The masculinity paradox: facial masculinity and beardedness interact to determine women's ratings of men's facial attractiveness

In many species, male secondary sexual traits have evolved via female choice as they confer indirect (i.e. genetic) benefits or direct benefits such as enhanced fertility or survival. In humans, the role of men's characteristically masculine androgen‐dependent facial traits in determining men's attractiveness has presented an enduring paradox in studies of human mate preferences. Male‐typical facial features such as a pronounced brow ridge and a more robust jawline may signal underlying health, whereas beards may signal men's age and masculine social dominance. However, masculine faces are judged as more attractive for short‐term relationships over less masculine faces, whereas beards are judged as more attractive than clean‐shaven faces for long‐term relationships. Why such divergent effects occur between preferences for two sexually dimorphic traits remains unresolved. In this study, we used computer graphic manipulation to morph male faces varying in facial hair from clean‐shaven, light stubble, heavy stubble and full beards to appear more (+25% and +50%) or less (?25% and ?50%) masculine. Women (N = 8520) were assigned to treatments wherein they rated these stimuli for physical attractiveness in general, for a short‐term liaison or a long‐term relationship. Results showed a significant interaction between beardedness and masculinity on attractiveness ratings. Masculinized and, to an even greater extent, feminized faces were less attractive than unmanipulated faces when all were clean‐shaven, and stubble and beards dampened the polarizing effects of extreme masculinity and femininity. Relationship context also had effects on ratings, with facial hair enhancing long‐term, and not short‐term, attractiveness. Effects of facial masculinization appear to have been due to small differences in the relative attractiveness of each masculinity level under the three treatment conditions and not to any change in the order of their attractiveness. Our findings suggest that beardedness may be attractive when judging long‐term relationships as a signal of intrasexual formidability and the potential to provide direct benefits to females. More generally, our results hint at a divergence of signalling function, which may result in a subtle trade‐off in women's preferences, for two highly sexually dimorphic androgen‐dependent facial traits.     

Beneath the beard: do facial morphometrics influence the strength of judgments of men's beardedness?

Converging evidence suggests men's beards, like many androgen-dependent masculine secondary sexual traits, communicate masculinity and dominance intra-sexually while effects of men's beardedness on attractiveness ratings are more equivocal. Beards may enhance perceived masculinity and dominance via amplifying aspects of underlying craniofacial masculinity, particularly the size of the lower face and jaw. Here we tested these predictions across two studies. In study 1, we tested how three facial metrics - objectively measured craniofacial masculinity, facial-width-to-height ratio (fWHR), and jaw size - calculated while clean-shaven impacted on ratings of attractiveness, masculinity and dominance of 37 men photographed when clean-shaven and with full beards. Results showed that beards exerted significant and positive effects on masculinity, dominance and to a lesser extent attractiveness. However, fWHR did not significantly interact with beardedness to influence the directions of any of the ratings, and while some linear and nonlinear interactions were significant between objective craniofacial masculinity and beardedness as well as between jaw size and beardedness, they tended to be subtle and dwarfed by the large main effect of beardedness on perceptual ratings. In study 2, we measured ratings of attractiveness, masculinity and dominance for composite clean-shaven and bearded stimuli experimentally manipulated in facial shape to represent ±50% the shape of a beard, essentially manipulating the size of the lower face and jaw of the stimuli. We found a strong main effect whereby bearded stimuli enhanced dominance and masculinity ratings over clean-shaven stimuli. Increasing the size of the lower face and jaw augmented ratings of masculinity and dominance in clean-shaven stimuli but did not exert strong effects within bearded stimuli. Attractiveness ratings were highest for bearded faces with smaller jaws followed by bearded and clean-shaven faces with larger jaws and lowest for clean-shaven faces with small jaws. Taken together, our findings suggest that beards exert main effects on masculinity and dominance possibly by amplifying male typical facial shape. Attractiveness ratings of facial hair may reflect a compromise between overly dominant looking faces with larger jaws and the additive effects beardedness has on these ratings.     

Negative frequency-dependent preferences and variation in male facial hair

Negative frequency-dependent sexual selection maintains striking polymorphisms in secondary sexual traits in several animal species. Here, we test whether frequency of beardedness modulates perceived attractiveness of men''s facial hair, a secondary sexual trait subject to considerable cultural variation. We first showed participants a suite of faces, within which we manipulated the frequency of beard thicknesses and then measured preferences for four standard levels of beardedness. Women and men judged heavy stubble and full beards more attractive when presented in treatments where beards were rare than when they were common, with intermediate preferences when intermediate frequencies of beardedness were presented. Likewise, clean-shaven faces were least attractive when clean-shaven faces were most common and more attractive when rare. This pattern in preferences is consistent with negative frequency-dependent selection.     

The role of facial hair in women's perceptions of men's attractiveness,health, masculinity and parenting abilities

Facial hair strongly influences people's judgments of men's socio-sexual attributes. However, the nature of these judgments is often contradictory. The levels of intermediate facial hair growth presented to raters and the stage of female raters' menstrual cycles might have influenced past findings. We quantified men's and women's judgments of attractiveness, health, masculinity and parenting abilities for photographs of men who were clean-shaven, lightly or heavily stubbled and fully bearded. We also tested the effect of the menstrual cycle and hormonal contraceptive use on women's ratings. Women judged faces with heavy stubble as most attractive and heavy beards, light stubble and clean-shaven faces as similarly less attractive. In contrast, men rated full beards and heavy stubble as most attractive, followed closely by clean-shaven and light stubble as least attractive. Men and women rated full beards highest for parenting ability and healthiness. Masculinity ratings increased linearly as facial hair increased, and this effect was more pronounced in women in the fertile phase of the menstrual cycle, although attractiveness ratings did not differ according to fertility. Our findings confirm that beardedness affects judgments of male socio-sexual attributes and suggest that an intermediate level of beardedness is most attractive while full-bearded men may be perceived as better fathers who could protect and invest in offspring.     

Young,formidable men show greater sensitivity to facial cues of dominance

There is considerable evidence that human male faces contain honest, detectable cues to their physical dominance, which are related to their objective facial masculinity. As such, some have argued that the extent to which observers' rate masculinised male faces as appearing more physically dominant is a useful measure of their ability to detect cues of dominance and threat in other men. We found across 3 studies (total n = 272) that younger, taller, and stronger men showed greater sensitivity to facial cues of dominance. Additionally, participants were more likely to associate younger than older masculinised faces with physical dominance. Self-perceived social dominance did not moderate perceptions. These results contrast with previous work which found that shorter, less socially dominant men had greater ability to detect facial cues of dominance. We propose the hypothesis that younger, more formidable males show greater sensitivity to facial cues of dominance as they are more likely to engage in violent intrasexual competition.     

Mate preferences and choices for facial and body hair in heterosexual women and homosexual men: influence of sex,population, homogamy,and imprinting-like effect

Recent research has reported that male body and facial hair influence women's mate preferences. However, it is not clear whether such preferences are typical for women or for individuals who prefer males as sexual partners. Here we explored body and facial hair in preferred and actual partners among men and women who prefer men as sexual partners. Including homosexual individuals provides a unique opportunity to investigate whether evolved mating psychologies are specific to the sex of the individual or sex of the partner. Based on an online survey of 1577 participants from Brazil and the Czech Republic, we found that, on average, homosexual men preferred hairier stimuli than heterosexual women, supporting past findings that homosexual men have strong preferences for masculine traits. Preferences for facial and body hair appear to be influenced less by sex of the preferred partner than sex of the individual, pointing to a possible sex-specific mating psychology. Further, Brazilians preferred bigger beards than Czechs, which was positively associated with the self-reported amount of beardedness in Brazil, suggesting that familiarity effects underpin cross-cultural differences in preferences for facial hair. Moreover, homosexual men preferred a self-similar degree of beardedness, and Czech women preferred a similar degree of beardedness as their fathers had during their childhood. However, these effects were not associated with the level of facial hair in their actual partners; in general, mate preferences and actual mate choices for facial and body hair differed. Thus, individual differences in some self-reported characteristics, cultural factors, and aspects of personal experience may modulate differences in preferences for masculine traits.     

Male facial width is associated with death by contact violence: narrow-faced males are more likely to die from contact violence

Male facial width-to-height ratio (bizygomatic width scaled for face height) is a testosterone-linked trait predictive of reactive aggression, exploitative behavior, cheating, deception, and dominance. We tested whether facial width was systematically related to cause of death in a forensic sample. We hypothesized that wider-faced males, being more aggressive and robust, would be less likely than narrower-faced males to die from contact violence (stabbed, strangled, or bludgeoned to death) compared with other forms of homicide. We tested this hypothesis in a forensic data sample covering 523 male and 339 female skeletons. In these data, men with narrower faces were more likely to have died as a consequence of homicides involving direct physical contact than men with wider faces. No such effect was found for women. This effect was found when considering all causes of mortality and when limiting the sample to homicides. This finding suggests that wider-faced males are less likely to die from male–male physical violence, perhaps because of their formidability. Our findings are discussed with reference to the previous literature indicating that facial width-to-height ratio is a marker for male dominance.     

Second to fourth digit ratio, testosterone and perceived male dominance

Previous studies have shown that male faces with extreme features associated with testosterone are perceived as dominant and masculine. Women have been reported to prefer more masculinized male faces as they may consider testosterone markers to be an 'honest' indication of good health, and such considerations may underlie their aesthetic preferences. However, pronounced testosterone facial markers are also associated with dominance, and several negative personality traits. This suggests that female aesthetic preferences may be an adaptive compromise between positive attributes associated with higher than average testosterone, and negative attributes associated with more extreme masculinization. This current study attempts to clarify the role of hormone markers in female perceptions of dominance, masculinity and attractiveness, in male facial images. Recent evidence suggests that the relative length of the 2nd to 4th finger (2D : 4D ratio) is a pointer to prenatal testosterone levels and may thus serve as a window to the prenatal hormonal environment. We measured 2D : 4D in a sample of male college students and took salivary samples to analyse circulating levels of testosterone. Women rated facial images of these males for dominance, masculinity and attractiveness. Our results show that male 2D : 4D was significantly negatively related to perceived dominance and masculinity but not attractiveness. Circulating testosterone levels were not related to dominance, masculinity or attractiveness. These findings suggest that: (i) high prenatal levels of testosterone serve to 'organize' male facial features to subsequently reflect dominance and masculine characteristics presumably activated during puberty; and (ii) attractiveness is not directly related to testosterone levels. We conclude that facial dominance and masculinity reflect a male's perceived status rather than his physical attraction to women.     

Is facial width-to-height ratio reliably associated with social inferences?

Theoretical considerations and early empirical findings suggested facial width-to-height ratio (fWHR) may be relevant to person perception because it is associated with behavioral dispositions. More recent evidence failing to find fWHR-behavior links suggests that mismatch or byproduct hypotheses may be necessary to explain fWHR-based trait inferences; however, these explanations may not be needed because it is not clear that fWHR is reliably associated with trait inferences. To investigate the robustness of fWHR-inference links, we conducted secondary analyses of a cross-national dataset consisting of ratings by 11,481 participants across 11 world regions who judged 60 male and 60 female faces on one of 13 social traits (ns per trait range from 760 to 975). In preregistered analyses—and exploratory analyses of a subset of traits in the larger sample of 597 faces from which the 120 faces were drawn—we found mixed evidence for fWHR-based social judgments. In multilevel models, fWHR was not reliably linked to raters' judgments of male faces for any of the 13 trait-inferences but was negatively associated with ratings of female faces' dominance, trustworthiness, sociability, emotional stability, responsibility, confidence, attractiveness, and intelligence. In exploratory analyses of a subset of traits using the larger sample of faces, fWHR was associated positively with perceptions of meanness and aggressiveness in male but not female faces, negatively with attractiveness and dominance in female but not male faces, and negatively with trustworthiness in male but not female faces. We interpret these mixed findings to suggest that (1) fWHR-inference links are likely to be smaller and less reliable than expected from prior research; (2) fWHR may play a larger role in perceptions of female faces than would be predicted from the theory underpinning fWHR hypotheses; and (3) future research should more closely examine the extent to which robust fWHR-inferences reflect mismatch in the reliability of fWHR-behavior links between ancestral and modern environments versus byproducts of other person perception mechanisms.     

The Relative Contributions of Facial Shape and Surface Information to Perceptions of Attractiveness and Dominance

Although many studies have investigated the facial characteristics that influence perceptions of others’ attractiveness and dominance, the majority of these studies have focused on either the effects of shape information or surface information alone. Consequently, the relative contributions of facial shape and surface characteristics to attractiveness and dominance perceptions are unclear. To address this issue, we investigated the relationships between ratings of original versions of faces and ratings of versions in which either surface information had been standardized (i.e., shape-only versions) or shape information had been standardized (i.e., surface-only versions). For attractiveness and dominance judgments of both male and female faces, ratings of shape-only and surface-only versions independently predicted ratings of the original versions of faces. The correlations between ratings of original and shape-only versions and between ratings of original and surface-only versions differed only in two instances. For male attractiveness, ratings of original versions were more strongly related to ratings of surface-only than shape-only versions, suggesting that surface information is particularly important for men’s facial attractiveness. The opposite was true for female physical dominance, suggesting that shape information is particularly important for women’s facial physical dominance. In summary, our results indicate that both facial shape and surface information contribute to judgments of others’ attractiveness and dominance, suggesting that it may be important to consider both sources of information in research on these topics.     

Individual Facial Coloration in Male <Emphasis Type="Italic">Eulemur fulvus rufus</Emphasis>: A Condition-dependent Ornament?

Researchers studying individual variation in conspicuous skin coloration in primates have suggested that color indicates male quality. Although primate fur color can also be flamboyant, the potential condition dependence and thus signaling function of fur remains poorly studied. We studied sources of variation in sexually dichromatic facial hair coloration in red-fronted lemurs (Eulemur fulvus rufus). We collected data on 13 adult males in Kirindy Forest, Madagascar, during two study periods in 2006 and 2007, to determine whether variation in facial hair coloration correlates with male age, rank, androgen status, and reproductive success. We quantified facial hair coloration via standardized digital photographs of each male, assessed androgen status using fecal hormone measurements, and obtained data on reproductive success through genetic paternity analyses. Male facial hair coloration showed high individual variation, and baseline coloration was related to individual androgen status but not to any other parameter tested. Color did not reflect rapid androgen changes during the mating season. However, pronounced long-term changes in androgen levels between years were accompanied by changes in facial hair coloration. Our data suggest that facial hair coloration in red-fronted lemur males is under proximate control of androgens and may provide some information about male quality, but it does not correlate with dominance rank or male reproductive success.     

Visualizing facial shape regression upon 2nd to 4th digit ratio and testosterone

Sex steroids are supposed to moderate the differences between male and female facial characteristics. Studies on women's preferences for male faces reported increased preferences for facial architecture developed under the influence of testosterone as this may indicate masculinity, dominance and social status. Recent research demonstrates that facial sexual dimorphism does not only develop at puberty but may be organized much earlier in ontogeny. However, the actual cause and timing of variation in facial shape due to sex-steroids remains speculative. This study uses data from Neave and colleagues who measured digit ratio (2D:4D) as a proxy to prenatal testosterone and also salivary testosterone samples in order to study differential effects of androgens on perceived male facial shape. Male facial shape was regressed upon 2D:4D ratio and circulating levels of testosterone by means of geometric morphometric methods. We found some evidence for opposite effects of early androgen action (via 2D:4D ratio) on the upper and the lower face respectively (i.e. low 2D:4D ratio results in a relatively robust and prominent lower face), whereas circulating testosterone seems to cause a rather uniform elongation of the face. Local deformations primarily show pronounced and medially tailed eyebrows for the shapes associated with increasing salivary testosterone. These preliminary results suggest that prenatal and pubertal testosterone have differential effects on male facial shape that should be considered in future studies on women's preferences towards male facial appearance.     

Genetic and social control of male maturation in Phallichthys quadripunctatus (Pisces: Poeciliidae)

Age and size at maturity can have significant fitness consequences. Selection often favors early-maturing individuals because of their higher survival to maturity and greater relative contribution to population growth rate, but it may also favor delayed maturation if fitness increases with age or size at maturity. Males of several poeciliid fishes exhibit variation in age and size at maturity primarily controlled by a sex-linked gene called the P-locus. Wild-caught Phallichthys quadripunctatus males show a bimodal size distribution, which is often associated with a P-locus polymorphism in other poeciliids. We conducted two experiments to evaluate the inheritance of male age and size at maturity and the influence of social environment (presence of mature or juvenile males during development) on these traits. We specifically tested the hypothesis that male age and size at maturity in P. quadripunctatus are governed by a single Y-linked locus, and modified by the social environment. Although our results imply both a genetic and an environmental component to the dimorphism in maturation, both large and small males were able to sire both large and small sons, allowing us to reject the hypothesis that age and size at maturity in this species are controlled by a single, Y-linked locus. Our data do not conform adequately to any of the genetic mechanisms described to date for maturation polymorphism in poeciliids. We suggest alternative mechanisms that may operate in P. quadripunctatus.     

Canine Length in Wild Male Baboons: Maturation,Aging and Social Dominance Rank

Canines represent an essential component of the dentition for any heterodont mammal. In primates, like many other mammals, canines are frequently used as weapons. Hence, tooth size and wear may have significant implications for fighting ability, and consequently for social dominance rank, reproductive success, and fitness. We evaluated sources of variance in canine growth and length in a well-studied wild primate population because of the potential importance of canines for male reproductive success in many primates. Specifically, we measured maxillary canine length in 80 wild male baboons (aged 5.04–20.45 years) from the Amboseli ecosystem in southern Kenya, and examined its relationship with maturation, age, and social dominance rank. In our analysis of maturation, we compared food-enhanced baboons (those that fed part time at a refuse pit associated with a tourist lodge) with wild-feeding males, and found that food-enhanced males achieved long canines earlier than wild-feeding males. Among adult males, canine length decreased with age because of tooth wear. We found some evidence that, after controlling for age, longer canines were associated with higher adult dominance rank (accounting for 9% of the variance in rank), but only among relatively high-ranking males. This result supports the idea that social rank, and thus reproductive success and fitness, may depend in part on fighting ability mediated by canine size.     

Social correlates of testosterone and ornamentation in male mandrills

We investigated relationships between fecal androgen concentrations, facial coloration and behaviour in semi-free-ranging male mandrills. We found that fecal androgen levels were significantly positively related to dominance rank, independent of rank stability and the mating period, suggesting that male mandrills live in a permanently aggressive context in which they must actively maintain their dominance status. Facial red coloration was also significantly related to both fecal androgen levels and rank, with high ranking males having both higher androgen levels and redder faces, although dominant males did not always have the highest androgen levels or the reddest faces. Predictive relationships between androgen levels, coloration and rank were short-term. Androgen concentrations and facial redness both increased in the presence of receptive females, as did the former during periods of rank instability. We conclude that male facial redness is likely to represent an honest signal (to other males) of current androgen status, competitive ability and willingness to engage in fights and that females may also use this to assess male condition. Further, our findings provide support for the “challenge hypothesis” as originally proposed for birds by Wingfield.     

Lack of Support for the Association between Facial Shape and Aggression: A Reappraisal Based on a Worldwide Population Genetics Perspective

Antisocial and criminal behaviors are multifactorial traits whose interpretation relies on multiple disciplines. Since these interpretations may have social, moral and legal implications, a constant review of the evidence is necessary before any scientific claim is considered as truth. A recent study proposed that men with wider faces relative to facial height (fWHR) are more likely to develop unethical behaviour mediated by a psychological sense of power. This research was based on reports suggesting that sexual dimorphism and selection would be responsible for a correlation between fWHR and aggression. Here we show that 4,960 individuals from 94 modern human populations belonging to a vast array of genetic and cultural contexts do not display significant amounts of fWHR sexual dimorphism. Further analyses using populations with associated ethnographical records as well as samples of male prisoners of the Mexico City Federal Penitentiary condemned by crimes of variable level of inter-personal aggression (homicide, robbery, and minor faults) did not show significant evidence, suggesting that populations/individuals with higher levels of bellicosity, aggressive behaviour, or power-mediated behaviour display greater fWHR. Finally, a regression analysis of fWHR on individual''s fitness showed no significant correlation between this facial trait and reproductive success. Overall, our results suggest that facial attributes are poor predictors of aggressive behaviour, or at least, that sexual selection was weak enough to leave a signal on patterns of between- and within-sex and population facial variation.     

The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp

Hair transplantation by use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session was initially described for the treatment of male pattern baldness. More recently, the author has found many other applications, particularly in facial and scalp reconstruction. The most common causes for aesthetic hair restoration of those areas in the author's experience include hair loss resulting from aesthetic facial rejuvenation surgery, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, and hair loss after oncologic resections. The basic technique is described in detail, with variations given for each of the challenging anatomic areas, including the sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Special attention is given to the direction of hair growth, hair texture, aesthetic planning, and absence of detectable scars, in order to mimic nature and to result in a minimal number of procedures. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable, and has provided a high level of patient satisfaction.     

Facial shape provides a valid cue to sociosexuality in men but not women

Existing work suggests that observers' perceptions of sociosexuality from strangers' faces are positively associated with individuals' self-reported sociosexuality. However it is not clear what cues observers use to form these judgements. Over two studies we examined whether sociosexuality is reflected in faces, which cues contain information about sociosexuality, and whether observers' perceptions of sociosexuality from faces are positively associated with individuals' self-reported sociosexuality. In Study One, Geometric Morphometric Modelling (GMM) analysis of 103 Caucasian participants revealed that self-reported sociosexuality was predicted by facial morphology in male but not female faces. In Study Two, 65 Caucasian participants judged the sociosexuality of opposite sex faces (faces from Study One) at zero acquaintance. Perceived sociosexuality predicted self-reported sociosexuality for men, but not women. Participants were also presented with composites of faces of individuals with more unrestricted sociosexuality paired with composites of faces of individuals with more restricted sociosexuality and asked to indicate which was more unrestricted. Participants selected the more unrestricted sociosexuality male, but not female, facial composites at rates significantly above chance. GMM analyses also found that facial morphology statistically significantly predicted perceived sociosexuality in women's and, to a greater extent, in men's faces. Finally, facial shape mediated the relationship between perceived sociosexuality and self-reported sociosexuality in men's but not women's faces. Our results suggest that facial shape acts as a valid cue to sociosexuality in men's but not women's faces.     

Sex differences in the impact of social status on hair cortisol concentrations in rhesus monkeys (Macaca mulatta)

Social status impacts stress in primates, but the direction of the effect differs depending on species, social style, and group stability. This complicates our ability to identify broadly applicable principles for understanding how social status impacts health and fitness. One reason for this is the fact that social status is often measured as linear dominance rank, yet social status is more complex than simply high or low rank. Additionally, most research on social status and health ignores the effects of sex and sex-specific relationships, despite known differences in disease risk, coping strategies, and opposite-sex dominance interactions between males and females in many species. We examine the influence of social status, sex, and opposite-sex interactions on hair cortisol concentrations (HCC) in a well-studied species, rhesus macaques, where the literature predicts low ranking individuals would experience more chronic stress. Animals in three captive, seminaturalistic social groups (N = 252; 71 male) were observed for 6 weeks to obtain metrics of social status (rank and dominance certainty [DC]). DC is a measure of one's fit within the hierarchy. Hair samples were collected from each subject and analyzed for HCC. Generalized linear mixed models were used to examine (a) whether rank, DC, or sex predicted HCC; (b) whether same- or opposite-sex dominance relationships differentially impacted HCC; and (c) whether aggressive interactions initiated or received could explain any observed relationships. Results indicated that DC, not rank, predicted HCC in a sex-specific manner. For males, high HCC were predicted by receiving aggression from or having high DC with other males as well as having low DC with females. For females, only high DC with males predicted high HCC. These results likely relate to sex-specific life history pattern differences in inherited versus earned rank that are tied to female philopatry and male immigration.     

Scalp expansion in the treatment of male pattern baldness

Tissue expansion has been extremely valuable in the treatment of traumatic scalp defects. We have recently used expansion techniques in the treatment of male pattern baldness. Expansion has been used in conjunction with scalp-reduction procedures and pedicled hair-bearing flaps. Flaps have been designed as Juri flaps, and in one patient, a new posteriorly based flap was used. This design gives the advantage of a more natural-appearing hairline and forward-growing hair. The major advantage of tissue expansion in the treatment of male pattern baldness is that it generates new hair-bearing scalp. The increase in vascularity which occurs during expansion allows for large, safe, and predictable flaps. Donor sites are also relatively easily closed. The disadvantages of expansion include the need for two or more surgical procedures and multiple office visits. There is also some discomfort following expansion and a cosmetic defect as the expanders become larger. Complications include infection, exposure or extrusion, deflation, and hair loss. Tissue expansion combined with scalp reduction and pedicled hair-bearing flaps have proved to be a valuable technique in the treatment of male pattern baldness with a high degree of patient satisfaction.