Friday, July 31, 2009

Virtually Painless Hair Transplant Anesthesia

I just attended the International Society of Hair Restoration Surgery (ISHRS) 17th Annual Meeting at Amsterdam last week.

Here is the abstract of my a pesentation about how to use anesthesia technique to perform a virtually painless hair transplant procedure.

Title: Virtually Painless HT Anesthesia

I Introduction
The ideal Anesthesia for HT includes many factors. Safety is a main priority. Blood pressure and heart rate must be monitored. Minimal blood loss, minimum airway obstruction and minimal if no discomfort for the patient is the ultimate goal for HT anesthesia.
This discussion will revolve around delivering painless anesthesia to the patient. There are so many nerves involved, so to apply painless HT Anesthesia is never an easy job.
The method I am going to mention I have being using for the past 15 years. We have modified it during the course of time and now all our patients appreciate it and have almost no side affects. I don’t recall the last time we have encountered airway obstruction, nausea or vomiting.

II, Technique- minimum sedation and stimuli
A. minimum IV sedation
The purpose of this is to relax the patients and not to put them to sleep.
Never give too much sedation. How to give the right dose is the most difficult part. Some practitioners might be reluctant to use IV sedation. The method works with just partial knowledge of the technique that I use.

B. always pre-numb the skin
Use a 30 gauge needle with bacteriostatic sodium chloride. Never use xylocaine for pre numbing purpose. Its ph is too low and will sting.

C. Two step super orbital block
Too my knowledge, not too many practitioners use a super orbital block because it is too painful to apply. I have created a 2 step block to reduce the pain to a minimum.
I pre numb the landmark with a 30 gauge needle and bacteriostatic sodium chloride and then apply 1cc of xylocaine on each side. I only stick the needle up to the subcutaneous area. The second block occurs after I remove the donor site and close it. It usual takes me about 30 minutes. By that time, even if I stick the needle deeper to numb the nerves, the patient usually doesn’t feel any or very minimum pain.

D. Massage.
Always use the vibrator if possible to interfere with the pain transfer path.

E. Inject the medication very slowly.
The speed of injection makes a lot of difference.

III Discussion
For sedation I use midazolam and narcotics fentanyl.

To prevent N&V, I screen my patients with two questions. Have they experienced nausea after previous surgeries and if they experience any type of motion sickness. If one of the answers is positive then I don't use any narcotics it at all. My max dose of fentanyl is 2ml.

I.V. midazolam relaxes the patient fast and efficiently, it never causes N&V, minimum cardiac impact and causes some amnesia.

We don't want to put patients into deep sleep, because it might cause airway obstruction. To give the right dose is very important and difficult. Everyone needs a different dose, so we give it incrementally in 10-15 minutes. In my experience I have never had to use antidote (Romazicon). I don't remember the last time I had to hold the chin to open the air way.