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Hair
transplant associated pain reduction techniques
Most often doctors and pain are so closely associated that
people tend to avoid them as much as possible. The doctor has
to answer
the primary question “does it hurt?” as a preliminary
confidence booster before any procedure of treatment. This fear
of pain extends to hair transplantation and when a patient who
has already undergone such a procedure has felt pain, he may not
be willing to follow up with a second procedure. As a result
the hair transplant is not complete. Feedback from this patient
may give other patients who are thinking of hair transplant a
negative impression. In hair transplantation, the administration
of local anesthesia itself is a little painful, but once this
process is complete there should be no further pain involved if
the patient is correctly managed.
Since the hair transplant sessions are lengthy it is necessary
that patients are given proper pain relief for that period of
time. The following are some of the methods that a hair surgeon
can apply to alleviate pain during hair transplant procedures.
1. Decrease a patient’s anxiety – The fear of pain
makes any patient anxious.
a. Hence don’t keep the patient waiting. If he needs to
wait, then prior intimation would put him at ease and he can go
around the locality to relax himself by way of window shopping,
going to a restaurant etc. and arrive a few minutes before the
procedure is set to begin.
b. Let the ambience of the surgeons work area be casual with
some music to soothe the nerves.
c. Be friendly while talking with your patient and also supportive.
d. Avoid display of all your gadgets such as needles, syringes
and surgical instruments so that the patient does not feel confined.
2. Premedication – to reduce anxiety and at the same time
keep him in communication for the surgeon to interact, the patient
may be given 20mg of diazepam 30-45 minutes before the procedure.
Diazepam is a benzodiazepine which is the most commonly used drug.
Triazolam and lorazepam are the other two common drugs of the
same class that are administered orally. When the threshold of
pain in patients is on the higher side, narcotics such as pethidine
or paracetamol are given in addition to diazepam. Since the use
of narcotics induces nausea and vomiting in patients, the drug
rofecoxib is used to alleviate this problem. While diazepam counteracts
neurological effects of lidocaine toxicity, roficoxib is gentle
on the gastric lining of the stomach and has been reported to
have no adverse effect on blood platelets. When intravenous administration
of pethidine or midazolam is undertaken, it is mandatory that
these drugs be administered under the care of a trained anesthetist
and anesthesiologist so that the drug monitoring is done by experts.
A few hair transplant surgeons use nitrous oxide for sedation
since its effect evaporates away sooner than the other intravenous
drugs after the procedure. It is very important that the age,
weight and other medical conditions of the patient is taken into
account before administering anesthesia as these conditions are
variable.
3. How to administer the drugs or infiltration techniques – When
the surgeon anesthetizes a small area and then administers the
rest of the anesthesia, the pain caused by insertion of needles
is minimized. Also, low pressure and slow administration of the
drugs decrease pain caused when the drug is getting into the system.
The drugs are always injected in the dermis region for maximum
effect and the nerves on the scalp are desensitisized by ring
block in which the nerves in the area in which the surgeon has
to work on are blocked of any feeling. Dr. Nusbaum anesthetizes
the donor area first for harvest and then the recipient area for
transplant in order to minimize the use of these drugs at a given
time.
4. Use of nerve blocks as an alternate to ring blocks – In
the scalp region two nerves namely the supraorbital and supratrochlear
which cater to the front region of the scalp are desensitized.
This is done by injecting 0.5% of 1-2mL lidocaine and subsequently
another 0.5 mL of the solution in the periosteum which is a dense
fibrous membrane covering the cranium. This procedure is done
on either side of the head. Patients who have been under nerve
blocks have had pain reduction up to 95%. When the nerve block
is not carried out under supervision, there is a possibility of
the patient experiencing damage to the nerves leading to abnormal
skin sensations such as tingling, burning or itching.
5. Reducing pain while injecting anesthesia – Apart from
distracting the patient to reduce anxiety during anesthesia administration,
the method of needle insertion, speed with which the solution
is injected, temperature and pH of the solution all form an integral
part of reducing pain during the process. Some of the common practices
followed prior to injecting anesthesia are as follows –
a. Ice packs – Ice packs, cryogel packs, frozen metal plates
and spraying of Freon or ethyl chloride applied 30 seconds before
using the needle helps the patient in lessening pain. This technique
is usually combined with other techniques for best possible effects.
b. Lidocaine Iontophoresis – In this method, 4% lidocaine
mixed with epinephrine in the ratio 1:50000 is transferred as
ions on the skin surface using an electric field. The application
is however restricted to bald regions because regions with hair
may be a hindrance to the ion transfer.
c. Topical local anesthesia – is a time consuming and unwieldy
option where in different anesthetic drugs are mixed and applied
on the skin surface one and half to two hours before the main
anesthetic is injected. Although the skin becomes numb, the subsequent
injections can still be painful. It is time consuming because
of the extra time required prior to the anesthesia administration
and unwieldy because it is not handy when the hair transplant
surgeon is pressed for time.
d. Needle-less injectors – are devices that transfer certain
amount of anesthesia under air pressure directly through the skin.
However, patients sometimes feel this pressure as painful.
e. Buffering of anesthesia – The presence of preservatives
in the anesthesia solutions decreases the pH of the solution which
is counterbalanced by adding buffers such as sodium bi carbonate
to raise the pH. The rise in pH decreases pain during administration,
but after the surgery many patients experience puffiness in the
injected regions. Hence its use is usually restricted to the donor
region.
f. Temperature of local anesthesia – warming of local anesthesia
to 37-40 deg C combined with buffering is seen to reduce pain
as compared with the non buffered solution at room temperature.
This technique has been adapted from dental practitioners for
hair transplants.
g. Vibratory stimulus – In this method a hand held battery
vibratory device is used to massage the area where local anesthesia
is to be injected. In comparison with the donor and recipient
sites, the donor site is shown to be benefited to a large extent.
Since the number of
patients who have undergone this method is limited, the effective
use of this method can be vouched for only after extensive study.
h. Computerized anesthesia injectors – This technique is
prevalent in dentistry and the same has been extended to hair
transplants. In this method an instrument called a ‘Wand’ is
used, which is a computerized instrument that can inject anesthesia
at a controlled and slow rate thereby helping in uniform distribution
and reducing tissue distension during administration. The procedure
takes some time due to which it can be used as a good
option for initiating ring blocks in the donor and recipient sites.
The advantage of using a Wand is its controllability and the design
which is pleasing to the patients and almost no post operative
puffiness of the areas worked on.
6. How to maintain local anesthesia – Since a hair transplant
procedure is time consuming, it is necessary that the patient
is maintained at an optimum level of anesthesia so that he can
still effectively communicate with the hair surgeon when he starts
to feel a drop in the anesthetic effect. The age of a patient
is a determining factor in administering anesthesia. In younger
patients the effect evaporates away faster and more so in the
frontal region as compared to the donor area. The most commonly
used local anesthesia for hair transplant is lidocaine while some
surgeons use bupivacaine or the two in combination with epinephrine
as a carrier for prolonged effect. Lidocaine has a faster effect
than bupivacaine and has no cardiac toxicity as seen to occur
with bupivacaine.
A patient is always encouraged by the surgeon to communicate
when the effect of anesthesia is diminishing. However, the surgeon
can anticipate a reduction in anesthesia effect when the transplanted
site experiences increased bleeding. In patients who have the
tendency to bleed more naturally, the surgeons use epinephrine
before preparing the recipient site for the hair transplant. When
excess epinephrine administration can be toxic, various other
methods of controlling blood loss such as identifying bleeding
patterns in patients prior to surgery, stoppage of medications
that lead to thinning of blood, controlling blood pressure, optimum
sitting or lying down positions of the patients during surgery,
use of lighting systems that do not generate heat and allowing
the patient to smoke if he is a heavy smoker, are all useful strategies.
Lower blood loss and longer anesthetic effect can also be achieved
by the method of using tumescent anesthesia. In this method, lidocaine
and epinephrine are administered at a certain pressure so that
the blood vessels in the injected skin are blocked temporarily.
The result is better permeation of the anesthesia and in the process
deep seated vessels are protected. The procedure can be done 10-15
minutes before the donor harvest and recipient site preparation.
This procedure has certain post operative disadvantages such as
a high level of edema or puffiness of the recipient sites, grafts
popping out from their insertion incisions and dimpling of the
scalp skin that makes the grafts seem like they have been placed
in small pits.
7. Pain after the surgery – During the first week after
surgery, most patients feel uneasy in the donor area mainly due
to the sutures. Once they are removed a patient feels much more
comfortable. In the recipient sites however, the patient may complain
of burning sensations for a short period of time 30-45 after surgery.
Normally a patient starts to feel pain 1 or 2 hrs after completion
of the procedure. To prevent this, surgeons inject bupivacaine
when the surgery is almost coming to a close. In some instances,
ice packs have been used to alleviate pain. Patients are also
prescribed acetaminophen for the first week if he feels some pain.
Less pain equals more confidence in both the doctor in question
and the surgical process and this aspect proportionally increases
the number of patients who can opt for hair transplant treatment
as a viable choice to combat hair loss.
Hair
transplant associated pain reduction techniques
references
- Nusbaum BP.
Techniques to reduce pain associated with hair transplantation: optimizing anesthesia
and analgesia.
Am J Clin Dermatol. 2004;5(1):9-15. Review.
PMID: 14979739
- Whalen K, Rabinovitz HS, Oliviero MC. Microprocessor-controlled
local anesthesia versus the conventional syringe technique in
hair transplantation. Dermatol Surg. 2003
Jan;29(1):113; discussion 113-4. PMID:
12534526
- Swinehart JM. Local anesthesia in hair transplant surgery.
Dermatol Surg. 2002 Dec;28(12):1189. No abstract available.
PMID: 12472507
- Seager DJ, Simmons C.
Local anesthesia in hair transplantation.
Dermatol Surg. 2002 Apr;28(4):320-8.
PMID: 11966789
- Field LM, Namias A. Bilevel tumescent
anesthetic infiltration for hair transplantation. Dermatol Surg.
1997 Apr;23(4):289-90. PMID: 9149797
- Hunstad JP. The tumescent technique
facilitates hair micrografting. Aesthetic Plast Surg. 1996 Winter;20(1):43-8.
PMID: 8746470
- Sadick NS, Militana CJ. Use of nitrous
oxide in hair transplantation surgery. J Dermatol Surg Oncol.
1994 Mar;20(3):186-90.
PMID: 8151032
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