Do you smoke? Do you drink alcoholic beverages? What medications do you take? Do you use herbal "health food" products? These are questions a patient will be asked before undergoing hair restoration surgery-or, for that matter, any type of surgery. What is the connection between smoking, drinking and surgery? What does it matter what medications a patient takes, or what herbal products or vitamin supplements a patient may use to improve his/her health?
The connection between all of these and surgery is their potential to contribute to excessive bleeding during the operation, and bleeding or "oozing" after the operation. That is why a patient will be asked:
- Do you smoke-if so, how much and for how long?
- Do you drink alcoholic beverages-if so, how much and for how long?
- Do you use so-called recreational drugs such as cocaine?
- What prescribed medications do you take?
- What over-the-counter (non-prescribed) medications do you take regularly?
- What vitamin supplements do you take?
- What, if any, herbal products do you consume?
The patient should be honest and forthcoming in answering these questions, even if he/she is embarrassed to do so. Patients who know that smoking and moderate to heavy drinking are generally regarded as unhealthful "bad habits" may be unwilling to admit to a doctor that they drink or smoke, or to admit how much they drink or smoke.
In a pre-surgical examination with medical history, however, the physician hair restoration specialist needs to have honest answers to these questions-not to change how the patient conducts his/her life, but to assess the potential for excessive bleeding or oozing from wounds during and after surgery.
Patients should be honestly forthcoming about their use of prescribed and over-the-counter medications, vitamin supplements and herbal products. Sometimes a patient may not remember the name of a prescribed medication-for example, "the pills my doctor prescribed for my leg pains". The patient may be asked to call the office later with the name of the drug and the name of the prescribing physician. If there are further questions about the patient's medical condition, the physician hair restoration specialist may call the physician who prescribed the drug to clarify the condition for which it was prescribed and whether the patient's medical condition increases risk for medical or surgical complications.
The presence of a risk factor for excessive surgical or post-surgical bleeding may be an indication to delay surgery until the risk factor has been reduced-for example, a period of "no smoking", "no drinking" and "no recreational drugs such as cocaine" prior to surgery, and discontinuation of smoking, certain prescribed and over-the-counter drugs, vitamin supplements and herbal products for a period of time before surgery.
The decision to delay or to proceed with surgery is made by the physician hair restoration specialist on the basis of individual patient characteristics including medical history, current prescribed and over-the-counter medications, vitamin intake and use of herbal products. The assessment of risk varies from patient to patient and must be individualized to the patient-a criterion that stresses the need for the patient to provide full information to the physician. Risk for excessive bleeding is minimal to none for most patients. The bleeding risk for hair transplantation patients is largely for "oozing" that can extend the time needed for implantation of hair grafts, and pose a potential threat for loss of some grafts postoperatively.
Some Major Risk Factors for Excessive Surgical and Post-Surgical Bleeding
Tobacco smoking-especially long-term and heavy tobacco smoking-has numerous ill effects on the body including increased risk for lung cancer, chronic obstructive pulmonary disease, heart disease and systemic circulatory disease. The nicotine and other chemicals in smoked tobacco may cause or contribute to disorders of blood circulation that can increase risk for excessive bleeding . They may also reduce elasticity of small blood vessels in the skin, diminishing the blood supply to hair transplants and thus increasing risk for transplant failure. Diminished blood supply to the skin (and thus to hair transplants) can also be an effect of long-term exposure to second-hand tobacco smoke, as discussed in the prestigious American Heart Association journal Circulation.
The physician hair restoration specialist may ask the patient to stop smoking for several weeks prior to hair restoration surgery. Heavy smokers may find it difficult to completely stop smoking for weeks prior to surgery. The risk for excessive bleeding, or for transplantation compromise, must be managed with the patient 's understanding of the risk imposed by long-term tobacco smoking.
Long-term ingestion of ethanol (the form of alcohol in beer, wine and hard liquors) is a well-known risk for excessive bleeding. Ethanol impairs blood clotting by its effect on blood platelets (the small blood cells that coalesce to form a blood clot) and on molecular clotting factors. See http://alcoholism.about.com.od/health/a/blacer051015.htm for more information. Its well-known damaging effects on the liver include impairment of blood clotting factors produced in the liver. Cessation of alcohol consumption for days to weeks prior to surgery may reduce risk for bleeding but does not reverse liver damage.
A single episode of ethanol consumption has been shown to increase risk for bleeding within one to two hours. The increased bleeding risk imposed by ethanol consumption is well known to emergency room physicians who receive the ethanol-impaired patients injured in vehicular crashes.
So-called recreational drugs such as cocaine can have interactions with medications that can cause unforeseen side effects and complications. For example, cocaine has the potential to dangerously enhance the effects of lidocaine, a short-acting local anesthetic commonly used in hair transplantation surgery.
A great many prescription medications are known to increase risk for bleeding; the bleeding risk may be dose-related in some instances-that is, the higher the drug dose, the greater the increased risk for bleeding. Many of these drugs have cross-reactivity with other medications and herbal products that can increase or diminish the effects of the drugs and increase or diminish their effects on blood coagulation.
A shorter list of prescription medications is made up of drugs given specifically to "thin" the patient's blood to prevent blood clots associated with heart attack, stroke, venous thromboembolism and pulmonary embolism. These drugs include:
· Warfarin (brand name Coumadin).
See www.chestjournal.org.cgi/content/full/126/3_suppl/205s for more information.
· Clopidogrel (brand name Plavix)
Aspirin is an over-the-counter medication often recommended by physicians for patients at risk for blood-clotting episodes; it has potent effects on platelets and thus on the ability of blood to readily clot. Millions of patients observe a "baby aspirin a day" regimen to reduce risk for heart attack. Patients should not neglect to include an "aspirin a day" regimen in their list of drugs.
Vitamin E, especially in large doses, has been reported to increase risk for bleeding by its effects on blood platelets and other blood clotting factors. Because many persons take vitamin E supplements that vastly exceed the Recommended Dietary Allowance, many surgeons ask patients to stop taking vitamin E supplements several weeks prior to surgery. See for more information.
Aspirin is a widely used over-the counter medication for minor pains and fever reduction. Many persons consume aspirin on a daily or almost daily basis for headache, muscle aches, etc. Because it is not prescribed, patients may neglect to mention their heavy use of aspirin when queried by a physician in a pre-surgical examination. Other over-the-counter pain medications include non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen that may increase bleeding risk at higher doses or with frequent use.
Many herbal products are known to have cross-reactivity with prescribed drugs that can increase risk for excessive bleeding. Some herbal products have cross-reactivity with warfarin that substantially increases risk for bleeding. Herbal products that, by themselves, increase risk for bleeding by their effects on blood platelets or other clotting factors include garlic, ginger, ginkgo bilboa, ginseng, saw palmetto, danshen, feverfew and flaxseed. See the American Academy of Family Physicians for more information.
Patients may neglect to tell their physician about use of herbal products, perhaps because they regard herbal products as "health foods" rather than "drugs".
Patients should tell their physicians about all drugs they take, whether prescribed, over-the-counter or health-enhancing. Physicians should explain why this information is important in pre-surgical assessment. Questions about medications should be resolved in discussions between the patient and the physician hair restoration specialist.