Dean Elterman, MD, MSc

Americans spent approximately $16 billion on cosmetic surgery in 2016, according to an American Society of Plastic Surgeons report. Traditionally, cosmetic surgeries have been popular among women, with approximately 90% of all cosmetic surgery cases performed in female patients. However, growth in the male aesthetics market has translated into increased interest in cosmetic surgical procedures 

 The male market has increased for several reasons: Shifting social attitudes, improved professional competitiveness, new trends in fashion, and the attainment of an idealized self are a few reasons most often cited in the literature 

Of concern is whether the increased demand for male cosmetic procedures is a passable trend or a lasting norm. Clinicians interested in servicing this new community will have to consider the benefits of shifting their practice in order to meet the demand for male-focused cosmetic procedures.

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In this article, we provide an overview of the key concepts a clinician must take into consideration when consulting with men interested in undergoing a cosmetic surgical procedure.

In order to understand what treatments men want and are eligible to receive, clinicians must first gain familiarity with the male pattern of aging. Males and females have distinct variations in anatomy, specifically in regards to bone structure, muscle mass, thickness of skin, and distribution of fat. In general, men have greater periocular changes as they age. They develop more severe rhytides (wrinkles) on the face, except around the mouth, and are more likely to experience hair loss.

As males have thicker skin and more muscle mass around their face, the loss of fat with age shows deeper and more prominent facial lines, making them appear much older than their actual age and their female counterparts 

 As men and women differ both in their anatomy and their goals for pursuing cosmetic surgery, it is important for clinicians to specialize their treatment, dosages, and technique accordingly 

It is also important to note significant behavioral differences between males and females. There are many external risk factors for aging including sunlight exposure, pollution, cigarette smoking, repetitive muscle movements, and poor diet, with the most common being ultraviolet light exposure and smoking 

 Men who smoke tend to smoke more than their female counterparts, which increases their risk for skin aging 

 Furthermore, men are more likely to be exposed to UV radiation and less likely than women to apply sunscreen and utilize sun-protective behaviors.

Physicians need to be more cognizant of these gender differences in behavior and how these behaviors affect overall patient management.

In a patient considering cosmetic surgery, it is crucial that physicians assess the patient’s goals and expectations. This includes a determination of the patient’s aesthetic goals. Typically, males want to look younger while also enhancing features to appear more masculine. However, there is a point at which an aesthetic can become too masculine and may be undesirable by the patient. Therefore, it is important for clinicians to determine what features are considered aesthetically appealing in advance. More often, this is crudely defined as a mixture of masculine and feminine facial features.

In general, males focus their facial cosmetic concerns around the hairline, periocular region, and jawline, according to statistics from the American Society for Aesthetic Plastic Surgery. Men want to maintain their scalp hair, tighten their jawline, reduce dark circles and bags under the eyes, and reduce the prominence of wrinkles. Men also want to maintain their figure by having a slim waistline and smaller breast size if they have gynecomastia 

Cosmetic surgery has also increased in males as a result of genitourinary concerns. Studies show that if a man feels negatively about his “genital self-image”-the way a man regards his genitals-it may affect his sexual performance. If men are anxious and worried about their genitals’ size, appearance, and function, the result could be increased anxiety and subsequent sexual dysfunction.

Research shows that approximately 20% of males are embarrassed or unsatisfied with the appearance of their genitals 

 As such, it is noted that the number of scrotal lift procedures, penile and testicular enhancements, and adult cosmetic circumcision procedures is also increasing.

A second consideration is the patient’s willingness to undergo intrusive therapies. Consideration for the degree of invasiveness tolerable by the patient will limit the degree to which the clinician is able to achieve the patient’s desired aesthetic. However, technological and technical advances are reshaping the extent of aesthetic change possible with noninvasive and minimally invasive techniques.

For example, over the last two decades, the way facial aesthetic procedures are typically performed has changed. Facial procedures were regularly completed in the operating room, but with the emergence of noninvasive techniques, many of these procedures can now be completed in an office setting. There has been a noticeable increase in nonsurgical procedures, such as botulinum toxin A (Botox, Dysport, Xeomin) injections, soft tissue fillers, and chemical peels 

The top five cosmetic surgical procedures for men in 2017 were liposuction, eyelid surgery, breast reduction, tummy tuck and facelift 

 In 2017, men accounted for 10% of all liposuction procedures, 15% of all eyelid surgeries, 22% of breast reduction cases, 6% of tummy tucks, and 10% of all facelift surgeries (Statistics: The American Society for Aesthetic Plastic Surgery. 2017. 

Minimally invasive procedures have increased in popularity among men as well. Over the last 5 years, there has been a 44% increase in injectables, with a 5% increase from 2016 to 2017. Of all the injectable procedures performed in 2017, men accounted for 9%, with botulinum toxin injections being the top nonsurgical procedure 

 (Statistics: The American Society for Aesthetic Plastic Surgery. 2017. 

 There has been a notable increase in nonsurgical cosmetic procedures, especially among men.

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In general, men prefer noninvasive cosmetic procedures, as they can be done in the office setting, are relatively quick, and deliver noticeable results. Minimally invasive procedures are suitable options for patients who want an alternative to surgery and often have the added benefit of producing a long-lasting patient-clinician relationship.

It is evident that although men are not the major consumer in the cosmetic industry, they are on track to become significant consumers of cosmetic procedures. Examination of data over the last two decades shows men are becoming an increasingly important sector of this industry, with greater attention paid in developing techniques and technologies to address the demands of this population.

As longevity increases, there will be greater societal focus on maintaining a healthy, youthful physical appearance. This interest will create novel opportunities for clinicians to develop and deliver novel cosmetic surgical solutions to address this demand. In the future, men may eventually surpass women as recipients of key cosmetic procedures.

 is assistant professor, division of urology, University Health Network, University of Toronto.  

 is professor of urology at the Icahn School of Medicine at Mount Sinai and director benign urologic diseases, Mount Sinai Health System, New York. Follow him on Twitter at 

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	Prostate cancer remains the most common neoplasm diagnosed in North American and Western European men. Furthermore, this disease appears to be on the rise throughout Asia, as well as many developing nations. Risk factors including age, family history, and ethnicity have been demonstrated to impact prostate carcinogenesis; however, recent molecular insights have implicated chronic inflammation as critical in early prostate cancer development 

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	As a consequence of these molecular insights into prostate health, a focus on the dietary components capable of triggering inflammation as well as those able to mitigate inflammation, thereby limiting cellular damage, have been postulated to play a role in prostate carcinogenesis (figure). The mechanisms through which lifestyle factors such as diet affect the endogenous inflammatory milieu, if better elucidated, may provide opportunities for improved prostate health and screening strategies for prostate cancer prevention, as well as opportunities for improved treatment outcomes.

	Inflammation resulting in prostatic epithelial injury has been primarily attributed to several factors, including dietary carcinogens, hormonal imbalance, and infection 

 Presence of corpora amylacea as a result of neutrophil discharge was observed in response to prostate epithelial desquamation secondary to recurrent prostate inflammation. Microscopic examination of prostate tissues including glands containing prostate cancer demonstrated this innate immune phenomenon to be evident in prostate glands both during and after inflammatory insult, with numerous corpora amylacea containing myeloperoxidase, alpha-defensins, and calprotectins diffusely observed throughout such tissues 

 Over time, prostate epithelial injury results in focal atrophy lesions, as these cells favor an abnormal stress response pathway, thereby promoting a tissue-localized pro-inflammatory environment that may support its progression to prostate cancer.

	Epidemiologic studies have demonstrated that prostate cancer incidence and mortality display distinct geographical patterns, with men residing in North America and Western Europe exhibiting the highest risk for disease development, while the lowest risk is noted in men residing in Asia. Furthermore, this geographic pattern of prostate cancer risk has been shown to change upon emigration by individuals from low- to high-risk geographies. This finding has been strongly attributed to changes in dietary practices, with the strongest dietary associations for prostate cancer appearing to be red meat intake and a diet high in dietary fats (HDF) of animal origin 

	With respect to red meat intake, cooking at high temperatures or barbecuing that results in charring creates carcinogens, including heterocyclic aromatic amines and polycyclic aromatic hydrocarbons. These cooking practices are also associated with pro-inflammatory cellular changes and may explain increased prostate cancer incidence among men of African-American ethnicity 

 The most abundant carcinogen that occurs in charred meats is 2-amino-1-methyl-6-phenynlimidazopyridine (PhIP), and has been the best studied with respect to its impact upon prostate cancer development. Although non-toxic and non-carcinogenic in its parent form, upon metabolism by cytochrome p450 1A1/1A2 into its reactive metabolite, PhIP has been demonstrated to induce acute inflammation resulting in recurrent prostatic epithelial injury, a precursor to chronic inflammation and prostate cancer development 

	Additionally, a diet rich in HDF has been closely associated with increased risk for benign prostatic hyperplasia as well as prostate cancer development 

 Multiple studies in rodent models have demonstrated that HDF diets induce a prostatic pro-inflammatory milieu, increasing risk for both prostate cancer development and progression. A proposed mechanism for these observed phenomenon focuses upon adipocyte cytokine production resulting in subclinical chronic inflammation and subsequent prostate epithelial cell injury. HDF-induced prostate inflammation was demonstrated to promote immune cell infiltration into prostate tissues in conjunction with basal-to-luminal cell differentiation, a process essential for the initiation of prostate cancer of basal cell origin 

	Given basal cell-derived prostate cancers tend to be invasive, the interaction between HDF and aggressive prostate cancer may provide an alternative explanation for the close association between metabolic syndrome and increased risk for high-grade, invasive prostate cancer.

Next: Quantifying inflammatory potential of diet

Quantifying inflammatory potential of diet

	The Dietary Inflammatory Index (DII), a validated and literature-derived scoring system developed to estimate the pro- and anti-inflammatory potentials of overall diet and its possible impact on chronic disease has been utilized to quantify potential inflammation resulting from dietary choices 

 The association between DII and overall prostate cancer risk was assessed through a prospective cohort study of middle-aged men, and a positive association was noted between the pro-inflammatory potential of the diets with higher DII scores and increased prostate cancer risk. Furthermore, this phenomenon was statistically significant in three out of four stratified cohort quartiles, thus suggesting a threshold effect of chronic inflammation upon prostate cancer risk 

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	Results of this study were consistent with additional epidemiologic studies that demonstrated correlations between DII and a pro-inflammatory background associated with increased cancer risk. DII validation has been associated with multiple reactive biomarkers, primarily IL-6, TNF-alpha, and high-sensitivity C-reactive protein.

	The DII has also been investigated with respect to its impact on prostate cancer survival. Zucchetto et al conducted a retrospective cohort study in 726 men with histopathologically confirmed prostate cancer originally enrolled in a multicenter study exploring lifestyle factors and prostate cancer risk. DII was calculated by way of a retrospective food frequency questionnaire, and the study reported two main findings: DII scores were not significantly associated with all-cause mortality in prostate cancer patients, nor among patients with Gleason score 2-6. However, DII was noted to be directly associated with all-cause and prostate cancer-specific mortality in patients with Gleason score 7-10 disease. This finding implicates the potential impact of the DII on prognostication in patients with histopathologically proven aggressive prostate cancer.

	Amassed evidence suggests that dietary inflammatory potential may play a significant role in the alteration of prostate health and development of prostate cancer. Although the precise molecular pathways potentiating diet-mediated prostate inflammation continue to be investigated, contemporary studies offer evidence supporting the association of dietary inflammatory potential in the alteration of prostate health. In response to dietary carcinogens secondary to cooking process, HDF, or both, the propensity for recurrent prostate inflammation induced by epithelial injury remains a potential mechanism in the progression of prostate carcinogenesis.

	Ultimately, population-scale intervention with respect to diet modification and choice of cooking practice, with promotion of healthy food intake demonstrated to be anti-inflammatory, may prove to be an inexpensive intervention to improve prostate health and reduce the societal burden of prostate cancer.

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Dean Elterman, MD, MSc

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