Under pressure? Alopecia related to surgical duration.

Virtual endoscopy of the upper, central and peripheral airways with multirow detector CT. Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bron-choscope in a patient with Cowden syndrome.ficacy of the Airtraq w laryngoscope with a fiberoptic bronchoscope compared with that of Airtraq w alone for tracheal intubation: a manikin study. Editor—We would like to share a rare and preventable case of pressure alopecia that emphasizes the importance of intra-operative pressure relieving manoeuvres. Figure 1 is a photograph of a 49-yr-old man who reported patches of hair loss during a postoperative follow-up appointment. Three weeks prior to the consultation, he had undergone a lengthy microsur-gical procedure. A large morphoeic basal cell carcinoma was resected from his left cheek. A free anterolateral thigh flap was used to reconstruct the defect in a procedure that took 9 h and 45 min. The patient had a past medical history of myocardial in-farction (MI), anxiety state, and he smoked 15 cigarettes a day. Figure 1 demonstrates a ring-shaped pattern of alopecia. This was assumed to be due to pressure-related ischaemia of the hair follicles caused by prolonged intraoperative immobiliza-tion with the patient lying supine with the scalp rested in a head ring. Fortunately, the hair growth returned and was near normal at 6 months. There are many cases of similar pressure-related post-operative alopecia documented. It may present within the first postoperative week as a swollen, painful, or ulcerated area on the scalp or as alopecia at postoperative clinic visits; most present within 1 month of surgery. 1 – 3 The alopecia may be scaring or non-scarring, temporary or permanent. The aetiology is thought to be due to prolonged pressure leading to local hypoxia and tissue ischaemia and is associated with anaesthetic immobilization with the highest risk of permanent hair loss in those patients undergoing periods of anaesthesia over 24 h. 1 One review article documented occurrence in operations with as short an anaesthetic time as 3 h (median 6 h), 2 while another in a paediatric population ranged from 4.4 to 7.1 h. 4 Hypotension and hypoxaemia may be contributing factors while the Trendelenburg position, obesity, and psychiatric disorders have been implicated as linked. 1 2 4 5 In the patient we present, the lowest arterial pressure documented in the intra-operative period was 80/50 and he remained normothermic throughout, but the history of ischaemic heart disease is suggestive of microvascular pathology that …