Pressure-induced alopecia in pediatric patients following prolonged urological surgeries: The case reports and a review of literature.

Postoperative alopecia has been reported as a rare complication after prolonged immobilization during general anesthesia. The constant pressure on the scalp is causative and may be exacerbated by hypoxemia or hypotension. There is a correlation between the length surgery duration under anesthesia and the development of permanent alopecia. Regular head turning schedules and vigilance for the condition should be used as prophylaxis to prevent permanent alopecia.

INTRODUCTION

Postoperative alopecia has been reported as a rare complication after prolonged immobilization during general anesthesia. Postoperative or pressure alopecia (PA) is the term used to describe a group of scarring and nonscarring alopecia that occur following ischemic changes to the scalp, with a pathophysiology similar to pressure ulcers. If recognized early, the condition may be reversible, or even preventable; a delayed diagnosis could lead to permanent hair loss. We report two patients underwent long urological procedures, developed PA 1 week after the postoperative period.

CASE REPORTS

Case report 1

A 7-year-old, Nigerian, 26-kg, American Society of Anesthesiologist (ASA) physical status class II boy presented for elective open ureterocystoplasty, right nephrectomy and closure of vesicostomy. His preoperative arterial blood pressure was 102/50 mm Hg, and his heart rate was 106 bpm. The remainder of the physical examination was unremarkable. He was premedicated with 1 mg of midazolam intravenous (IV). General orotracheal anesthesia was induced with 60 mg of propofol, 60 μg of fentanyl, and 30 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 sevoflurane and oxygen. The patient remained supine throughout surgery, and the head was not repositioned during the case. The surgical and anesthesia times were 7.0 and 7.5 h, respectively. The intraoperative period was unremarkable. Specifically, there were no episodes of hypotension, that is, systolic blood pressure <80 mm Hg. Temperature maintained up to 36.6–37.0°C. The estimated blood loss was 60 mL. The patient received 2000 mL of lactated ringer's fluid IV. The patient remained in the hospital for 2 weeks. Six days after discharge from the hospital, the patient's mother noticed a patch of hair loss over the occipital area. The area of alopecia was 3.5 cm × 2.5 cm in the occiput. Dermatology consultation sought, and it diagnosed to have PA. And family reassured and advised only observation and follow-up within 3 months.

Case report 2

A 3-year-old, Saudi, 14-kg, ASA physical status class II boy presented for elective robot-assisted laparoscopic bilateral ureteric reimplantation. His preoperative arterial blood pressure was 90/55 mm Hg, and his heart rate was 110 bpm. The remainder of the physical examination was unremarkable. He was premedicated with 1 mg of midazolam IV. General orotracheal anesthesia was induced with 40 mg of propofol, 40 μg of fentanyl, and 20 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 sevoflurane and oxygen. The patient remained supine throughout surgery, and the head was not repositioned during the case. The surgical and anesthesia times were 9.0 and 9.5 h, respectively. The intraoperative period was unremarkable. Specifically, there were no episodes of hypotension <80 mm Hg. The estimated blood loss was 40 mL. The patient received 1000 mL of lactated ringer's fluid IV patient remained in the hospital for 3 days.

Two weeks after discharge from the hospital, the patient's mother noticed a patch of hair loss over the occipital area. This was well-demarcated single alopecia patch on the occiput with a background of the normal skin area of alopecia was 3.0 cm × 1.5 cm in the occiput. Dermatology consultation sought, and it diagnosed to have PA. Family re-assured and adviced only observation and follow-up within 3 months.

DISCUSSION

Postoperative transient hair loss was first described after long-lasting gynecological operations.[1] Subsequently, it has been reported after cardiac, gynecologic, abdominal, esthetic, and breast reconstruction surgery.[23] Transient hair loss is characterized as localized hair loss without scar formation. Hair loss can be in a localized part of the occipital area that develops 2–3 weeks after long-lasting surgery. Ischemic changes in the scalp exposed to pressure during long-term surgery are blamed for the hair loss. In our two cases, PA noted within 1–2 weeks postoperative period.

Lwason et al.[4] were the first to report permanent alopecia following surgery and believed that the duration of surgery was directly correlated with the probability of the alopecia being permanent. In this series, the 29 patients who developed permanent alopecia had been intubated on average 10 h longer than the 31 patients whose alopecia was temporary. They influenced the development of alopecia with different head-turning schedules; when the head was turned every 30 min during the procedure and postoperatively, the incidence of PA was zero. In our cases, average surgical and anesthesia time was 8 h.

A 15-year-old girl developed temporary symptomless alopecia following breast surgery lasting more than 6 h. The hair loss corresponded to the shape of the soft doughnut-shaped head rest, which had been used during surgery.[5] A doughnut-shaped headrest was one of the possible solution offered by Abel and Lewis[1] to the problem of PA. In this case, it was insufficient to prevent the development of alopecia.

The difficulties of repositioning the head during head and neck surgery were raised by Bruce et al.[6] who reported temporary alopecia corresponding to the shape of a horseshoe headrest used for a maxillectomy operation lasting more than 7 h. A similar case was published recently in a 29-year-old male, who developed temporary PA following 7 h of surgery for distraction osteogenesis.[7] Postoperative alopecia shares same risk factors with the postoperative visual loss (POVL). An increased risk of POVL has been shown in cases with steep Trendelenburg, as well as prone positioning. Secondary to patient positioning, increased intraocular pressure and decreased ocular perfusion pressure lead to optic nerve ischemia and visual loss in nonocular cases.[8] Furthermore, intraoperative hypotension is another risk factor. A mechanism as similar to POVL can explain postoperative alopecia. Our patient had occipital alopecia wherein her head was in contact with adult-sized silicone-based donut head pad for prolonged duration in steep Trendelenburg position. Additional risk factor could have been inadvertent or unrecognized mechanical compression of the scalp by electrocardiography (ECG) cable trunk yoke assembly that lies between ECG trunk cable and ECG lead set. This could have potentially caused hair follicle ischemia or venous engorgement secondary to scalp compression. This reduction in blood inflow, as well as outflow might have contributed to her hair loss. If recognized early, the condition may be reversible, or even preventable; a delayed diagnosis could lead to permanent hair loss. Regular head turning schedules and vigilance for the condition should be used as prophylaxis to prevent permanent alopecia. Repositioning the head every 30 min and providing adequate head padding during surgery are advised to protect the patient and prevent such incidents.

CONCLUSION

PA is probably underreported. It occurs following hypotensive or complicated surgery and prolonged stays in Intensive Care Unit when patients require intubation. The constant pressure on the scalp is causative and may be exacerbated by hypoxemia or hypotension. There is a correlation between the length surgery duration under anesthesia and the development of permanent alopecia.

There are other possible measures to minimize pressure related morbidity in the operating room.

Minimizing surgery's duration

Keeping patient's head at or above the level of heart

The patients should also be made aware of risks of postoperative alopecia in suspected prolonged surgery

Anesthesia providers should be aware of its risk-reducing methods with:

Proper head positioning

Avoidance of mechanical compression by rigid objects

Maintenance of intraoperative hemodynamics

Avoid hypothermia

Provide more care to patients in steep Trendelenburg position

Frequent turning of the head during prolonged surgery and use of soft padding for the head support.

Because pressure-induced alopecia is under reported we should work on it by updating our hospital policy concerning preventable measures in long operative procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.