Chapter 256

Hair Transplantation
and Alopecia
Reduction
Walter P. Unger, Robin H. Unger,
& Mark Unger

EQUIPMENT
The equipment required for hair restoration surgery
is listed in Box 256-3.

ANESTHESIA

10

Hair transplantation is conducted under local anesthesia, using field blocks in both the recipient and
donor areas. A great deal of care is taken to avoid
unnecessary patient discomfort during the administration of local anesthesia. To that end, patients
receive a sedative, either orally or intravenously,
prior to beginning surgery. In addition, the pain of
local anesthetic infiltration is minimized by utilizing 30G needles, by buffering the anesthetic, and
by using freshly mixed lidocaine and epinephrine,
rather than premixed stock solutions that tend to
be acidic.
In the donor area, the author uses a multiple
wheal technique to establish the field block (Fig.
256-12). This involves raising isolated wheals of
anesthesia along the inferior edge of the donor
area, at 3-cm intervals, using buffered 2% lidocaine
with 1/100,000 epinephrine. The gaps between
those wheals are then closed by inserting the
needle through the anesthetized regions, and injecting laterally in both directions; thus, the patient
feels less than half the total number of injections.
Subsequently, a solution of 1/50,000 epinephrine
is infiltrated into the donor area. This offers an opportunity to test the effectiveness of anesthesia and,
if needed, supplement it. More commonly, extra
local anesthetic is used in patients with multiple
previous surgeries who develop aberrant nerve
pathways that circumvent the anesthetic block.
The recipient area is anesthetized by creating a
similar field block anterior to the proposed hairline.
However, 3% or 4% lidocaine is sometimes needed

for hot spots, and buffered solutions are not used

as these may increase frontal edema). Both the
donor and recipient field blocks are reinforced
every 23 hours with 0.5% bupivicaine, although
the anesthetic effects can dissipate more rapidly.
If this occurs, a supraorbital nerve block can be
performed using 2% lidocaine, since the duration
of anesthesia is longer when using this technique.
Additional sedatives, analgesics and antiemetics are
administered throughout the operation as necessary. Problems that may occur despite proper management include anxiety, palpitations, and syncope.
These are all easily treated, but as with most things,
an ounce of prevention is worth a pound of cure.

PATIENT INSTRUCTIONS
Preoperatively, patients are advised to stop any
medications or herbal supplements that may cause
excessive bleeding. If they are scheduled to receive
conscious sedation from an anesthetist, they are
instructed not to eat or drink after midnight. Otherwise, they are encouraged to have a large breakfast
the morning of surgery. All patients receive prophylactic antibiotics prior to arriving to the office for
surgery.
Postoperatively, patients have their scalp bandaged, and are given a selection of analgesics,
antiemetics and sedatives to take as needed. The
following day, they return for bandage removal and
gentle hair washing. In the first postoperative days,
periorbital edema is a potential concern, and thus
patients are encouraged to apply ice to the forehead to diminish edema, and, if possible, to lie flat
to allow gravity to drain edematous fluid away from
the eyes. From the time of surgery until the time
that the sutures are removed, patients are advised
to soak their heads twice daily, and to apply 3% minoxidil solution and a water soluble lubricant and
moisturizer to the recipient and donor areas. Minoxidil is continued for a total of 4 weeks to promote
vasodilatation in the surgical area, which theoretically may improve healing, reduce the possibility of
any telogen effluvium and accelerate the regrowth
of the transplanted hairs. It is recommended that
patients avoid any significant physical activity for 1
week after surgery and weight lifting and contact
activities for 2 weeks.

Copyright McGraw-Hill Companies, Inc. All rights reserved.