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Postoperative Alopecia

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									                                                                             loss was 400 ml. Five percent dextrose in lactated Ringer's
Postoperative Alopecia                                                       solution (1050 ml) was given during the procedure.
                                                                                O n her follow-up visit to the clinic, a month after surgery,
Kita D. Patel, MD," and                                                      the patient complained of excessive hair loss. She reported
E. 0. Henschel, MDT                                                          that two bald spots on the occipital area were noted by a
                                                                             friend. The loss of hair was not associated with pain,
                                                                             tenderness, swelling, itching, exudation, or scaling.
   Postoperative alopecia due to intraoperative pres-                           O n examination (Fig I), two symmetrical areas 3 x 2 cm
                                                                             and 3 x 5 cm in size resembling alopecia areata were noted.
sure on the scalp has been described as a minor
                                                                             The bald areas, identical in shape, followed the outline of
reversible complication of anesthesia.' Review of the                        the foam "doughnut" on which the patient's head rested
literature2-" shows that postoperative pressure alope-                       during the surgical procedure (Fig 2). Reexamination 2
cia is most likely to occur after lengthy anesthesia                         months after anesthesia revealed short stubs of hair. Com-
associated with hypotension, blood loss, or continued                        plete regrowth of hair occurred in 6 months.
pressure over an area of the scalp. The present case
describes development of temporary alopecia with                                                     Discussion
none of the precipitating factors reported in the lit-
erature which resulted from pressure of a soft foam                             Postoperative pressure alopecia, though a minor
"doughnut" used to rest the head of a patient during                         and self-limiting complication of general anesthesia,'
a lengthy anesthetic.                                                        is disturbing to both patient and physician. Tempo-
                                                                             rary loss of hair unaccompanied by atrophy or scar-
                         Case Report                                         ring may occur from a number of etiologic factors
   A 15-year-old white girl was scheduled for an elective
left reduction mammoplasty and right mastopexy. Preop-                         Abe16 has reported a series of 16 cases of reversible
erative evaluation showed the patient to be in excellent                     postoperative alopecia. The majority of these patients
health. She gave a past history of spinal meningitis as a                    had undergone lengthy gynecologic procedures in the
child with complete recovery. She had no previous surgery                    Trendelenburg position with associated hypotension.
and was not on any medications. Physical examination, in                     In the immediate postoperative period, 50% of the
addition to the mammary findings, revealed only a soft                       patients complained of pain, swelling, or serous exu-
systolic murmur, heard best at the apex. Laboratory data                     dation and crusting in the area of scalp upon which
were within normal limits
                                                                             the head rested during the operation. Central vertex
   The patient was premedicated with Innovar (1.5 ml) and
                                                                             was the most common area to be affected, although
atropine (0.6 mg) intramuscularly. Anesthesia was induced
with thiopental (450 mg) and, after 3 mg of d-tubocurarine,                  alopecia also involved the occipital and parietal areas
succinylcholine (100 mg) was given and the trachea intu-                     in some patients. Alopecia appeared about the 15th
bated with a size 36 oral endotracheal tube. Anesthesia was                  day (range of 3 to 28 days) following anesthesia.
maintained with N 2 0 , 0 2 , and halothane.                                 Complete regrowth occurred in all cases within 120
   The patient was placed in a 40' Fowler's position with                    days. The authors advised the use of foam doughnuts
both arms at her side. Her waist-length hair was covered                     under the head as one of the measures for prevention
with a paper cap and the head positioned over a soft foam                    of this complication.
"doughnut."                                                                     Gormley and Sok011'~in 1967 reported a case of
   Anesthesia was uneventful during the 6Y4-hour operation.                  permanent alopecia resulting from the use of a head
Specifically, there was no hypotension. Estimated blood
                                                                             strap with a face mask during the 6%-hour anesthetic.
     ' A s i s t a n t Professor, Acting Chief, Department of Anesthesiol-   During this time the head strap was not loosened or
ogy, Mount Sinai Medical Center, Milwaukee.                                  detached and permanent alopecia resulted.
     -1 Late Professor and Chairman, Department of Anesthesiology,              The head of a normal adult weighs about 2.8 kg.
The Medical College of Wisconsin; Director, Department of Anes-
t h e s i o l o ~ y ,Milwaukee County Mrdical Complex; and Chief, Anes-      This weight usually rests on the same scalp area when
thesiology Services, Veterans Administration Center, Wood, Wis-              the patient is in the supine position. The pressure on
consin                                                                       the scalp may be increased in certain positions, es-
  Iieceivcd from the Department of Anesthesiology, Mount Sinai
Medical Center, 950 North Twelfth Street, Milwaukee, Wisconsin               pecially the Trendelenburg position.' The resultant
53201. Accepted for puhlicdtion December 24, 1979.                           pressure-induced ischemia may cause temporary ces-
   Iieprint requests to Dr. Patel.                                           sation of follicular activity leading to loosening and

                                                                                                  ANESTHESIA AND ANALGESIA
                                                                                                  Vol 59, No 4 , April 1980            31 1
                                                 CLINICAL REI'ORTS




              FIG 1 . Two symmetrical areas of postoperative pressure alopecia seen 60 days after anesthesia

depilation. Comparable pressure-induced ischemia
probably explains the case of permanent alopecin
                                            '~
reported by Gormley and S ~ k o l l . By holding the
anesthesia face mask, the dependent force is increased
by t h e an est h esi o 1og i st 's hand. '
   Scalp ischemia secondary to pressure could be ag-
grevated by blood loss and vasoconstriction or by
hypotension in further circulatory insufficiency of the
skin.'
   Abel and Lewis' found pressure-induced alopecia
to be associated with obliterative vasculitis in experi-
mental animals.
   It is of interest, that our patient developed alopecia
even though her hair was protected with a cap and
her head placed o n a soft foam rubber "doughnut."                             W
The Fowler's position places the maximum pressure              FIG 2. Areas of alopecia followed the outline of the foam rubber
on t h e base of the occiput, not the dorsum, where the         'doughnut" on which the head of the patient rested for 6'h
alopecia was noted. Moreover, the patient was not              hours.
hypotensive during the prolonged anesthetic.                   rence of alopecia areata. However, in alopecia areata
   O u r patient developed relatively sudden onset of          the spontaneous regrowth is often associated with
symptomless loss of hair. The differential diagnosis           depigmented hair, o r faulty stubs of hair, the so-called
included concomitant and purely coincidental occur-            "exclamdtion point" hairs."' Microscopic examination
31 2       ANESTHESIA AND ANALGESIA
           Vol 59, No 4 . April 1980
                                                                  CLINICAL REPORTS

TABLE                                                                      pecia is reported, where none of the usual contribut-
Etiologic Factors of Alcopecia                                             ing factors were present. A soft foam "doughnut" was
1 . Traction          Acute: trichotillomania                              used to stabilize the head during the procedure and
                      Chronic: "Pony tail" a l o p e c i a a n d           yet postoperative alopecia occurred.
                          a l o p e c i a marginalis
2. Chemicals          Dyes, b l e a c h e s , ammonium                                                 REFERENCES
                          thioglycolate. chlorobutadiene                    1    Riding IL: Complications of general anaesthesia. Br I Anacsth
3. Infection          S t a p h y l o c o c c u s a u r e u s ; ringworm         47.91-101, 1975
                         infection                                          2    Abel RR, Lewis G M : Post-oper'itive pressure alopecia. Arch
4 . Drugs             Anticoagulants                                             Llerinatol 81:72-78, 1960
                      Chemotherapeutic a g e n t s                          3    Wintrobe M M : Harrison's Principles of Internal Medicine.
                      Chlorpromazine                                             Sixth edition. New York, McGraw Hill Book Co, 1966, p p 294-
                      Excessive doses of vitamin A                               295
                                                                            4.   Oya M : Post-operative alopecia. IRYO 16:l-7, 1962 (Japanese)
5. Miscellaneous      Alopecia areata
                                                                            5.   Fischer R, Bircher J, Reich T: Der Haarausfallnach Antikoagu-
                      Prolonged febrile illnesses
                                                                                 lierender Therapie. Schweiz Med Wochenschr 83:509-51 ,      I
                      Systemic l u p u s e r y t h e m a t o s u s
                                                                                1953
                      Severe cachexia                                       6 . Abel RR: Post-operative (pressure) alopecia Anesthesiology
                      Endocrine d i s o r d e r s                              25.869-871, 1964
6. Trauma             Acute trauma-blow to t h e s c a l p                  7. Aaronson CV: Etiologic factors in traction alopecia: South Med
                      Prolonged p r e s s u r e                                162:185-186, 1969
                                                                            8. Morgan M V : Traction alopecia. Br M e d J 2: 115- 117, 1960
                                                                            9. Rciches AJ, Lane C W : Temporary baldness d u e to cold wave
                                                                               preparation: thioglycolate preparation5. J A M A 144:305-306,
of the area confirms the diagnosis as the underlying                          1Y50
process is inflammatory.                                                   10 Abel     RR, Lewis L M - Postoperative (pressure) alopeci'i Arch
   In our patient, the clinical picture did resemble                             [krniatol 81:79-80, 1960
                                                                           11.   Thomson NB, Estrellado R: Occurrence of alopecia after open
alopecia areata, but as biopsy of the area of alopecia                           hrart surgery Arch Surg 85392-896, 1962
was refused by the patient, the concomitant occur-                         12.   Muneyuki M, Kurimoto S , Araki Y, et ~ l Anaesthesia a n d
                                                                                                                                  :
rence of alopecia areata cannot be ruled out.                                    heart surgery. 1. Minor complications with special reference to
                                                                                 post operative alopecia. J p n I Anesthesiol 15:71-76, 1966
   The occurrence of postoperative alopecia can be                         13.   Lee \ A , Atkinson RS: A Synopsis of Anaesthesia. Seventh
avoided by intermittent repositioning of the head, by                            edition. Bristol, John Wright and Sons Ltd, 1973, p 829
                                                                           14.   Gormley T, Sokoll MD. Permanent alopecia from pressure of
minimizing areas of unavoidable pressures, and by
                                                                                 head strap. J A M A 199:157-158, 1967
avoiding hypotension."                                                     15.   Shelly WB: Consultation of Dermatology. Philadelphia, WB
   In summary, a case of postoperative pressure alo-                             S.iunders Co, 1972, p p 14-19




                                                                                                    ANESTHESIA A N D ANALGESIA
                                                                                                    Vol 59. No 4 , April 1980            31 3

								
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