Anagen Effluvium after Therapeutic Scalp Surgery: Unreported Phenomenon

Abstract

Introduction

Many procedures are performed on the scalp, such as excision of pilar and sebaceous cysts, melanocytic nevi, and reduction surgery for scarring alopecia, among others. In hair transplants, telogen effluvium is often reported 3 months after surgery; however, hair loss usually happens much earlier, around second week after the procedure, not compatible with the time required for hair to enter telogen and exogenous phases in normal conditions.

Case Reports

We report 3 cases of anagen hair loss 4 weeks after surgeries, with perilesional trichoscopy suggesting anagen effluvium, with typical signs such as black dots and exclamation hairs.

Discussion

There are only a few reports about hair loss around operated areas. The cause of this postoperative anagen effluvium is probably a transient ischemia.

Conclusion

The practical importance of this phenomenon is to properly orient patients because most of the hair will be lost, since 85% of them are anagens, and also will have spontaneous recovery in the next 3 months.

Established Facts

• There are few reports of hair loss around surgical areas on the scalp, which cause an effect similar to alopecia areata in the perilesional region.

Novel Insights

• We describe cases of anagen effluvium after reduction surgery for scarring alopecic areas, nevi removal, and scalp graft.

• We question the possible causes, which, in the reported cases, appear to have been due to ischemia due to excessive traction, to the use of a solution with adrenaline or local compression.

Introduction

Many procedures are performed on the scalp, such as excision of pilar and sebaceous cysts, melanocytic nevi, and reduction surgery for scarring alopecia, among others. In other procedures, such as hair transplantation, telogen effluvium is often reported 3 months after surgery; however, it is observed that hair loss usually happens much earlier, around the second week after the procedure [1, 2, 3], not compatible with the time required for hair to enter telogen and exogenous phases in normal conditions [4, 5]. Anagen effluvium has not been reported so far. We report 3 patients with anagen effluvium after scalp surgery.

Case Reports

A 15-year-old male patient, with cicatricial alopecia from burn in parietal region for 1 year, was anesthetized with a 1:3 solution of lidocaine 2% with epinephrine 1/200,000 and saline solution, after topical chlorhexidine (2%) antisepsis (used in all described cases) for excisional reduction surgery, mild hemostasis with electrocautery, followed by total skin graft, occluded with brown dressing and nylon 4.0 stitches, without significant pressure for 5 days. One month later, hair loss was observed around the lesion, with black dots on trichoscopy and positive anagen pull test. The skin graft was successful, but implanted hair loss was observed after 2 months, having lost follow-up afterwards (Fig. 1).

Fig. 1.

Burn scar (a); skin graft (b); loss of hair around graft after 1 month (c); black dots in trichoscopy (d); graft survival without hair maintenance and hair regrowth of surrounding areas (e).

A 43-year-old woman, with scarring alopecia after a history of atrophy by corticosteroid infiltration was submitted to reduction surgery and anesthetized with the same solution above, with mild hemostasis. Sutures were made with internal stitches with 4.0 poliglecaprone 25 (Monocryl®) and external stitches with 4.0 nylon. After 1 month, there was hair loss around the operated area with exclamation mark hairs (Fig. 2). Two months later, hair regrowth started and covered almost the entire affected area.

Fig. 2.

Cicatricial alopecia after corticosteroid injection (a); aspect after reductive surgery (b); hair loss around operated area (c); trichoscopy showing exclamation mark hair (d); partial hair regrowth after 2 months (e); trichoscopy with short regrowing hairs (f); after 3 months, hair regrowth around operated area (g).

A 49-year-old woman was subjected to reduction surgery for excision of sebaceous nevus in the vertex, with the same anesthetic solution and antiseptics described above, excision of lesion, hemostasis with electrocautery, and internal suture with moderate tension were performed. Seven days later, areas of ischemia were noted around the operated wound, and anagen effluvium occurred 1 month later. Trichoscopy showed black dots, with hair regrowth after 3 months (Fig. 3).

Fig. 3.

Nevus sebaceous (a); transient ischemia after procedure (b); loss of perilesional hair (c); black dots in trichoscopy (d); hair regrowth around operated (e); clinical aspect 3 months after the surgery (f).

Discussion/Conclusion

Loss of transplanted hair on the scalp is a known fact. Most authors report telogen effluvium after hair transplants [3, 6, 7]. But these data are confusing, since in the same paper, telogen effluvium is reported and there is information that hairs are extruded in an anagen phase [1].

Not much is reported on hair loss around operated areas and in donor areas in transplants [2, 3, 6, 8, 9]. Loh et al. [2] described telogen effluvium around scalp transplanted areas. Kerure and Patwardan reported hair effluvium in the donor area, which they attributed to overharvesting and/or hampered blood supply and a shock loss of recipient site effluvium that they imputed to anagen effluvium, telogen effluvium, or sometimes combination of the two and typically begins 2–6 weeks following surgery [7].

We report anagen hair loss, 4 weeks after the procedures, with perilesional trichoscopy showing anagen effluvium, with typical signs such as black dots and exclamation hairs. Biopsies were not performed. Clinical and trichoscopic differential diagnosis is alopecia areata. Rapid hair regrowth, without therapeutic approach, and alopecia restricted to the areas described without expansion, disprove this hypothesis.

The cause of this postoperative anagen effluvium is probably a transient ischemia, which could be caused by vasoconstrictors or microtrauma (posttransplant anagen effluvium), excessive pressure (case 1), internal suture with trapping of hair bulbs (case 2), or excessive traction in suture (case 3) [6], which would lead to acute and abrupt hair loss, before entering telogen phase. Greater caution on surgical technique, with lighter traction, and less small quantity of epinephrine could reduce this hair loss phenomenon. The practical importance of this phenomenon is to properly orient patients, because most of the hair will be lost, since 85% of them are anagens, and also will be recovered in next 3 months without a need for any type of treatment.

Statement of Ethics

The study complies with the guidelines for human studies, and the research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The subjects have given their written informed consent to publish their case (including publication of images).

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors did not receive any funding.

Author Contributions

Leticia Arsie Contin: acquisition, analysis, interpretation of data for the work, drafting the work and final approval of the version to be published. Leopoldo Duailibe Nogueira Santos: drafting the work and revising it critically for important intellectual content and final approval of the version to be published. Ivan José Netto Pereira: drafting the work and revising it critically for important intellectual content and final approval of the version to be published. Vanessa Barreto Rocha: analysis, interpretation of data, drafting the work and final approval of the version to be published.