May 2003

Diagnosis: Postoperative Pressure Alopecia

Histopathology: Pressure alopecia is classified, along with trichotillomania, as a nonscarring traumatic alopecia. Histopathologic examination reveals increased numbers of hair in the catagen phase and anagen phases, as well as empty hair ducts. In addition, dilated follicular infundibula, clefts surrounding the lower portion of the hair follicle, hair bulb distortion, and dissociation of the cells of the hair matrix may all be seen.1

Discussion: Postoperative pressure alopecia is a rare, non-scarring alopecia that occurs as a complication of prolonged surgical procedures. Factors that have been found to correlate with pressure alopecia include length of procedure, intubation, and use of general anesthesia. Localized pressure induced ischemia is the causative agent. The pattern of hair loss corresponds to the areas of maximum pressure during the immobilized state. Preventative measures include use of a support pillow to cushion the head as well as re-positioning the head on a periodic basis during the procedure.

Patients typically complain of occipito-parietal pain and tenderness within 24 hours of surgery. Edema, ulceration and crusting may follow over the subsequent week. Hair loss is usually complete within 28 days of surgery. Most cases are self-limited and regrowth occurs within 12 weeks. Irreversible hair loss has been reported and is associated with intubation times in excess of 24 hours.2

In this case, the patient underwent modified radical mastectomy with immediate reconstruction via a transervse rectus abdominis myocutaneous (TRAM) tissue transfer. The length of the entire procedure was approximately 8 hours and the patient was extubated immediately following the procedure. Of note, the patient's head was placed in a doughnut-shaped pillow prior to the procedure for support. At her 3 month follow-up visit, some regrowth of hair in the affected area was noted.

References:
1. Weedon D. Skin Pathology. 2002.
2. Lwason NW, Mills NL, Ochsner JL. Occipital alopecia following cardiopulmonary bypass. J Thorac Cardiovasc Surg 1976;71:342-7.
3. Boyer JD, Vidmar DA. Postoperative alopecia: a case report and literature review. Cutis 1994;54:321-2.
4. Dominguez E, Eslinger MR, McCord SV. Postoperative (pressure) alopecia: report of a case after elective cosmetic surgery. Anesth Analg 1999;89:1062-3.
5. Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am Acad Dermatol 1985;12:195-8.