Hemostasis with Minimal Epinephrine

Robert M. Bernstein, MD, New York, NY
William R. Rassman, MD, Los Angeles, CA

Hair Transplant Forum International 1999; 9(5): 153.

The scalp’s rich blood supply has allowed the surgeon great flexibility in the types of hair restoration procedures that can be performed and has helped to ensure graft survival under a wide variety of conditions. However, poor visibility from bleeding has posed technical problems for the hair transplant surgeon ever since the inception of the procedure. With the popularity of large hair transplant sessions of very small grafts, bleeding has become more problematic.

To manage bleeding during the hair restoration process, surgeons have often resorted to using increasingly higher concentrations of epinephrine (Adrenaline) in the anesthetic solution. However, the possible adverse consequences associated with the overzealous use of this medication during the hair restoration procedure and its short half-life in tissue limit its usefulness, especially in longer hair transplant sessions. This study addresses ways of minimizing bleeding without relying on high concentrations of epinephrine.

Follicular Unit Hair Transplantation, in sessions ranging from 600 to 2,500 grafts, was performed using previously published methodology. Components of the hair restoration procedure examined include the pre-op evaluation, patient positioning, the use of tumescence, traction, cooling the scalp, creating recipient sites, timing of hair transplant, coordination of staff functions, and the use of systemic agents.

Adequate intra-operative hemostasis was achieved during a hair transplant procedure using a number of simple techniques that do not require the direct injection of epinephrine into the recipient site, or its use in high concentrations in the local anesthetic.

In order to control bleeding during the hair restoration, Adrenaline in concentrations as high as 1:50,000 or greater are routinely used. In those patients who are sensitive, epinephrine can cause anxiety, headache and palpitations. Rarely, they may predispose to ventricular arrhythmia. Epinephrine may also interact with commonly prescribed medications such as beta-blockers. Because intra-operative bleeding during the hair restoration can be controlled by simple methods that are easy to administer and free from adverse affects, the use of epinephrine in high concentrations should be re-assessed.

The use of large amounts of epinephrine for the purpose of establishing hemostasis in large hair transplant procedures is neither necessary nor desirable. Adequate intra-operative hemostasis can be achieved by other techniques that pose less risk of problems for the patient.