the more we will help increase their confidence in non-surgical tweaks. Doing so will also help break the stigmas It’s vital to take into about these treatments and demonstrate very clearly how we respect their masculinity. Communicating this at every available consideration the different opportunity is extremely important. angles, shapes and projections that must be respected so as not to

REFERENCES

feminise the male face 1. Lucy Alexander, Robb Report, 2020. <https://robbreport.com/lifestyle/health-wellness/men-turning-tocosmetic-procedures-to-impress-in-bedroom-and-boardroom-2936788/> 2. John Hawks, Mandibles and Sex, 2011, <https://johnhawks.net/explainer/laboratory/mandible-sex. html>

After After