The age of brotox
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Noninvasive options lure more men to cosmetic treatment

Smoothing, tightening, lifting, slimming — they’re not just for women anymore. Encouraged by the availability of noninvasive techniques that leave few telltale signs of having had “work done,” more men are opting for cosmetic treatments, say dermatologists who specialize in these procedures. “There’s been a certain stigma associated with cosmetic surgery in men, and historically they have stayed away from that,” said Mark S. Nestor, MD, PhD, voluntary associate professor of dermatology at the University of Miami Miller School of Medicine and director of the Center for Cosmetic Enhancement in Aventura, Fla. “What’s happening now is that as men realize that they can have nonsurgical procedures that look natural and help them look young, more and more are opening up to having them.”

The 2011 Plastic Surgery Statistics Report, published by the American Society of Plastic Surgeons (ASPS), shows a 56 percent increase in minimally invasive procedures in men. Meanwhile, it shows a 48 percent drop in cosmetic surgical procedures in men since 2000. Botulinum toxin type A injection has become by far the most popular cosmetic treatment among men, and the term “brotox” now appears in the online Urban Dictionary. The number of toxin procedures (363,018 in 2011) has leaped by 286 percent since 2000 and 8 percent since 2010. (The ASPS statistics represent procedures performed by member surgeons and other board-certified specialists, including some dermatologists.)

Nonetheless, men still represent only a small slice of the market for cosmetic procedures — and that presents an opportunity for dermatologists, say the experts. Results from the 2011 American Society for Dermatologic Surgery (ASDS) Survey on Dermatologic Procedures indicate that men accounted for about 10 percent of the overall total for injectable neuromodulator procedures, and 8 percent of the total for procedures involving soft-tissue fillers. The ASPS survey found that men accounted for 9 percent of all cosmetic procedures. Dermatologists point to a confluence of factors that are likely to further drive demand among men: an aging population, increasing acceptance of aesthetic treatment for men, competition in the workplace, and improvements in noninvasive products and techniques. And, dermatologists are particularly well suited to address men’s needs, said Dr. Nestor, because non-invasive treatments are “where dermatologists live, as opposed to plastic surgeons. They’ll feel comfortable with us. We’re in a unique situation where men come to us with a rash or a growth, and we can educate them not only about how we can help them medically but how we can help them aesthetically.” [pagebreak]

Key factors that affect men’s choice of procedure include expected results, degree of discomfort, required downtime, and longevity, the experts said.

Hair, more or less

Hair transplants, which Dr. Nestor called “the only cosmetic procedure that’s been totally male-driven over the years,” continue to be popular with men, and Tina S. Alster, MD, whose practice is located two blocks from the White House, maintained that “a ton of attorneys come in on their lunch hour for hair enhancement” via low-level diode laser treatments. Dr. Alster, who is clinical professor of dermatology at Georgetown University and director of the Washington Institute of Dermatologic Laser Surgery, noted that many younger men are as intent on removing hair as middle-aged men are on restoring it. “There’s a greater acceptance among young men to be groomed,” she said. “They want no hair in their private areas, and certainly laser hair removal is a better option than ongoing waxing treatments.” In fact, teenagers and college-age men can become “distraught over mild amounts of hair on their chest or back — that concern didn’t exist 10 years ago,” said Jeffrey S. Dover, MD, associate clinical professor of dermatology at Yale University School of Medicine and director of SkinCare Physicians in Boston.

Fillers and toxins

Fillers and toxins are gaining acceptance among men for a variety of reasons, in addition to the fact that they’re among the least obvious procedures to detect. Jonah Shacknai, chairman and chief executive officer of Medicis Pharmaceutical Corporation (which markets the Restylane family of fillers and Dysport, a toxin), said patients likely view these products as a better value than they were just a few years ago. “And, we know that with the toxins, there’s some relaxation of the muscle. So I think it’s perceived as a good bang for the buck, and it doesn’t require the expense and downtime of a facelift.” Longevity is key because unlike women, men are reluctant to come in for multiple treatments, Dr. Alster said. “I have women with standing appointments every month — I have no guys who do that,” she said. “They want one-stop shopping, easy in, easy out, and they don’t want to feel like they’re wed to you.” [pagebreak]

Dr. Nestor warned that although men respond well to toxin injections, “it’s harder to treat men because a lot of them have low brows, and when you knock out the frontalis, the brows get lower and don’t look good. So you have to be careful, you have to know what you’re doing.” He also pointed out that men are now more open to treating their nasolabial and mesolabial folds because fillers, when used to replace volume in the cheeks, look more natural than earlier treatment approaches.

Body sculpting

Like women, men are looking to dermatologists for noninvasive body sculpting. “Sometimes they’re way overweight, but often they’re very fit but have a tiny bulge over their belts, or love handles, or gynecomastia,” Dr. Dover said. “Zeltiq [coolsculpting] works beautifully for localized areas of fat reduction — we get 22 percent fat layer reduction per treatment.” Susan Weinkle, MD, clinical professor of dermatology at the University of South Florida and president of the ASDS, predicted that sodium deoxycholate, an injectable fat-dissolving agent now in clinical trials, may prove to be an effective weapon against the double chin that plagues many men as they age. Currently, men are opting for ultrasound and a variety of radiofrequency procedures to tighten jowls and other facial areas, Dr. Nestor said. [pagebreak]

Men are from Mars

To a certain extent, men are motivated to seek cosmetic treatment for the same reasons women are, but there are key differences. While women may view a more youthful appearance as a goal in itself, men tend to see cosmetic treatment as a means to an end, the experts said. “Everybody wants to look better for their mates, but you may see more men getting cosmetic treatment for socioeconomic reasons,” said Dr. Nestor. “Men do not say, I’m doing this for myself.’” Men’s major motivation for seeking treatment “is either occupation or women,” agreed Mary P. Lupo, MD, clinical professor of dermatology at Tulane Medical School and director of the Lupo Center, an aesthetic and medical dermatology practice in New Orleans. “Either they’re divorced and they want to get into dating again, and they feel they look spent and tired, or they want to keep a competitive edge within their profession. Even teachers and college professors, because they interact so much with young people, want to look vibrant and energetic and relevant, not like old fogies.” Dr. Weinkle said she sees 50- to 60-year-old patients “who maybe lost a loved one, and want to look better in a competitive social environment.” Dr. Nestor cited a patient in his 60s who told him, “I’ve never had work done, but I’m engaged to a 27-year-old woman. I have to look younger.”

In Dr. Alster’s K Street practice, male (and female) patients who normally might not seek cosmetic treatment are coming in because it’s a presidential election year, and many are thrust into the spotlight of HDTV. “I am just inundated with politicians on both sides of the aisle, and with print journalists who may not normally need to be on TV,” she said. “All bets are off in an election year — I see everybody.” Apart from the election-year crowd, men focus on different cosmetic issues than women and tend to wait longer, she maintained. “Men are not as picky about lines; they’re not looking at crow’s feet, by and large, or lines around their mouth. A lot of them come in because they have a red nose, or scaly, pigmented bumps. I do more PDT for rosacea and photodamage treatments in men than in women — women would never let themselves get to the point that men do, with a lot of skin keratoses and discoloration. Regardless, the clinical success of treatment in men is very high.”

Often the motivation to seek cosmetic treatment doesn’t come from the men themselves, but from significant others and family members. “If they’re heterosexual, they usually come in with their wife or girlfriend, or the suggestion has been made very strongly that they come in,” remarked Dr. Dover. “I actually prefer that they come in with that person because sometimes, if they come in alone, they say, I don’t know why I’m here, my wife told me I should come.’” In contrast, gay men and those Dr. Dover characterizes as “metrosexual” are more likely to come to him of their own volition. “And they’re actually a delight to take care of; they can be very particular, sometimes more particular than my female patients, which is interesting. They appreciate good results, so they appreciate our talent.” [pagebreak]

Who’s seeking treatment

With the advent of noninvasive, natural-looking cosmetic procedures, the range of men opting for cosmetic treatment has broadened to include patients of all ages, ethnicities and sexual orientations. “I think that as gay men set trends in many markets, particularly in fashion and appearance, they have done so in this market, and now we’re seeing straight men come to view these kinds of treatments as completely acceptable and appropriate,” Shacknai said. Dr. Dover said he is seeing the biggest increase among “metrosexual” men: a “younger group, in general — men in their 30s, 40s, 50s — who care significantly about their appearance and want to be in touch with their feminine side.”

Among men of different racial groups, specific procedures may be dictated by how a particular group tends to age, said Dr. Lupo, who treats Asian, African-American, Hispanic, and Caucasian men. “My laser hair removal patients tend to be Caucasian, if it’s for cosmetic purposes, and white men also come in for jowl treatment and body sculpting,” she noted. “For Asian males, it’s usually toxin and midface fillers. For African-Americans, it’s usually cheek augmentation, because they get cheek flattening, and the nasojugal fold.”

Tapping into the male market

In partnership with a young dermatologist who just completed his residency at the University of Miami and suggested the idea, Dr. Alster said she plans to open a men’s center in the same building as her current practice, but on the first floor, so men can walk in and out without feeling like they have to pass as many people. “I think you almost have to have a little bit of a man cave,’” she said, suggesting that men seeking cosmetic work may be uncomfortable sitting in, or passing through, a waiting room full of women and fashion magazines. Instead, the waiting room is populated with other men and features magazines like Sports Illustrated, Men’s Health, and Esquire, Dr. Alster said. She views men as a “virtually untapped market,” and said a focus on males might be a point of differentiation for young dermatologists just launching their practice, “especially in a market saturated with cosmetic dermatologists.” [pagebreak]

None of the other experts routinely target men in a formal way, but they offered a number of suggestions for dermatologists looking to address the cosmetic needs of their male patients. First, realize that men are more apprehensive than women about pain, reassure them that pain will be minimal, “and then follow through with that reassurance,” Dr. Lupo said. “I do that through the generous use of topical anesthetics, and I only use injectables with lidocaine.” Second, show them photos of real results after fillers “to let them know that the Real Housewives’ are not a good representation of what filler results will look like. Men don’t want to look done.’” And finally, enlist the wives and daughters as partners, forming a “conspiracy to get them to do things.” Such a strategy could allow cosmetic services to be purchased as gifts, she said.

Dr. Weinkle emphasized the importance of a “slow introduction,” keeping in mind that some men are still afraid of “not being manly” if they address aesthetic issues. She also suggested pointing out the value of cosmetic procedures — that “for a small outlay, there’s much to be gained. Also, in this competitive market, removing their brown spots, their seborrheic keratoses, helping treat their rosacea, which is very much a cosmetic disorder, helps to get the male population to buy into why it’s good for them. We need to continue to teach the public and our patients about what we can do for them.” 

Learn more about marketing cosmetic procedures to men in our online-only supplement to this story.