Cause of male pattern hair loss – is the answer to be found in the face?
Hypothesis: Increased muscle tone of the facial and masticatory muscles as a result of psycho-neural conditioning (stimulus-response pattern) caused by interpersonal interaction.
Hypothesis + approaches to refute it (at the end):
The special role of the face as a body part is taken into account in order to indicate a psycho-physiological phenomenon that is possibly causative for male pattern hair loss:
In modern, anonymous, populous societies, the face (especially the mouth, eyes, eyebrows) is the primary tool for interpersonal communication, interaction, and identification. A wrong or inappropriate facial expression can have serious, life-threatening consequences – depending on the situation:
Example 1 (exaggerated): a wrong facial expression in an area characterized by crime and violence → physical attack by easily provoked/violent individuals → injury/death
Example 2 (exaggerated): a wrong facial expression in a job interview → no job → no income → no money for food → hunger/death
Through interpersonal mimic and verbal interaction, humans are conditioned since birth to have their facial expressions under control so as not to provoke unwanted/wrong interpretations and associated reactions from their fellow humans that could have a detrimental effect on their lives in the short or long term, directly or indirectly. The basis for this conditioning is the association of emotion and facial expression anchored in the human mind or predefined by society. Each emotion is assigned a corresponding facial expression. It is a widespread assumption that a person’s facial features (facial expressions) basically represent his or her emotional state at all times, since everyone has adjustable facial expressions. This means, for example, that when someone relaxes his/her facial muscles, his/her face, and thus he/she as a person, then also makes a relaxed or neutral impression on other people.
“Problem”: some people have a facial shape that does not make a relaxed or neutral impression on other people when physically relaxed. These people are consciously or unconsciously conditioned through interpersonal mimic interaction, but also through verbal communication, to keep their facial and masticatory muscles permanently in tension in order to be able to adjust their facial expression if necessary, since their physically relaxed face triggers undesirable/wrong interpretations and associated reactions in other people. This permanent, subliminal tension (increased muscle tone) of the facial and masticatory muscles possibly sets off a chain of effects that ultimately causes hair loss.
Example 1 (hair loss in the forehead and temple area):
In a man with eyes that appear “piercing” to outsiders or an eye area that appears threatening or irritating, a permanent, subliminal tension of the following muscles arise (increased muscle tone):
Musculus frontalis (function: frowning, raising the eyebrows)
Musculus occipitalis (function: smoothing the forehead)
Musculus corrugator supercilii (function: pulling down the eyebrow, wrinkling the forehead)
The final result of the increased muscle tone of the mentioned muscles is hair loss in the forehead and temple area. Because of the connection to the galea aponeurotica, hair loss can also occur on the vertex and tonsure. Simultaneous tension (increased muscle tone) of the above-mentioned mimic muscles is not necessarily visible in a person’s facial expression – just as, for example, the biceps and triceps can be tensed at the same time and the arm can still hang down and make a relaxed impression on outsiders. Because the muscle tone of the aforementioned muscles builds up over time and is in a subliminal range, it is not necessarily noticed by the affected person.
Example 2 (hair loss in the tonsure area – at the crown of the head):
In a man with a slightly open and slanted mouth in a physically relaxed state, and partially visible teeth – which in combination can have a threatening or irritating impression on surrounding people – a permanent, subliminal tension of the following muscles arise (increased muscle tone):
Musculus buccinator (function: pressing the jaws)
Musculus orbicularis oris (function: contraction of the mouth opening)
Musculus depressor anguli oris (function: lowering the corner of the mouth)
Musculus risorius (function: lateral and headward movement of the corner of the mouth, retraction of the dimple of the cheek – laughing muscle)
Musculus zygomaticus (function: pulls the corner of the mouth up and back – smile muscle)
Musculus levator labii superioris (function: lifting the upper lip)
Musculus depressor labii inferioris (function: lowering the lower lip)
Musculus levator anguli oris (function: lifting the corner of the mouth)
Musculus masseter (function: lifting and lateral movement of the lower jaw)
Musculus temporalis (function: jaw closure, retraction of the lower jaw)
Musculus pterygoideus medialis (function: lifting of the lower jaw, jaw closure)
Musculus pterygoideus lateralis (function: opening of the jaw, advancement of the lower jaw, grinding movements from right to left or vice versa)
Musculus mylohyoideus (function: opening the mouth, raising the hyoid bone)
Musculus geniohyoideus (function: advancement of the hyoid bone – involved in mouth opening)
Musculus digastricus (function: opener of the oral fissure – involved in mouth opening)
The final result of the increased muscle tone of the mentioned muscles is hair loss in the tonsure area (at the crown of the head).
The following video visualizes the increased tension of the facial muscles and masticatory muscles and the progress of hair loss as a function of time.
Questions and answers – to identify possible weaknesses of the hypothesis:
Q: What could be the chain of effects triggered by the increased tone (chronic contraction) of the facial and masticatory muscles that ultimately leads to hair loss?
A: The consequence of the increased tone/chronic contraction of the muscles mentioned could be a permanent direct or indirect squeezing of blood vessels by the tense mimic muscles and the masticatory muscles (a) and/or a malposition of the mandible (b) and/or increased regional tension of the scalp and/or the galea aponeurotica (c).
(a) The consequence of a direct squeezing of blood vessels by the tense mimic muscles and the masticatory muscles could be a disturbance of blood circulation and thus an obstruction of the removal of metabolic products from the scalp sites. The assumption is that especially the veins and thinner venules (function: blood backflow to the heart) are affected. Chain of effects: Accumulation of metabolic products at scalp sites → Inflammation → DHT at scalp sites → TGF beta 1 → scarring of the hair follicles → hair loss.
As can be seen in the following dissection photos (see left picture) you can see how the superficial temporal vein (blue) runs close to the frontalis muscle, in some places the vein even seems to be slightly ingrown into the muscle?
(b) The consequence of a malposition of the mandible could be a squeezing of blood vessels, whereupon a regional circulatory disturbance occurs, i.e. an obstruction of the removal of metabolic products from the scalp sites. Chain of effects: Accumulation of metabolic products at scalp sites → Inflammation → DHT at scalp sites → TGF beta 1 → scarring of the hair follicles → hair loss.
(c) The consequence of the increased regional tension of the scalp and/or the galea aponeurotica could be inflammatory processes. Chain of effects: Inflammation → DHT at scalp sites → TGF beta 1 → scarring of the hair follicles → hair loss.
The assumption is that the degeneration process (a/b/c → scarring of the hair follicles) takes place over a period of about 5 to 20 years, until the function of the hair follicles is so severely impaired that there is clearly visible hair loss. The basis for this assumption is the observation of people with transplanted hair, whereby the transplanted hair follicles – contrary to common claims – are apparently also affected by the described degeneration symptoms after a certain time.
Q: Surgeons report normal bleeding of the scalp after incisions – what is the explanation?
A:
Heavy bleeding of the scalp reported by surgeons after an incision would say nothing about the quality and quantity of blood flow to the scalp if it is assumed that the problem is an obstruction to the outflow of blood from the scalp in the lower part of the head. In the video of a dental technician – who is convinced that he has found the cause of pattern hair loss – it is claimed (minute 21:21) that the vertex follicle pad of the head is an organ that has no muscle and no nerve and that therefore communication between the body and this region can only take place via blood (-pressure?). Assuming this statement is correct, this would mean that an incision in the scalp (blood flowing out of the scalp) would lead to a drop in pressure in the surrounding blood vessels, which would immediately lead to an increased blood flow to this scalp region, giving the impression of normal (healthy) conditions.
Based on the hypothesis, it is assumed that the permanent tension (increased muscle tone) is a consequence of the conditioning of the mind (a psycho-neural reflex). The permanent tension is therefore only present in states in which the mind is active or the reflexes are functioning. During incisions by a surgeon, the patient is usually full anaesthetised. It is assumed that the mind and reflexes are not active during anaesthesia, which results in the following chain of effects: Anaesthesia → described reflex inactive → no increased tension of the facial and masticatory muscles → no squeezing of veins and venules → normal blood flow to the scalp.
Q: How can the Norwood hair loss pattern be explained?
A: The Norwood hair loss pattern is the direct or indirect result of the tension created by the mimic and masticatory muscles. The effects of increased muscle tone (the hair loss pattern) are additionally influenced by the anatomy (e.g., shape of the skull, shape development and position of muscles and blood vessels, thickness of the galea aponeurotica, skin structure).
Q: How is hair loss "inherited"?
A: Head and face shape is genetic. The facial features of a son resembles the facial features of his father and mother. Due to the similar facial features, the son is subject to the same subconscious psycho-neural conditioning process, which leads to similar tensions (increased muscle tone/chronic contraction) and, as a result, to a similarly hair loss pattern. Because facial expressions are learned by imitation, and parents spend most of their time interacting with their children during the first years after birth, parent-infant interaction could contribute significantly to the psycho-neural conditioning described above.
Q: Why are significantly more men than women affected by pattern hair loss?
A: The conditioning (establishment of psycho-neural reflex → increased muscle tone) that leads to hair loss in men does not lead to hair loss in women because of the different Anatomy (e.g., different skin structure, thinner galea aponeurotica, lower muscle mass and strength, different skull shape). For example, according to studies, women only have 60-70% of the bite force of a man.
Q: How can the alleged successes due to the use of muscle relaxants in the face be explained?
A: The muscle relaxants injected into the face and scalp relax parts of the mimic muscles and the masticatory muscles, which partially relaxes the described muscle tensions that ultimately lead to hair loss.
Q: Why does transplanted hair grow?
A: Pattern hair loss is thought to be the result of a degeneration process that takes place over several years. With a hair transplant, healthy tissue is transplanted along with it, so the degeneration process – which can take up to 20 years before there is clearly visible hair loss – only starts after the transplantation.
Q: Why does hair loss in identical twins (same genetic makeup) develop differently?
Identical twins have identical genetic material, but environmental factors during adolescence can lead to slight differences in anatomical (craniofacial) development. Slight differences in anatomy could lead to one twin being more affected by pattern hair loss than its twin. Example: Increased muscle tone as a result of the described psycho-neural reflex leads to a greater pressure on veins and venules (→ more hair loss) in a twin due to a slightly less beneficial craniofacial development resulting from a less favorable diet during adolescence.
It is possible that the twins grew up in different environments: different number of interpersonal interactions and different sensitivity of the twins and surrounding people to facial expressions. The result would be a different degree of psycho-neural conditioning (differently increased muscle tone) and consequently a different progression of hair loss.
Q: Why does a lack of sleep accelerate hair loss?
A:
In addition to the known negative effects (hormone fluctuations, inflammatory processes, limited regeneration of hair follicles), sleep deprivation is also associated with increased muscle tone and increased blood pressure. It is also known that muscle tone is reduced during sleep. Less time asleep means more time with increased muscle tone.
According to the hypothesis, a psycho-neural reflex is the cause of the tension that leads to hair loss. During sleep, the activity of the mind is reduced and reflexes that are not essential for survival are reduced in their activity. The described psycho-neural reflex is therefore possibly switched off during sleep.
Q: Why are isolated/uncontacted groups (hunter-gatherers) not affected or less affected by pattern hair loss?
A: They are usually smaller, non-anonymous groupings of people where everyone knows everyone else from birth and interacts with each other, making facial expressions and the need to adjust and interpret them less important. The necessary framework conditions for the described psycho-neural conditioning that leads to hair loss are therefore not given. So if the hypothesis is correct, pattern hair loss could also be described as a disease of an anonymous and populous society. In the modern, anonymous societies, in which people are usually clothed up to the head, the focus during interaction is furthermore mainly on the face or the head, which possibly intensifies the described psycho-neural conditioning.
Q: Assuming the hypothesis is correct, what are the possible reasons for the “failure“ of research into the cause of pattern hair loss?
A:
Pictures of faces are largely useless as a basis for a pattern recognition because people taking pictures of themselves or being photographed by others usually adjust their faces. It is rare to see physically relaxed faces in pictures. This is equally true when observing the facial features of the people surrounding one, where physically relaxed faces are also rarely seen.
The impression that facial features have on an outside person is something very subjective, making pattern recognition difficult.
A person's sensitivity to other people's mimic and verbal reactions to their own facial features is something very subjective, making pattern recognition difficult.
According to the hypothesis, a conditioned reflex is the cause of hair loss (increased muscle tone → squeezing of blood vessels → degeneration of hair follicles). During surgical procedures (body is anaesthetized) and during dissection (body is dead), the reflex is not active, i.e. during examination methods that allow a clear insight, the mechanism that according to the hypothesis leads to hair loss is switched off and therefore not detectable.
As described in the hypothesis, it could be that the anatomy (skin structure, thickness of the galea aponeurotica, position and shape of muscles and blood vessels, muscle mass and strength, skull shape) is decisive in whether increased muscle tone leads to a circulatory disorder that is sufficient to degenerate the hair follicles. This means that there are people with increased muscle tone who have hair loss and those with increased muscle tone who do not. This circumstance makes pattern recognition difficult.
In general, it should be considered that pattern hair loss can have several causes. For example, it could be that a disadvantageous craniofacial development as well as a misalignment of the mandible are separate causes of pattern hair loss.
Q: Assuming the hypothesis is correct, what is the cure for hair loss?
A:
If mankind were to reach a state of development in which a assessment of the state of mind based on facial shape and facial posture is no longer necessary, the phenomenon ("genetic hair loss") would disappear (die out) on its own over time. The same would apply to the scenario in which humanity again breaks down into numerically small, isolated, non-anonymous groupings.
Understanding the mechanical/physiological chain of effects that leads to pattern hair loss: If a detailed understanding of this chain of effects were developed, it may be possible to intervene in this chain of effects using appropriate methods.
Understanding the functioning of the causative psycho-neural reflex: If a detailed understanding of how this reflex develops and functions in everyday life were developed, it might be possible to prevent its development and possibly counteract its “triggering” in everyday life.
Q: Assuming the hypothesis is correct, are there further implications?
A:
Cardiovascular diseases: Some epidemiologic studies have observed that men with pattern hair loss have a higher risk of coronary heart disease. A study published in the journal “Heart” has shown that men with severe hair loss (especially in the tonsure area) may have an increased risk of cardiovascular disease. One risk factor for cardiovascular disease is increased blood pressure. Here are two possible explanations:
The known causes of cardiovascular diseases (e.g. atherosclerosis) can also intensify the circulatory disorder caused by the increased muscle tension, for example by a narrowing of the blood vessels, and thus further increase hair loss.
The hypothesis presented assumes a slowing and stagnation of blood flow through veins and venules, which – if not otherwise regulated by the body (e.g. by bypass via neighboring veins) – leads to a local slowing or stagnation of blood circulation and can thus increase the blood pressure in the supplying arteries. If the hypothesis presented is correct, it could be investigated whether the mechanism that leads to hair loss (psycho-neural reflex → muscle tension → impairment of blood circulation) could also play a relevant role in the development of cardiovascular diseases.
Tinnitus and hearing loss: Assuming that the consequence of chronic tension of the facial and masticatory muscles is an obstruction of venous drainage from the scalp and muscles, this could also have a detrimental effect on blood flow to the ear. The consequence of increased blood pressure in the ear could be tinnitus. Chronic reduced blood flow could affect the auditory hair cells in the inner ear over time, which can lead to a deterioration in hearing.
Q: How is the described psycho-neural reflex established and how does it work?
A:
A closer examination of the reflex described in the hypothesis should be preceded by evidence of the mechanism described (e.g. squeezing of veins and venules by muscles). Nevertheless, the following are two possible approaches:
a) A conditioned protective reflex: The psycho-neural reflex described in the hypothesis could be assigned to the category of protective reflexes. The body or the autonomous part of the mind recognizes a dangerous situation or a dangerous object via the sensory organs (eyes, ears, nose, nerves) and automatically initiates a body movement (a reflex). Known protective reflexes:
The automatic withdrawal of the hand when something hot is touched.
The automatic closing of the eyes when an object approaches the eyes at high speed.
The psycho-neural reflex and thus the tensing of the facial and masticatory muscles may be triggered by the following:
Interaction with other people (looking at faces)
Thoughts of other people: The mind automatically associates people with their faces.
b) Mental focus increases muscle tension: It is known within neuroscience that a mental focus on a muscle-containing part of the body can lead to an increase in the tone of the muscles there, which is pragmatic. For example, if you have the intention to perform a certain body movement, the subsequent body movement can be initiated and performed more efficiently if the muscle already has a slightly increased muscle tone in advance. It is possible that the conditioning described in the hypothesis is characterized by the fact that the mental focus of the person concerned is excessively directed to the face or the person cannot take the focus off the face, which leads to a permanently increased tension of the facial and masticatory muscles.
Refutation of the hypothesis:
Epidemiology: If the hypothesis is correct, people who are completely blind and completely deaf since birth should be less or not at all affected by hair loss, since the described conditioning (establishment of psycho-neural reflex → increased muscle tone) occurs mainly due to the visual and the acoustic perception of the reaction of outside persons (note: deaf-blindness often does not mean the complete loss of hearing and vision). A person who became completely blind and completely deaf at the age of 5, for example, is not suitable for a refutation. A person who is totally blind and totally deaf since birth but who was previously able to recognise facial features or understand the spoken word by means of technical devices is not suitable for refutation. It must be ensured that the person’s hair loss is not due to another condition. If the group of people mentioned is not less affected by pattern hair loss, the hypothesis is refuted.
Measurement of the muscle tension:
Measurement of the muscle tone of the mimic and masticatory muscles of men affected by pattern hair loss (age > 30 years) and measurement of the muscle tone of men of the same age who are not affected by pattern hair loss (e.g. EMG). Both groups have to set their – in their opinion – relaxed facial expression for the measurement. If no increased muscle tone is detected in men with pattern hair loss, this weakens the hypothesis.
Measurement (e.g. EMG) of the muscle tone of the mimic and masticatory muscles of male twins (age > 30 years) whereby one of them is affected bei pattern hair loss und the other one not at all. The twins have to set their – in their opinion – neutral (relaxed) facial expression for the measurement. If no increased muscle tone is detected in the Twin(s) with pattern hair loss, this weakens the hypothesis.
The Hypothesis assumes that the increased tension is the result of a reflex. Under anesthesia reflexes are switched off. One could measure the muscle tone of the mimic and masticatory muscles of men affected by pattern hair loss (age > 30 years) before and under anesthesia. If no decreased muscle tone is detected under anesthesia, this weakens the hypothesis.
Some men who take oestrogen report that their pattern hair loss has slowed down or even reversed as a result. The common assumption is that this is due to a reduction in testosterone and therefore a reduction in dihydrotestosterone (DHT), which is declared to be the cause. However, the reduction in testosterone is also accompanied by a reduction in muscle mass and muscle strength. One could measure the muscle tone of a man's facial and masticatory muscles before and after taking oestrogen – if there is a slowdown or reversal of hair loss. If no reduction in muscle strength and muscle mass can be detected, this weakens the hypothesis.
Muscle Relaxation: If men with hair loss (age > 30) are found to have increased tension in the facial and masticatory muscles, an attempt could be made to relax the muscles where increased tension has been detected with muscle relaxants. Beforehand, a 3D model could be created based on the results of the muscle tone measurement (EMG), from which it can be deduced at which points an injection of muscle relaxant makes sense. It would first be necessary to find out which muscles are only tense because they are compensating for the tension of an antagonising or connected muscle. Injecting muscle relaxant into a muscle that only automatically compensates for the tension of another muscle would not be effective. In addition, an MRI or other imaging procedure could be performed in advance to determine the position and shape of the veins and muscles as well as possible locations where veins penetrate and touch the muscles. After the muscle relaxant has been injected into the relevant muscles, another measurement of muscle tone (EMG) could be carried out to see whether relaxation of the relevant muscles has taken place and, if so, how this affects the tension of antagonising and connected muscles. If relaxation has occurred as a result of the injection, the injection of muscle relaxant could be continued over a longer period of time (> 6-12 months) and the effects observed. In addition, a time-resolved MR aniogram of the head with contrast medium (if suitable) and Doppler blood flow measurements of relevant blood vessels could be carried out before and after injection of the muscle relaxant in order to determine the influence of muscle relaxation on blood flow to und form the scalp. In the final evaluation, however, it must also be taken into account that it is not known whether the function of degenerated hair follicles can be fully restored at all and, if so, how long this regeneration process takes. It must of course be taken into account that the facial muscles and especially the masticatory muscles fulfill a vital function (e.g. when eating) and therefore cannot be completely relaxed with muscle relaxants. It must also be taken into account that suitable muscle relaxants (e.g. Botox) are neurotoxins.
Blood flow measurements:
Doppler blood flow measurements of the blood flow in veins and venules that have previously penetrated the facial expression and masticatory muscles of men affected by hair loss (age > 30 years) and the same measurement of men of the same age who are not affected by hair loss at all. Both groups have to set their – in their opinion – relaxed facial expression for the measurement.
Doppler blood flow measurements of blood flow in veins and venules that have previously penetrated the mimic and masticatory muscles of men affected by pattern hair loss before and during anesthesia. If a reduced flow velocity was observed before anaesthesia, it could be observed whether the blood flow velocity normalizes during anaesthesia (reflexes are inactive). The influence of anesthesia on blood flow velocity must be taken into account during this examination. If no reduced blood flow velocity is measured during anesthesia, this weakens the hypothesis.
Imaging techniques and dissection: Review existing MRI results and dissection results and perform targeted dissection to show that a chronically increased tension (increased muscle tone) of the mimic muscles and masticatory muscles does not exist or that it has no influence on the quality and quantity of blood flow to and from the scalp or any other kind of negative influence on the surrounding tissue that could trigger an effect leading to hair loss.