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Pressure alopecia in living donors for liver transplantation

Tokyo, Japan

To the Editor:

We wish to report three living donor liver transplantation (LDLT) donors who developed occipital pressure alopecia (PA) in the perioperative period. All donors were healthy without past medical history. We had experienced about 100 LDLT surgeries until then. Anesthesia consisted of a combination of general and epidural anesthesia. General anesthesia was maintained with O₂-N₂O-isoflurane, and paralysis with vecuronium. Throughout the operations each patient was placed in supine position while the hair was covered with a paper cap and the head was positioned on a soft foam doughnut made of urethane sponge covered with vinyl chloride. Surgeries were prolonged but uneventful. There were no episodes of intraoperative hypotension (systolic blood pressure < 90 mmHg), hypoxia (SpO₂ < 94%), or use of vasoconstrictor agents. All donors were extubated immediately after the operation.

The donors noticed occipital alopecia several days after the operation. Alopecia almost corresponded with the site of the circular headrest. All cases were treated with mometasone furoate ointment and received a scalp massage. We did not obtain skin biopsies and alopecia regressed in a few months.

Abel et al. reported eight gynecological patients who developed alopecia during the postoperative period and speculated that pressure-induced ischemia caused alopecia by resulting in the temporary cessation of follicle activity.¹ Lawson et al. reported that localized scalp pressure was the cause of alopecia following cardiopulmonary bypass surgery, and the duration of pressure determined the extent of the damage.² The putative cause of PA is localized-induced ischemia to the scalp caused by head immobilization but it is still unclear which situations are prone to favour PA. Risk factors for PA include peripheral circulatory failure, such as hypotension secondary to dehydration or massive blood loss. Endotracheal intubation and intraoperative Trendelenburg position have also been implicated.^2–5 However, none of these risk factors were present in our patients.

In summary, we describe three LDLT donors who developed occipital PA. Clinicians should be aware that LDLT surgery may be associated to PA. However, the reasons for this potential association remains obscure.

References

1 Abel RR, Lewis GM. Postoperative (pressure) alopecia. Arch Dermatology 1960; 81: 72–80.

2 Lawson NW, Mills NL, Ochsner JL. Occipital alopecia following cardiopulmonary bypass. J Thorac Cardiovasc Surg 1976; 71: 342–7.[Abstract]

3 Patel KD, Henschel EO. Postoperative alopecia. Anesth Analg 1980; 59: 311–3.[Abstract/Free Full Text]

4 Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am Acad Dermatol 1985; 12(1 Pt 2): 195–8.[Medline]

5 Calla S, Patel S, Shashtri N, Shah D. Occipital alopecia after cardiac surgery (Letter). Can J Anaesth 1996; 43: 1180–1.[Medline]

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