Postoperative (pressure) alopecia after general anesthesia is a rare but disturbing complication. Although this condition has been widely reported in the surgery and dermatology literature (1–4), it has received scant attention in anesthesiology journals. An English language Medline® search produced only two reports in the anesthesia literature during the last 35 yr (5–6). These reports describe patients subjected to procedures longer than 6 h (5) or to cardiopulmonary bypass (6). We present a case of postoperative (pressure) alopecia after general anesthesia for cosmetic plastic surgery in which none of the previously documented risk factors were identified.
A 50-yr-old, 64-kg, ASA physical status class I woman presented for elective bilateral breast reduction. Her preoperative arterial blood pressure was 118/90 mm Hg, and her heart rate was 96 bpm. The remainder of the physical examination was unremarkable. She was premedicated with 5 mg of midazolam IV. General orotracheal anesthesia was induced with 90 mg of propofol, 200 μg of fentanyl, and 50 mg of rocuronium IV. All pressure points were checked and padded, and the head was placed over folded sheets in a neutral position. Anesthesia was maintained with isoflurane and nitrous oxide. The patient remained supine throughout surgery, and the head was not repositioned during the case. The surgical and anesthesia times were 4.0 and 4.5 h, respectively. The intraoperative period was unremarkable. Specifically, there were no episodes of hypotension <90 mm Hg. The estimated blood loss was 100 mL. The patient received 1250 mL of lactated ringer’s fluid IV.
Twelve hours after surgery, the patient complained of soreness and tenderness over the occipital area. She was discharged from the hospital 23 h after admission. During the following days, she noticed progressive hair loss over the previously tender area. Two weeks after surgery, an area of alopecia of 3.5 X 2.5 cm in the occiput was observed (Figure 1). Hair growth was noted within weeks. A follow-up visit 6 mo after surgery revealed normal hair distribution within the affected area.
Abel and Lewis (7) first described postoperative (pressure) alopecia in 1960. They reported eight cases of pressure-related alopecia in women after prolonged gynecologic procedures. Abel (8) also demonstrated experimentally induced lesions in cats that were clinically and histologically similar to his initial series in women. Subsequent reports have demonstrated that this complication can develop in patients of both sexes and of all ages (1–4).
The putative cause of postoperative (pressure) alopecia is localized pressure-induced ischemia to the scalp caused by head immobilization during prolonged periods of unconsciousness. The continuous pressure of the immobilized human head causes ischemic changes to the blood vessels. Furthermore, severe hypotension, massive blood loss, and the use of vasoconstrictors aggravate ischemia on the scalp. Other risk factors include prolonged endotracheal intubation, prolonged head immobilization, and the intraoperative use of the Trendelenburg position (1,3,5,6). None of these known risk factors were present in our patient.
Patients with this condition typically complain of occipito-parietal pain and tenderness within 24 hours of surgery. Signs observed during the first week also include swelling, edema, crusting, and ulceration. Histological findings are dependent on the stage at which the biopsy specimen is obtained and have been described elsewhere (9). Hair loss is usually complete within 3–28 days after surgery. As in our patient, most cases are self-limiting with regrowth occurring within 12 weeks (5). Lawson et al. (1), however, reported cases of permanent alopecia. In their series, 65 cardiac surgical patients developed postoperative (pressure) alopecia; of those, 29 developed permanent alopecia. All the patients with permanent alopecia remained endotracheally intubated for periods of 24 hours or more, whereas none of the patients intubated for 17 hours or less developed permanent alopecia.
Postoperative (pressure) alopecia is believed to be preventable. A prospective study that incorporated head repositioning every 30 minutes in cardiac surgical patients, both during general anesthesia and recovery, significantly reduced the incidence of alopecia from a prospectively determined value of 14% to 1% (1). The role that IV or inhaled anesthetics may play, if any, in the genesis of this condition has not been studied. There are no case reports of patients’ receiving spinal or epidural anesthesia as their primary anesthetic. This final observation lends further credence to the notion that frequent head repositioning is protective.
In summary, we have presented a case of postoperative (pressure) alopecia in a patient after elective cosmetic surgery. Based on the proposed etiology of this condition and the available prospective evidence, practitioners are encouraged to periodically reposition the head during surgery in all but the briefest general anesthetics.
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