What do treatment for severe acne, daily aspirin to prevent heart attack, and heavy smoking or drinking have to do with hair restoration surgery? They are all risk factors that have the potential to affect the successful outcome of hair transplantation or other form of hair restoration surgery. Here are some examples:
Acne and hair loss are both conditions that detract from one’s appearance, and both are conditions for which effective treatments are available. The same person might seek treatment for both-treatment for acne by a dermatologist or primary care physician and treatment for hair loss by a physician hair restoration specialist. The patient may not see any obvious relationships between treatment for acne and treatment for hair loss, other than his or her concern for correction of cosmetic deficits. The patient’s inability to see any relationship between treatment for acne-especially treatment for severe acne-and effective hair restoration surgery is understandable if the patient is not a physician. A physician hair restoration specialist recognizes that some medical treatments for severe acne can influence the timing of surgical hair restoration to assure optimal outcome but rarely prohibits hair restoration surgery. Potential side effects of isotretinoin are hair loss and changes in the cellular structure of skin and hair, both of which can influence the outcome of hair restoration surgery. Hair restoration surgery is usually delayed for about six months after isotretinoin treatment is discontinued to be certain that no more side effects will occur. (See Isotretinoin section below for more information).
Anticoagulants are “blood thinning” drugs that include some commonly taken by millions of people. Aspirin is self-prescribed for everyday aches and pains and often prescribed in “baby doses” by physicians to lower risk for heart attack (myocardial infarction). Warfarin (Coumadin®) is a “blood thinning” anticoagulant prescribed to lower risk for blood clotting. Clopidogrel (Plavix®) is a newer anticoagulant prescribed for prevention of myocardial infarction, stroke, and other conditions associated with blood clots. Aspirin, warfarin and clopidogrel all may put a patient at risk for excessive bleeding during and after a surgical procedure. (See Anticoagulants section below for more information).
Sometimes it isn’t medical treatment but the condition being treated that may affect the outcome of hair restoration surgery. These include conditions such as diabetes that may be risk factors for delayed healing after surgery.
Behavioral risk factors that can influence the outcome of surgery include heavy tobacco use and heavy use of alcohol-both of which can be associated with operative and postoperative risk. Patients are sometimes shy about revealing behavioral risk factors such as smoking and drinking that may cause personal embarrassment, but the surgeon should know about these risk factors before undertaking surgery.
The patient who neglects to reveal all current and recent medical treatments to the physician hair restoration specialist puts himself at risk for less than optimum hair restoration outcome and denies the physician information that may critically influence outcome. The patient should provide all information about recent and current medical treatments when asked to do so. No information should be withheld because the patient fails to see its relevance to hair loss treatment, or for any other reason such as embarrassment about a medical condition currently or recently under treatment. The physician should be allowed to put all information about the patient’s medical treatment into context with overall medical history, physical examination and laboratory tests. (See Hair Restoration Surgery Risk Factors for more information.)
Isotretinoin (Accutane®) is a drug prescribed for treatment of severe acne that is resistant to treatment with any other drug. It is a drug of the type called retinoids that have multiple effects on the skin. Unlike most other acne-treatment drugs it is taken orally rather than applied to the skin.
Isotretinoin is a powerful medication. It has many side effects, some of which can have implications for the success of surgical hair restoration. Among these are hair loss and changes in the cells (keratinocytes) that provide structure to the skin and hair. Hair loss caused by isotretinoin treatment is usually temporary but may be permanent in some patients. Whether the hair loss resulting from isotretinoin treatment is temporary or permanent may not be apparent for some weeks or months after isotretinoin treatment is stopped. Surgical hair restoration is usually not undertaken until (1) the full extent of hair loss associated with isotretinoin treatment is known, and (2) it is apparent that the hair loss is temporary or permanent.
Leading physician hair restoration specialists recommend that surgical hair restoration should be delayed for 6 to 12 months after the end of isotretinoin treatment in order to assess the status of hair loss and condition of the scalp skin. It would be unwise for a patient to stop isotretinoin treatment early in order to undergo surgical hair restoration; isotretinoin is given in a course of treatment over a period of time and early cessation would work against the drug’s success in treating severe acne.
In summary, surgical and nonsurgical hair restoration can be carried out successfully in patients with acne. Acne in itself is not a contraindication for surgical or nonsurgical hair restoration. In patients with severe acne, hair restoration may be delayed until treatment with isotretinoin is completed.
Anticoagulants (Warfarin, Aspirin, Clopidogrel)
Warfarin (Coumadin®) is a “blood thinning” drug given to reduce the blood’s ability to form clots. Warfarin is widely prescribed for prevention of blood clot formation in patients at risk for pulmonary embolism, myocardial infarction and stroke due to blood clots. Atrial fibrillation and heart valve replacement are common risk factors for blood clot formation and subsequent stroke. Patients with these conditions are likely to be using warfarin as clot prevention therapy; these patients are also likely to be men aged 30 to 60 who may seek hair restoration surgery.
Patients with “thinned” blood are at higher risk for excessive bleeding during and after any surgical procedure. A patient known to be receiving warfarin therapy will be sent for a laboratory test to determine the blood’s ability to clot (prothrombin time and International Normalized Ratio or INR). A patient with INR near normal may be considered a candidate for surgical hair restoration. A patient with INR in the moderate to high therapeutic range is usually not a good candidate for any surgical procedure. In some cases, however, the physician who manages the patient’s warfarin therapy may, in consultation with the physician hair restoration specialist, agree to suspend or reduce the patient’s warfarin dose for the period of time necessary for surgical hair restoration and immediate postoperative recovery.
Aspirin is the major non-prescription drug that is taken to reduce blood coagulability. Because aspirin use is so common, a patient may neglect to include it in the list of drugs regularly taken. Many people take a “baby aspirin” daily to reduce risk for heart attack (myocardial infarction), and may in addition take aspirin to relieve headache or other aches and pains. The patient will be advised to suspend aspirin use for a period before and after surgical hair restoration because aspirin puts the patient at risk for excessive bleeding, including postoperative oozing that can increase risk for transplant graft failure.
Clopidogrel (Plavix®) is a newer anticoagulant sometimes described as “super aspirin” because of its potent activity in preventing the aggregation of platelets, the tiny blood cells that clump together in the formation of blood clots. Clopidogrel may be prescribed for patients at risk for myocardial infarction, stroke and peripheral vascular disease.
Patients should not omit mention of a drug therapy that ceased shortly before consultation with the physician hair restoration specialist. Some drugs have effects that persist in the body for days to weeks after cessation of therapy.
The Scalp Examination’s Extra Benefits:
Finding Melanoma at One of Its Secret Sites
When was the last time you looked at the top of your head from forehead to nape and from ear to ear? The answer is probably ‘never’, as it is for most people. The scalp is one part of your body that you cannot see in totality without the aid of photography or specially arranged mirrors. It is possible that you can begin to have hair loss before you are aware of it. Someone may call your attention to the beginning of a “monk’s tonsure” bald spot on top of your head-a spot difficult for you to see.
It is possible also that a melanoma-the deadliest form of skin cancer-can develop on your scalp without your being aware of its existence. For a number of reasons, including its often late discovery and treatment, melanoma of the scalp has a poorer prognosis for successful treatment than melanoma at many other body sites.
Although melanoma of the scalp is not as common as melanoma at many other body sites, its contribution to melanoma deaths is significant. As for all other forms of cancer the prognosis for scalp melanoma is improved when it is diagnosed and treated early in its development.
Even when a melanoma is noted on the scalp, its recognition as a possible pathologic lesion is not always easy. Melanoma can masquerade as a small area of scalp discoloration or as a pigmented or non-pigmented mole. The tell-tale indications of its possible deadly nature is likely to be more apparent to a trained and experienced physician.
A full scalp examination is an essential part of the physical examination conducted by a physician hair restoration specialist on every patient being considered for surgical or nonsurgical hair restoration. While the scalp examination is directed principally to assessment of hair loss, the patient’s scalp is also examined for its overall health and for any indications of pathologic conditions. Examination of your scalp by a physician hair restoration specialist’s practiced eye can thus provide significant extra benefit-confirmation that no pathologic conditions exist, or early warning of a possibly pathologic problem that requires medical attention by an appropriate medical specialist.