INTRODUCTION
The study of the perception of facial beauty is as old as it is poorly
understood. Attractiveness is believed to go far beyond individual or cultural
parameters.
Studies show that babies have innate predilections for specific facial patterns,
in a kind of imprinting, corroborating the hypothesis that attractiveness is not
a cultural and particular individuality of the viewer1-3.
Physical appearance, especially of the face, is the most accessible and ready
information for interpersonal relationships and studies show a correlation
between beauty and the impression of kindness, intelligence, and
reliability4.
For many centuries it was believed that structures that respected the golden
ratio or divine proportion were considered more beautiful in human eyes. This
fact was evident in several areas of knowledge such as the arts, architecture,
and sociology, causing several works to respect a proportion close to the number
1.6185-7. Interestingly, this proportion, also
referred to as Phi about the Greek sculptor Phidias, is also found in various
human body structures such as segments of the face, teeth, and phalanges8,9. Although several studies have tried to prove this hypothesis, it
is impossible to relate the use of the golden ratio as an absolute justification
to explain what human beings automatically consider beautiful on a face,
especially when observing ethnic and gender variations. However, it is known
that certain facial features allow faces to be more or less attractive,
including the outermost layers such as the skin, the distribution of the fatty
pads of the face, the bone structure, and the facial frame.
Treating and caring for the individual’s facial aesthetics not only translates
into an improvement in his self-esteem but, broadly, improves his
self-acceptance, interpersonal relationships, and perception of life in the
global context. Therefore, it is not surprising the significant increase in the
search for non-surgical aesthetic procedures, notably fillers and botulinum
toxin, since they offer good results, safely and without departing from daily
activities10. This growth is even
more significant among men, with an estimated increase of more than 273%,
between 2007 and 201411. The difference
between genders is not restricted to the evident physical characteristics. Men
habitually seek medical offices discreetly and demand less impactful results per
session. In the treatment schedule, the complete mastery of the attractions of
each gender is fundamental because, more unpleasant than not meeting the
patient’s expectations, is to promote stigmatization, such as over-corrected
lips, poorly positioned eyebrows, and, mainly, sexual dysmorphia (men with
feminized and women with masculine faces).
Despite all current computer technology and the relentless search for
pre-established proportions for the treatment of the face, an adequate physical
assessment of the patient is, even today, the best way to achieve good
results.
This article’s objective is to provide a critical sense for an adequate facial
evaluation with emphasis on the difference between the sexes and, in this way,
to guide the treatment with botulinum toxin and fillers.
METHODS
An exhaustive literature review was carried out, using the PubMed and Cochrane
Library database, using the following keywords: “fillers” AND “botulinum toxin”
AND “gender” AND “male” AND “female.” From this textual search, the articles
were selected respecting the following criteria:
Criteria for assessing anatomical differences between female and male
faces;
Technical differences in the use of injectable treatments, focusing
on botulinum toxin and hyaluronic acid-based fillers, in the
beautification of female and male faces;
Parameterization of results and adverse effects, with sexual
dysmorphia as the primary focus.
RESULTS AND DISCUSSION
Facial symmetry, thirds of the face, and main sexual
characteristics
Despite all the importance of facial symmetry, recent studies show that small
regional asymmetries in no way alter the perception of beauty. On the
contrary, experiments with digital mirroring of a hemiface to the
contralateral side, intending to produce perfectly symmetrical faces, ended
up building artificial and unattractive12,13. Thus,
greater facial harmony is credited to the proper balance between their
anatomical subunits and respect for the thirds of the face, which must have
similar proportions14. The upper
third of the face extends from the capillary line (trichion) to the
glabella, the middle third from the glabella to the subnasal region, and the
lower third from the subnasal region to the chin. One of the significant
challenges of the face’s cosmiatric treatment is to minimize the importance
of asymmetries and restore the balance between the thirds.
Another point of great importance that should always be considered when
planning facial treatments is sex differences. The lack of specialized care
and disrespect for individualities have produced results far below the
desired level, culminating in dysmorphic and stereotyped faces. In the
beautification of the male face, the characters related to virility should
be valued, aiming at more square faces, with horizontal zygomatic arch,
greater bigonial distance15, and
striking chin. In women, the goal is more triangulated and smoother faces,
more oblique zygomatic arches, delicate noses, more voluminous and
well-shaped lips, as well as a tapered and poorly designed chin.
Frontal and temporal region
The frontal region in men tends to have a more oblique presentation, the
glabella and frontonasal suture are more pronounced; the upper orbital ridge
is usually more projected, featuring a more acute transition with the
forehead, the bitemporal distance tends to be larger and usually aligned to
the bigonial distance15. Women have a
more rectified frontal region, the transition with the glabella and the
upper orbital margin tends to be more delicate, and the bitemporal distance
tends to be less than in men16.
The use of botulinum toxin on the male forehead aims to modulate the action
of the occipitofrontal muscle and prevent and slow down hyperkinetic
wrinkles. Every care must be taken not to “freeze” the region and avoid
raising the tail of the eyebrow, feminizing the look. Concerning the
temporal region, in some situations, the toxin can be used to produce
relaxation and atrophy of the temporal muscle, which is excessively
functioning and hypertrophic. In women, the tendency is to use smaller doses
for frontal treatment, distributed over a greater number of points, thus
providing greater relaxation to the region. The rise of the eyebrow tail is
usually desired. The temporal region treatment can be performed with the
same indications as in men. However, its use is less frequent.
To produce “beautification,” 17
fillers are indicated for the attenuation of horizontal frontal cracks when
present; in the smoothing of the fronto-orbital transition, when very
pronounced, in the definition of the upper orbital rim, to bring virility to
the follow-up and the treatment of the glabellar region. The temporal region
can be treated to extend the bitemporal distance and the correction of
regional lipoatrophy, secondary to natural deficiencies or after weight
loss. In women, the main objective is to provide delicacy and femininity to
the follow-up. Irregularities, furrows, and excessively angled foreheads can
be corrected with the use of fillers. The fronto-orbital transition can be
treated in order to alleviate possible dystopias. The temporal region can be
filled to soften the frontotemporal transition, which should be smoother and
more delicate in women.
Facial fillers with hyaluronic acid are the method of choice for the
treatment of the facial frame since high G ‘prime products are capable of
volumizing, defining contours, in addition to providing a lifting effect.
The most relevant points for the facial frame are anterior temporal,
zygomatic arch, and mandibular angle. Careful analysis and the balance of
bitemporal, bizygomatic, and bimandibular distances will be decisive in the
result of any filling (Figure 1).
Figure 1 - The appropriate balance of bitemporal, bizygomatic, and
bimandibular distances, associated with mental width,
collaborate with the female triangular or male quadrangular
facial frame.
Figure 1 - The appropriate balance of bitemporal, bizygomatic, and
bimandibular distances, associated with mental width,
collaborate with the female triangular or male quadrangular
facial frame.
Eyebrow position
Eyebrows in men tend to be thicker and more marked, thanks to more intense
hair growth. Concerning their presentation, the male eyebrow is usually
lower, resting on the upper orbital rim, and they are usually rectified. In
women, eyebrows tend to be thinner and have less hair; they are positioned
slightly above the orbital rim and have an arcuate appearance, thanks to the
higher lateral third18,19.
The inconvenient stigmatization in the eyebrows’ position and shape after
cosmiatric treatment is relatively frequent, then, adequate planning is
essential. It should be remembered that the position of the eyebrows is
nothing more than a balance of forces, between the only musculature that
ascends it (occipitofrontal) and those that depress it (orbicular,
corrugator and proterus). Botulinum toxin treatment is the eyebrows’
position the treatment of the eyebrow position. Much more than treating
rhythms related to the muscles involved, it plays a vital role in
programming muscle forces and reorganizing traction vectors. The
distribution of application points and doses of toxin in the muscles
involved must be planned appropriately. In men, the frontal application is
generally straight so as not to alter the eyebrows’ position, while in women
it may be possible to program a more significant release of more significant
frontal muscle, in its lateral portion, with the purpose of arching and
raising the eyebrow. Studies show that the strength of the male face’s
muscles demands higher doses of toxin and that the potential for
complications, such as bruising, is greater among men due to greater
hairiness and consequent skin vascularization20.
In some instances of intense eyebrow ptosis, the toxin alone does not achieve
the goals of suspension. When this occurs, another etiology other than the
muscle should be sought. The resorption of the frontolateral and superficial
temporal fat pads, as well as tissue deflation, may have a direct role in
this phenomenon. In this case, the botulinum toxin must be supplemented with
the filling of hyaluronic acid. Due to the vascular richness, the
volumization of the frontolater is usually performed with microcannulas in
the supraperiosteal plane, with a product of high or medium G ‘prime. In
addition to promoting skin distension and consequent traction of the
eyebrow, hyaluronic acid modifies the muscle’s anchorage point, potentiating
its activity by a mechanism called myomodulation21. Other points that also impact the positioning of
the eyebrow tail are the anterior temporal and the direct filling to support
the eyebrow tail. The first is performed with a needle, in a single bolus,
supraperiosteal, and with a high G ‘prime product, while the second can be
performed with a needle or cannula, also supraperiosteal, with a medium or
high G’ prime product (Figure 2).
Figure 2 - The position and shape of the eyebrows are important
determinants of sexual characteristics (see blue line). The
filling points, adjuvant to the botulinum toxin, for
repositioning the eyebrow are shown (yellow - frontal; red -
anterior temporal; green - tail of the eyebrow).
Figure 2 - The position and shape of the eyebrows are important
determinants of sexual characteristics (see blue line). The
filling points, adjuvant to the botulinum toxin, for
repositioning the eyebrow are shown (yellow - frontal; red -
anterior temporal; green - tail of the eyebrow).
Zygomatic-malar region and middle third
The woman is characterized by presenting a more defined and angled zygomatic
arch, a more evident zygomatic prominence, and a more rounded and graceful
malar region. On the other hand, men are characterized by having a more
horizontal zygomatic arch, less zygomatic prominence, more flattened malar
region, and the middle third, as a whole, broader.
The use of botulinum toxin in the middle third treatment to produce
“beautification” is rarely indicated. However, hyaluronic acid-based fillers
are widely used in this segment.
In a juxtaperiosteal plane, bolus points, combined with linear retrojections
on the zygomatic arch, are usually indicated on female faces to produce lift
and the redefinition and angulation of the zygomatic region. Such filling
techniques collaborate for facial triangulation and for enhancing
femininity10. The volumization of
the malar region and designing and providing gracefulness to the segment
also aim to mitigate the eyelid transition, helping to beautify the look.
Patients with large weight losses or lipoatrophy, secondary to intense
physical activity, may still need filling in the pre-parotid regions, in the
buccal fat pad’s projection, and close to the deep compartments of the
cheek. According to recent studies, the medial padding tends to be more
volumizing and the lateral padding more suspending, under the direct
influence of the retaining ligament line of the face22 (Figure 3).
Figure 3 - The middle third should be the prominent third on the female
face. Filling hyaluronic acid in supraperiostal structural
points (red - zygomatic arch; blue - zygomatic eminence; green -
malar) or subcutaneous filling with a cannula for greater
prominence (yellow).
Figure 3 - The middle third should be the prominent third on the female
face. Filling hyaluronic acid in supraperiostal structural
points (red - zygomatic arch; blue - zygomatic eminence; green -
malar) or subcutaneous filling with a cannula for greater
prominence (yellow).
On male faces, bolus points, in a juxperiosteal plane and with high G ‘prime
hyaluronic acid, are often used to produce the lift of the middle third.
Linear retroinjections on the zygomatic arch and the enhancement of
zygomatic prominence are rarely indicated. The volumizing of the malar
region, when indicated, must be performed sparingly to avoid the
feminization of the follow-up. Like the female faces, in large weight
losses, one can fill the pre-parotid region, the projection of the buccal
fat pad, as well as the deep compartments of the middle third of the cheek.
Female and male patients, if necessary, can have the nasolabial fold filled.
For this purpose, high G ‘prime hyaluronic acids can be used, in a
juxperperiosteal plane, in bolus, next to the canine fossa, and medium G’
prime hyaluronic acids, in a justadermal plane, by back-injections and
cannula, or in plane intradermal with a needle.
Eye region and tear trough
The beauty of the look is related to the size and position of the eyes,
varying degrees of dermatocalazole, relationship of the eyes to the eyebrow,
presence of eyelid bags, deformity of the tear trough and changes in the
orbital bone frame, more or less evident23. Anin-planetric measurements demonstrate that the narrower
the orbital frame is, the more aesthetically acceptable it will be. With
aging and consequent bone remodeling and fat absorption, there is
inferolateral widening of the orbit and skeletonization thereof24. Naturally, female skeletons have a
proportionally larger orbital diameter. Larger, protruding eyes are graceful
on female faces, while narrow eyelid slits are more pleasant on male
faces25.
The deep lacrimal canal is a frequent complaint in offices, denoting an air
of fatigue, what we call a tear trough deformity. There are several studies
related to this region, most of them looking for an adequate classification
and treatment proposal. In general, milder cases are restricted to the
medial region, becoming more severe as the groove advances laterally in the
orbit26. When programming a
facial beautification, it is extremely important to treat this deformity
with the use of fillers. As it is considered an area of vascular risk, it
must be performed by experienced professionals, with products with low G
‘prime, use of microcannulas, and submuscular/justaperiosteal application.
Neglecting the need for treatment or fearing the application essentially
negatively impact the results.
Lips
The lip shape and volume, regardless of individual and ethnic
characteristics, undergo important changes with the aging process, related
to the absorption of the superficial and deep fatty cushions, the atrophy of
the orbicularis muscle, changes in the dentition, and bone absorption.
A lip considered ideal must have the distance between the commissures
coinciding with the distance between the eyes’ medial corners. It must
present a good definition of cutaneomucosal line, well-designed filter
ridges, and cupid’s bow, have a good relationship between the upper and
lower lips, in addition to maintaining a proportional relationship with the
face as a whole (the lip must occupy about 40% of the lower third of the
face) 27. It is believed that the
ratio between upper and lower lip, in the previous view, is one of the few
attributes that obey the golden ratio, being a ratio of 1.6 considered
ideal. Another study showed that the least attractive lip is the one that
has its proportions inverted (2: 1), that is, a more remarkable exuberance
of the upper lip28,29. Anthropometric studies suggest that
wider, voluminous lips are more attractive to female faces28. Popenko et al., In 201729, proved that the most accepted lip
volumization in their study was that which increased the lip by 53% of the
original. In the lateral view, drawing a line between the subnasal region
and the chin, the upper lip is more projected than the lower one. In this
line, called Ricketti, the upper lip protrudes approximately 3.5mm and the
lower 2.2mm5.
The difference in thickness between the upper and lower lip is one of the
most important characteristics in differentiating between genders. In women,
this contrast tends to be more evident and the lips more convex, whereas in
men, the contrast is less, and the lips tend to be thinner and
straighter30. In women, the lip’s
anatomical subunits, such as filter, contour, and cupid’s bow, when well
defined, are more attractive, being favored by cosmiatric treatment with
fillers. In men, in addition to not requiring such a definition of subunits,
their volumization is still considered taboo, and the characteristics of
aging in the perioral region are less striking, impacting less demand for
male treatments for this region (Figure 4).
Figure 4 - The lips are structures that usually obey the golden ratio
(1: 1.6). Sexual dimorphism is evident. Female lips tend to be
more voluminous and have well-defined subunits.
Figure 4 - The lips are structures that usually obey the golden ratio
(1: 1.6). Sexual dimorphism is evident. Female lips tend to be
more voluminous and have well-defined subunits.
Lip filling in women looking for beautification should be encouraged when
necessary, avoiding overcorrections and inversions of proportions. As it is
a dynamic structure with exuberant vascularity, it deserves special training
to avoid undesirable results and vascular complications.
Usually, the lip contour is made with low G ‘prime hyaluronic acid, using
needles or microcannulas. The needle allows more refinement, but is more
painful, results in more bruising, and is less safe from a vascular point of
view. Lip volumizing is done with an intermediate G ‘prime product and can
be performed in three planes: in the superficial fat compartment of the lip,
intramuscular plane, or deep fat compartment. From a vascular point of view,
the safest plane is the superficial fat compartment since, in only 2% of
cases, the labial artery is in this plane31,32. The
plane with the most significant potential for vascular complications is the
deep lip fat compartment, where the labial arteries are usually found31.
The repositioning of the corner of the mouth also contributes to the
beautification of the perioral region. The treatment of the commissures and
the lip-mandibular groove in the subcutaneous plane, with medium G ‘prime,
fill, can promote the commissures’ rise, reducing the aspect of sadness and
bravery. Botulinum toxin is more rarely indicated in the perioral region’s
treatment to produce “beautification”.
The treatment of the oral angle depressor muscle (OAD) with 2 to 3 units of
toxin (50U/mL), at the point of greatest muscle power, contributes to the
rise of the commissures, enhancing the results of the fillers. The treatment
of the orbicularis muscle in “beautification” patients is usually not
indicated.
Mandibular contour and chin
While in women, the attractiveness is concentrated in the middle third of the
face, in men, the lower third is the one that stands out the most due to its
square characteristics and well-defined mandibular contours. The male chin
is usually wider and more protruding, in contrast to the thinner, more
rectified lips.
The treatment of mandibular contour and chin has been the main reason for the
male visit to doctors’ offices regarding facial beautification. Hyaluronic
acid-based fillers are applied to widen the distance between the jaw angles,
matching the bitemporal and bimalar distances and the redefinition of the
body branch of the jaw. Male angles are more acute, redefined using high G
‘prime hyaluronic acids, applied with cannulas or needles, in the
subcutaneous or supraperiosteal plane. The treatment of the body and the
branch of the mandible is usually performed with cannulas, with products of
high G ‘prime, by retroinjection and in a superficial subcutaneous plane.
There is a tendency to fill the mandible body close to its lateral edge to
widen the lower third.
The delicacy of the lower third of the female face should be encouraged.
Although well-defined angles are acceptable in women, the mandible should
not be enlarged and should not protrude from the middle facial third. When
filling the mandible branch and body, when indicated, it must be performed
delicately, tending the lower margin of the mandibular body in order to
lengthen and not to widen the lower third.
The use of botulinum toxin can be carried out in treating hypertrophy of the
masseter muscle, both in women and in men, with care in the latter not to
over-tune the lower third. In more selected situations, female faces can be
submitted to platysma treatment, helping to define the mandibular contour,
treating platysma bands, and so-called “necklaces” lines (horizontal lines
that form in the neck secondary to platysma hyperkinesia).
The mentum is a structure still little valued in cosmiatric treatments;
however, it has an essential role in the beautification process. The filling
of the lip-mandibular groove promotes rejuvenation and elongation of the
lower third of the face, which can also be associated with filling the
chin’s apex, giving it greater projection and triangulation.
The female mental filling should be done with a single central point or two
points very close to the midline, with a high G ‘prime product, with a
cannula or needle, in the subcutaneous or juxtaperiosteal plane. The
objective is to provide delicacy to the chin and collaborate for facial
triangulation. In women, the width of the chin should match the width of the
nasal base.
For the male chin treatment, the points of application must be more distant
from each other to promote its enlargement. It is also possible to treat the
lateral subcutaneous tissue to gain even more horizontal dimension,
providing more virility to the segment. The male chin’s width should
coincide with the distance between the medial margins of the iris limbs
(Figure 5).
FIGURE 5 - The female chin’s width should not exceed the interim
distance, while the male chin has the distance between the
iris’s internal limbs (blue lines). For mental enlargement with
fillers, spaced mental projection points (circles) and lateral
subcutaneous filling (triangle) can be made.
FIGURE 5 - The female chin’s width should not exceed the interim
distance, while the male chin has the distance between the
iris’s internal limbs (blue lines). For mental enlargement with
fillers, spaced mental projection points (circles) and lateral
subcutaneous filling (triangle) can be made.
In both men and women, the presence of pronounced mental grooves can be
minimized with the linear filling, with a cannula, in the subcutaneous
plane, with products of high G ‘prime. More marked mental grooves are more
accepted in men, being a sign of virility. Botulinum toxin can be used in
the chin to minimize hyperkinesia and mental muscle tone, both in men and
women.
CONCLUSION
Cosmiatry is a rapidly expanding area of medical practice, especially about the
use of botulinum toxin and fillers based on hyaluronic acid. These procedures
can be used to prevent and restore the signs of aging and promote facial
beautification. Anatomical knowledge applied, refined technique, and full
control over the main sexual characteristics, are fundamental to produce facial
beautification with all the excellence expected from great specialists, such as
plastic surgeons and dermatologists.
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1. Instituto Boggio, medical center, São
Paulo, SP, Brazil.
Corresponding author: Gladstone Eustaquio de Lima
Faria, Rua Desembargador Eliseu Guilherme, 200, 2°andar, Conjunto
207, Paraíso, São Paulo, SP, Brazil. Zip Code: 04004-030. E-mail:
gladstonefaria@hotmail.com
Article received: November 14, 2019.
Article accepted: July 15, 2020.
Conflicts of interest: none
