The pre-operative phase is that period leading up to the performance of the surgery. Sometimes, certain medications, like antibiotics, will be started the night before. Occasionally, in extremely anxious patients, sedation or sleeping medication will be given the previous night as well, to insure a good nights sleep. It is the rare patient that requires this extra effort. Photos may be taken from various angles to document the level of pre-operative balding. The patient may have a movie they wish to watch, or music they wish to hear, during the procedure. This can be determined in advance or after the surgery begins.
Often, a brief second consult with the surgeon takes place, during which the patient may restate his or her goals and desires, and the surgeon may respond or help the patient modify these goals into a more realistic and aesthetically appropriate plan. The physician may at this point draw in the hairline with a surgical marker, with the patient observing in a mirror, and may mark other points, such as the boundaries of the crown, if that area is being grafted, and reexamine the donor area for scarring, density, and laxity. This is a good time for final questions relating to the surgical plan, and the long-term plan, to be put forth, so that all parties are satisfied that they are moving forward with an acknowledged and satisfactory effort on the part of the patient.
At this point, after checking for the presence of drug allergies, medication for limiting swelling and inflammation may be administered. Other drugs for sedation may also be given. This will be discussed further in the section below.
Is sedation mandatory for follicular unit transplantation? Strictly speaking, no, it is not. However, there exist many good reasons for using mild sedation for this procedure, not the least of which is the patient’s comfort during what may be a long procedure. Much of the time spent in the surgical chair can be quite boring. There are other reasons, though, as we shall see.
The only part of FUT that is remotely painful is the injection of the numbing medications, or local anesthetics (see below). This is necessary in the donor area in back and also in the recipient areas that will receive the grafts. This is one of the first things that are done during the operation, and it can sting a good bit. People demonstrate a wide range of pain tolerances, and it has nothing to do with being strong, or “manliness”, or a lack of these attributes. It’s simply how our nervous systems are “wired”. For some patients, the injection of local anesthetic barely gets their attention; they continue talking as though nothing was happening. For others, the shots are quite bothersome, and they may begin to sweat or feel dizzy. So often, if a little sedation is used at the beginning of the procedure, this potential for pain and anxiousness is relieved before it even occurs.
Another reason for using the type of sedation we prefer is that it can prevent or relieve the potential side effects of the local anesthetics we use (see below). Generally, we choose a class of drugs known collectively as the benzodiazepines, specifically diazepam, midazolam, and lorazepam. These are similar to the drug Valium, and are considered sedatives and anti-anxiety agents. They may be given orally, intravenously, or intramuscularly; the intravenous route works the quickest and the oral route has the longest time to onset of effect. Used appropriately, they are quite safe, and we seldom see complications associated with their use. Given by any of the methods above, these medications render the patient relaxed, maybe slightly drowsy, and usually with a noticeable sense of wellbeing. The local anesthetic injections may become unnoticeable, or just a slight annoyance. Depending on the drug used and the route by which it is given, it may last an hour, or several hours. We have found this method of sedation to be safe, effective and well accepted by our patients.
Some physicians routinely give opioids, or narcotic type drugs (pain relievers). Although this class of drugs is quite effective as well, it does not relieve anxiety as well as the Valium class of drugs, and in some instance can cause dysphoria (a sense of non-wellbeing). Also, the narcotics have a much stronger effect on the respiratory centers in the brain, and can depress the breathing. Moreover, they can cause nausea and vomiting quite frequently, which is distressing to the patient (and the last thing you want is vomiting in a fresh hair transplant patient – you could pop a graft!). Also, itching is a common side effect of narcotic drugs, which can be a miserable situation for the operative team and for the patient during a long case that requires stillness on the part of the transplant recipient. Lastly, if these narcotics are used along with the Valium type of drugs, a synergistic action takes place: they may greatly enhance one another’s effects, which could lead to depressed breathing, over-sedation, lowered blood pressure, or other problems. For these reasons, we usually choose not to administer opioids/narcotics, and try to stick with the relatively safe, tried-and-true sedatives mentioned above (the benzodiazepines).
Others have advocated the use of nitrous oxide (N2O, or laughing gas). While this drug can be a quick acting, effective sedation and pain relief agent, there are problems with its use and its effects, too. First of all, it requires a more complicated system (you may have seen these at the dentist’s office) than for the oral or injectable agents. Secondly, it must always be used with oxygen, and both oxygen and nitrous oxide come in relatively bulky metal tanks. Special monitoring of the patient’s vital signs is necessary, and when the nitrous oxide is stopped, the patient must always inhale pure oxygen to avoid decreased levels of oxygen in the blood (called diffusion hypoxia). Occasionally, patients will experience dysphoria, which may present much like a panic attack; this quickly resolves with discontinuation of the gas.
Others promote the use of heavier sedation, citing the patient’s comfort, the length of the procedure, and the ease with which the surgical team may work, as their rationale. This author feels that, unless one has a strong anesthesia background, that the benzodiazepines (Valium family of drugs), and, possibly, the less potent opioid/narcotics, should remain the agents of choice for sedation in hair transplantation.
Many people think of anesthesia as being “put to sleep”. However, there are other ways of achieving anesthesia, which just means rendering one insensitive to pain impulses. In hair transplantation we use local anesthesia, which, as the name implies, locally deadens (temporarily) the nerves, rather than the whole central nervous system (unconsciousness). This is most desirable because, when using local anesthesia, no pain is felt, the procedure can be done in the office, we avoid the expense and hazards of the hospital operating room and general anesthesia, and the patient is awake throughout the process, and can remain an active participant in decision making.
There are two main classes of local anesthetics: esters and amides. The esters are more prone to causing allergic reactions than the amides, and are less widely used. Even amongst the esters, however the incidence of true allergic reactions is extremely rare. Very often, people claim an allergy to “Novocaine” or all the “-caine” drugs, when they have actually experienced either a temporary reaction to too much anesthetic (mild overdose), or a reaction to the epinephrine (adrenaline) that is often added to local anesthetics to prolong their action and to decrease bleeding.
The most widely used local anesthetic agents (LA’s) in hair transplantation are of the amide class, namely, lidocaine (Xylocaine) and bupivicane (Marcaine). These have an established safety record, and we rarely see problems with them. Comparatively, they are similar in effect, with lidocaine being faster acting, and bupivicaine lasting for a longer time. They are injected into the skin and subcutaneous layers, and/or around larger nerves in the form of nerve blocks.
There are several areas where nerve blocks can be used. The first is the occipital nerve, which is in the back of the head, above the neck. When this nerve is blocked, the back of the head (donor area) and crown
are numbed; this can be of benefit after the surgery, also, as the donor area may be painful that night. The supraorbital nerve, above the eye, may also be injected; this results in hairline and frontal area numbness. Two other nerves in front and behind the ear may also be blocked to help with anesthesia in the top of the head and around the sides.
However, we do not do the surgery with just the blocks; we always inject locally, wherever incisions will be made. One of the reasons for this is that the blocks may be incomplete at times, and we want the scalp completely numb and unable to feel any pain; the other reason is to add epinephrine (adrenaline) to the area. This has a two-fold purpose: 1) to prolong and intensify the action of the LA’s and 2) to constrict the small blood vessels in the area and decrease the amount of bleeding. The importance of diminishing the amount of bleeding, especially in the recipient area, cannot be overemphasized. The less bleeding there is, the more easily and accurately the recipient incisions can be placed; likewise, with minimal bleeding, placement of the FU grafts causes less trauma to the follicles and is generally smoother and quicker.