Hair transplant in patients suffering from Diabetes

[Dr Arvind]

Dear forum readers,
Recently we happened to come across a patient with diabetes, who thought we were rejecting a hair transplant for him on arbitrary grounds.

We have a policy that, for a diabetic patient:
1. His endocrinologist/physician treating his diabetes should be in picture,
2. The patient's blood sugar levels should be within normal range for atleast 1 day before the procedure to 7 days after(in FUSE/fue method), and 20 days after (in strip FUHT method).

We tried to explain the risk of infection, necrosis and attendant complications if this is not adhered to.
However, when we tried to show him articles on the net about the precautions required for diabetic people planning hair transplant, we realized there was no information.

Therefore, I hope this thread will be the "missing link" and a helpful source of information on this topic for prospective patients and hair transplant doctors alike.
As a start, I would refer readers to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1026786/ to get a background information.

Do not hesitate to post your queries and suggestions.
Regards,
Dr. A

 

[Bigmac]

Thanks for this post Dr Arvind as i never knew the complications associated with Diabetes and Hair transplants.

 

[ANTOINE]

Dr.Arvind,

Do you ask patients to declare if they are Diabetic before they book surgery?

 

[Dr Arvind]

Categories of Diabetic patients

Diabetic patients can be divided into following categories -

1. Those with family history of diabetes but who are not themselves Diabetic

2. NIDDM (non insulin dependant Diabetes Mellitus) sub divided into:
2a. Those whose blood sugar levels are in normal range by dietary precautions and they do not need medication
2b. Those patients who require oral medications to bring their blood sugar levels in normal range
2c. Those patients who need insulin injections with/without above medications
to bring their blood sugar levels in normal range
2d. Those patients whose blood sugar levels are not in normal range inspite of all above measures.


3. IDDM (insulin dependant Diabetes Mellitus) sub divided into:
3a. Those whose blood sugar levels are in normal range by dietary precautions and they do not need insulin
3b. Those patients who need insulin injections with/without above medications
to bring their blood sugar levels in normal range
3c. Those patients whose blood sugar levels are not in normal range inspite of all measures.


-------------------------------------------------

Category 1 qualifies for getting hair transplant performed;
Categories 2d and 3c are absolutely not suitable candidates (informing them of inherent dangers and getting their consent is not suitable enough as hair transplant is elective surgery - not a life and death situation).


Its the categories in between that we need to talk about.
Q.1 Whom to involve in the decision making (definitely the patient's endocrinologist). Also the patients spouse or close relative who can make sure he adheres to the regimen required post HT. Remember there are privacy issues involved here.

Q. 2 What regimen to follow during the procedure for the different category of patients?

Q. 3 Whom to refuse based on the psychological profile of the patient?

Regards,
Dr. A

 

[ANTOINE]

Appreciate the information.

 

[Dr Arvind]

ANTOINE wrote:

Dr.Arvind,

Do you ask patients to declare if they are Diabetic before they book surgery?

Dear Antoine,
Yes, blood sugar level test is among the lab reports required from the patient.
Regards,
Dr. A

 

[ANTOINE]

Thankyou Dr. Arvind.

 

[Dr Arvind]

Metabolic effects of surgery

During the surgery
Here I borrow extensively from the resources available knowing that they talk about major operations requiring general anesthesia.
But to keep things in perspective, we have to remember that -
1. while most major operations are completed in a couple of hours, a typical hair transplant lasts 6 to 7 hours (if not over multiple 8 hours for a few days).
2. The actual number and surface area of the surgical cuts (both in donor and recipient) is more then in most other surgeries.
3. Stress (not just due to anxiety but also due to the anesthetic fluids injected) is more then for a simple dental procedure.


In short, a hair transplant surgery will lead to increased production of cortisol, glucagon, growth hormone etc., (all of which increase blood sugar levels)with a simultaneous decrease in insulin production.
As a result the insulin requirement for the patient during the procedure will be more then otherwise.
At the same time, the traditional method of giving an IV bolus dose of insulin before the start of operation will not necessarily work (will cause hypoglycemia if the dose is too high or as the effect wears off will cause hyperglycemia and ketosis in 4 to 5 hours).

So, if a diabetic patient is chosen for surgery, the ideal intra operative requirements would be:
1. Regular intra operative blood glucose level monitoring (you do not wait to send the blood sample to lab and wait for results to come the next day)
2. Administering insulin (preferably in form of an infusion) depending on the blood glucose levels obtained from the above tests irrespective of the dosage the patients was taking in routine.
3. To keep IV dextrose (glucose) ready in case its required due to low blood glucose levels.

Regards,
Dr. A

 

[Dr Arvind]

NIDDM patients (especially category 2c)

NIDDM patients, theoretically, should not need insulin injections to keep their blood glucose levels in normal range.

However, in reality a significant proportion of these patients can not keep their blood glucose levels in normal range with diet, exercise and oral medications alone. (They will need insulin injections for that). But they carry on with blood glucose levels 20 to 30% higher than the upper limit of the normal range.
One of the reason behind this is their fear that once they start insulin injections they will be stuck for life with ever increasing doses of the injections.

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Most NIDDM patients, (2b and 2c especially, in certain instances 2a), will require insulin injections during and for a certain period of time after their hair transplant surgery due to :
1. Additional surgery induced stress leading to higher blood glucose levels.
2. Higher chances of infection due to the nature of the procedure and diabetes.

It is important for the doctor to educate the patient in this respect and to refuse surgery if the patients refuses to comply.

---------------------------------------------------
This brings us to the next question - since hair transplant is an outpatient procedure and the patient will not be admitted and under observation - how should the doctor proceed.
That is where careful patient screening, keeping the patient's endocrinologist and a close family member in picture comes in.

The moral responsibility of the HT doctor should not end with the end of the surgery. He/she does not have the luxury to say "I told you so!!" .

Regards,
Dr. A

 

[hairtech]

The physicians at Shapiro Medical in Minnesota, USA, evaluate every diabetic patient thoroughly for risk. The last severe diabetic patient we performed a hair transplant on... we monitored the glucose at bedside every hour and she adjusted her insulin per her needs.

In my opinion... diabetic patients should not altogether be ruled out for a hair transplant. A common sense approach is probably best for these situations.

 

[Dr Arvind]

Dear readers,

Complications that may be encountered in Diabetic patients undergoing hair transplants €“
1. Diabetic Ketoacidosis,
2. Hypoglycemia
3. Hyperglycemia

Given that modern Hair transplants last over many hours and sometimes over multiple days (in case of FUSE/fue), it is important for hair transplant doctors as well as technicians to be aware of the earliest signs and symptoms of such conditions to diagnose and treat such conditions at the onset.

 

[Dr Arvind]

Diabetic Keto acidosis (DKA) €“
DKA is a potentially life threatening complication in patient suffering from Diabetes. It happens predominantly in those with Type 1 Diabetes but can also occur in those with Type 2 Diabetes.
DKA results from a shortage of insulin. As a result, the body starts burning fatty acids and producing ketone bodies.
DKA may also be the first symptom of previously undiagnosed diabetes. So it is important to ask for family history of diabetes in all patients going for hair transplant surgery and take all necessary precautions.
Signs and symptoms :-
The earliest signs and symptoms of Diabetic Ketoacidosis are:-
1. Dehydration
2. Polyuria
3. Vomiting
4. Abdominal Pain
5. If the condition worsens, these may be followed by typical deep, gasping breathing called Kussmaul breathing.
If left unchecked or undiagnosed it can progress to mental disorientation and eventually coma.



Clinical Examination:-

There will be clinical evidence of dehydration such as dry mouth as well as reduced skin turgor. Tachycardia (rapid heart beat) and low blood pressure may be observed. A ketotic odour (fruity smell) may also be present.

Diagnosis -
At the earliest symptoms, suitable tests should be performed. These tests include :-
1.Blood Sugar level
2.Blood and urine ketone levels
3.Blood Potassium levels


Treatment

Diabetic Ketoacidosis is distinguished from other diabetic emergencies by the presence of large amounts of ketones in urine and marked metabolic acidosis.
Management:-
1. Fluid replacement
2. Insulin administration
3. Potassium level monitoring and replacement


It is very important to remember the coordination between Insulin administration and potassium levels in DKA.
Insulin administration in conditions like DKA may decrease potassium level in blood (hypokalemia) by redistributing it into cells.
In addition, potassium has also been lost in urine because of diuresis.
Therefore, blood potassium levels should be measured during the treatment/insulin administration.
Hypokalemia often occurs in during the treatment of DKA leading to irregularities in heart rate/pulse. If not treated in time hypokalemia can lead to Cardiac arrest.
Continuous observation of the heart rate is recommended, as well as repeated measurement of the potassium levels and addition of potassium to the intravenous fluids once levels fall below 5.3 mmol/l. If potassium levels fall below 3.3 mmol/l, insulin administration must be stopped to allow correction of the hypokalemia.

Resolution:-

Resolution of DKA is defined as general improvement in the symptoms, such as the ability to tolerate oral nutrition and fluids, normalization of blood acidity (pH>7.3), and absence of ketones in blood (<1 mmol/l) or urine. Once this has been achieved, insulin may be switched to the usual subcutaneously administered regimen, and intravenous administration discontinued.

If Diabetic Ketoacidosis occurs in someone with Type 2 diabetes, their condition is called €œketosis prone type 2 diabetes €. The exact mechanism for this phenomenon is unclear, but there is evidence both of impaired insulin secretion and insulin action. Once the ketoacidosis has been treated, insulin production resumes and often the patient may be able to resume diet or tablet treatment as normally recommended in type 2 diabetes.

Suggestion for the Hair Transplant Center.

1.Blood and urine testing facility including blood sugar level
2.Blood and urine Ketone levels measurement testing
3.Blood potassium level testing,
should all preferably be available in the center.
The doctor and/or the technicians should be well trained in performing these tests. Simultaneously, the doctor and the technicians should be well trained to suspect DKA by its earliest signs and symptoms.

 

[Dr Arvind]

Hyperglycemia

Diabetic patients control their blood sugar levels by exercise, regulated food intake, oral medications and/or insulin. During a prolonged hair transplant procedure for example FUE/FUSE procedure lasting over 4 -5 days the patient may not be able to have sufficient exercise to lower the blood glucose levels. Similarly, the stress of actual surgical incisions and patient €™s mental anxiety could lead to hyperglycemia even while the patient is administered his/her regular dosage of medicine.
In a hair transplant surgery, patients would usually require a higher level of treatment. For example €“ a non diabetic patient with family history of diabetes may need oral hyperglycemic drugs, while another patient of Type II diabetes whose blood sugar levels are within normal range by oral hypoglycemic drugs may need insulin during and few days after surgery.

Symptoms:
Signs of hyperglycemic in patient undergoing hair transplant would include headaches, difficulty concentrating, blurred vision, frequent urination, fatigue (weak, tired feeling). Since the patient would be under sedation most of these symptoms could be missed.
Regular blood sugar level monitoring is, therefore, very important. The diet the patient is given during the procedure should also be carefully considered and monitored.

Treatment:
Many diabetic patients are notoriously against insulin injections. Therefore, before the start of the surgery they must be advised that even if they do not need the insulin injection during the normal course of life, Insulin administration may be required during the procedure and their consent to the same should be taken before the procedure.

 

[jcristy]

Thank Dr Arvind for information about diabetic patient and hair-transplantation. My uncle who has been diabetic had his skull hair transplantation from  hairtransplantcenterindiaHe is enjoying his hair happily nowadays...

 

[Dr Arvind]

Hyperglycemia and Hypoglycemia are relatively easier to diagnose. It is advisable to do blood sugar level tests at regular intervals during the procedure of Hair Transplant.

This should be done even for non diabetic patients who have strong family history of diabetes.

Hypoglycemia:-

Causes of Hypoglycemia €“

The commonest cause of hypoglycemia during hair transplant surgery would be over dosage or bolus administration of insulin.

Hypoglycemia is a true medical emergency, which requires prompt recognition and treatment to prevent organ and brain damage.

Symptoms:

Early symptoms of hypoglycemia may include:-

Confusion, dizziness, palpitations, hunger, headaches, irritability, pounding heart, racing pulse, pale skin, sweating, trembling, weakness and anxiety.

Without treatment more severe hypoglycemic symptoms may develop including:-

Severe headache, poor coordination, poor concentration, numbness in mouth and tongue, passing out, nightmares or bad dreams and coma.

Since the patient is often under sedation during hair transplant, most of the early signs may be missed unless the doctor and technicians are diligent.

It is advisable for hair transplant centers to also have pulse oximeter, which can be easily used to keep a tab on the pulse and oxygen saturation levels on a continuous basis. This simple and inexpensive tool should also be a part of every hair transplant centre.

Treatment

Oral intake of glucose - The blood glucose can usually be raised in minutes with 15 €“ 20 gms of carbohydrates. It can be given as food or drink (fruit juice, non diet cola etc., 120 -150 ml), or one slice of bread or about 1 serving of more starchy fruits.
However, over treatment should be avoided. It is important to remember that symptoms will begin to improve within 5 €“ 10 minutes but full recovery may take 10 €“ 20 minutes. Also, adding fat or protein at this stage will retard digestion of glucose. Over treatment in form of giving higher quantities of glucose will not speed up recovery. It will mainly lead to hyperglycemia that will again have to be treated.

In case patient cannot consume orally then intravenous glucose may be required. It is advisable to administer a solution containing dextrose and saline.

In rare cases, glucagon hormone may have to be injected.


Regards,
Dr. A