The Consultation and Surgical Planning

16 The Consultation and Surgical Planning

Bernard P. Nusbaum and Aron G. Nusbaum

Summary

The key to success in hair restoration surgery is proper patient selection. Obtaining a medical history and performing a thorough scalp evaluation determine the patient’s candidacy for the procedure. It also includes educating the prospective patient on the various surgical techniques available. Examples of realistic expectations regarding achievable results must be clearly communicated and meticulous attention must be paid to the patient’s response to ensure their understanding and acceptance of the surgical plan. Hair restoration surgical results take time to develop and the nature of hair loss is progressive. These two factors make it important that a long-term trusting relationship is established between patient and surgeon.

Keywords: patient selection hair transplant consultation body dysmorphic disorder hair loss diagnosis

Key Points

•Proper patient selection is one of the most essential components of the consultation process to ensure patient satisfaction with surgery.

•A thorough history should be obtained from each patient to identify potential contraindications to surgery.

•It is imperative to accurately communicate to each patient the type of result, which is attainable taking into account the degree of hair loss as well as hair and scalp characteristics.

16.1 Introduction

The success of a hair restoration procedure is determined by multiple factors, one of the most important being proper patient selection during consultation. This process begins by educating the patient on the general principles of hair transplantation and the various techniques available. In addition, an explanation is provided of what to expect on the day of surgery, the immediate postoperative period, and the time course for expected hair growth. After obtaining a detailed history to identify possible medical risk factors, the scalp examination involves correctly diagnosing the etiology of alopecia as well as determining the patient’s overall candidacy for the procedure. Donor quality and supply must be assessed, as it pertains to present and future extent of hair loss. Moreover, obtainable results must be clearly communicated to the patient to assure that their expectations can be met. Throughout the entire encounter, the surgeon should try and pay close attention to body language and cues to gain insight as to the patient’s psychological and emotional status. It is important to establish a connection with the patient on a personal level and ensure that there is compatibility for a strong doctor–patient relationship. At the first sign of discord, careful consideration should be given to whether it is prudent to proceed toward surgery, and at this time it is often wise to suggest that the patient obtain opinions from other colleagues. See Video 16.1 and Video 16.2 on patient consultation and evaluation.

16.2 General Information Provided to Patients

With the ever-increasing amount of information available on the Internet, it is not uncommon for patients to present for consultation already having done extensive research on the procedure. Nevertheless, information is provided to all patients both verbally and in written form regarding the concept for follicular unit transplantation, differences between strip donor harvesting and follicular unit excision (FUE), the finite nature of the donor supply, as well as the individual factors that determine the number of grafts to be transplanted in one procedure. With respect to the donor area, evolutionary developments in strip harvesting such as the trichophytic closure 1^,² should be explained as well as the variability in scarring that is observed between patients. The fact that FUE is not a scarless procedure should be emphasized. Patients should understand that while no linear scar results from FUE and hair can be worn shorter than with a strip harvest without evidence that a procedure has been performed, small dot-like scars will be visible if the hair is completely shaved. In addition, it should be conveyed that with repeated FUE sessions, visible thinning of the donor zone can occur. FUE may be particularly suitable for younger patients in whom advanced baldness may develop and may decide in the future to forgo more procedures and keep their hair very short. Another indication for FUE is to harvest hair to place into existing linear scars to camouflage their appearance. Patients who have undergone multiple strip procedures rendering the donor area too tight for further strip excisions might also be candidates for FUE. Additionally, FUE is the method of choice for obtaining donor hair for non-scalp areas such as the beard, chest, or leg.³ The degree of preoperative shaving necessary for each type of donor harvesting should be considered by the patient with regard to their current hair style as well as social and professional constraints regarding their appearance in the immediate postoperative period. General information regarding the operative experience as well as the postoperative course can be conveniently presented in a simple FAQ written format. A list of potential complications and their relative frequencies should also be provided during the consultation process.

16.3 Medical History

To identify potential contraindications, a thorough history must be obtained from each patient. This should include medical conditions, previous surgeries, social and psychological history, allergies, current medications, and a complete review of systems (Table 16.1). It is important to note when the patient underwent their last general medical examination to ascertain the accuracy and reliability of the information being provided. A family history of hair loss may be helpful in ascertaining the patient’s future hair loss potential.

Table 16.1 Medical history screening checklist

•Allergies

–Medications

–Antiplatelets or anticoagulants

–Tricyclic antidepressants

–Sympathomimetics

–Nonselective beta-blockers

•Cardiac history

–Coronary disease

–Valvular disease

–Arrhythmias

–Hypertension

•Prosthetic implants

–Pacemaker

–Cardiac valves

–Orthopedic hardware

•Diabetes

•Seizure disorder

•Coagulopathy

•Hepatic disease

•Sleep apnea

•Peptic ulcer disease

•Glaucoma

•Disorders of the spine

•Abnormal scarring

•Scalp dermatoses

•Skin infections or history of MRSA

•Prior surgery involving scalp or cranial bone

•Previous hair transplants

•Alcohol, tobacco, drug use

•Psychological history

An overall assessment of the general health of the patient must be arrived at, with a particular attention to cardiac history. Patients with coronary or valvular disease, arrhythmias, or hypertension must obtain medical clearance prior to surgery, as local anesthesia with epinephrine is generally utilized. The decision on whether aspirin or anticoagulant medications can be safely discontinued should likewise be made by the patient’s physician. Active hepatic disease must be taken into consideration, as it may result in altered coagulation as well as impaired metabolism of local anesthetic agents. Patients with diabetes are at risk for poor wound healing as well as hyperglycemia with the stress of surgery and therefore must be under medical care and have their disease well controlled. In addition, the usual corticosteroids given to prevent edema post–hair transplantation can result in hyperglycemia in these patients and therefore are either contraindicated or should be reduced in dose. Likewise, systemic corticosteroids may exacerbate peptic ulcer disease or glaucoma. As hair transplant procedures are usually performed with some form of sedation, doses should be adjusted when sleep apnea is present. A history of seizures is relevant, as therapeutic levels of certain antiseizure medications such as phenytoin should be confirmed in the immediate preoperative period. Patients with a bleeding diathesis should be worked up with pertinent blood work and/or be referred for hematological consultation. Those with disorders of the spine or limitations in mobility should be given special consideration as hair restoration requires static positioning for long time periods. Patients with poor wound healing, enlarged scars, or keloid formation should be counseled appropriately and perhaps scheduled for small test areas prior to undergoing a definitive procedure. A dermatologic history focusing on scalp conditions such as seborrheic dermatitis, psoriasis, or folliculitis must be obtained as such disorders must be treated and cleared prior to surgery. In addition, a history of frequent skin infections may indicate a MRSA carrier state which, if confirmed, should prompt decolonization measures.

Information regarding all previous surgeries especially those involving prosthetics implants such as pacemakers, cardiac valves, or orthopaedic hardware is pertinent and current guidelines regarding antibiotic prophylaxis should be followed. In the case of pacemakers, special precautions regarding electrocoagulation should be noted. Prior surgery involving the scalp may lead to diminished local circulation and increased risk of necrosis. Patients who have had surgeries involving the skull should have neurosurgical or craniofacial surgical clearance as infection or compromise of cranial prostheses or areas devoid of cranial bone may have devastating consequences. Obviously any previous hair transplant surgeries need to be identified including the number of grafts performed and method of donor harvesting.

A complete list of medications should be compiled including both prescriptions and nonprescription items such as vitamins or herbal supplements. Of particular importance are antiplatelet or anticoagulant agents, as well as drugs that can potentiate the effect of epinephrine such as tricyclic antidepressants and sympathomimetic agents. It is recommended that nonselective beta-blockers be discontinued or substituted because when they are combined with epinephrine, there is a potential for unopposed alpha adrenergic stimulation and marked hypertension.4

A social history identifies current or past use of tobacco, alcohol, or other illicit drugs. The psychological history elicits information on whether the patient has suffered from depression, anxiety, or any other mental illness and if they have been under the care of a psychologist or psychiatrist. If there is significant psychiatric pathology and one decides to proceed with surgery, it is helpful to communicate with the treating physician to assure a hair transplant would be beneficial and to determine the best timing for the procedure as it pertains to the patient’s condition. As in all cosmetic procedures, it is important to identify patients with body dysmorphic disorder (BDD) as they generally are dissatisfied due to unrealistic expectations that cannot be met. While the prevalence of BDD in the general population has been estimated to be between 0.7 and 7%, in the cosmetic surgery setting, rates as high as 53.6% have been reported.⁵ Two screening tools that have been validated in a cosmetic surgery/dermatology setting are the BDD Questionnaire-Dermatology Version (BDDQ-DV) and the Dysmorphic Concern Questionnaire (DCQ).⁶^,⁷ Both can be administered during the consultation process, are minimally time consuming, and are self-reporting in nature. The BDDQ-DV is considered positive if the patient acknowledges preoccupation with his/her appearance and has at least moderate distress or impairment in functioning (Fig. 16.1).

Fig. 16.1 The BDD Questionnaire-Dermatology Version (BDDQ-DV), which is considered positive if the patient acknowledges preoccupation with his/her appearance and has at least moderate distress or impairment in functioning.

Only gold members can continue reading. Log In or Register to continue