You can’t have a hair transplant without local anesthetic, and of course the numbing agent of choice is lidocaine. While generally believed to be an innocuous, safe agent that works by blocking nerve signals to your body, unless it is administered correctly and precisely, tailored to an individual's medical history and physiology, severe side effects can occur, including death. The hair transplant industry is seeing more lidocaine toxicity than ever before and many believe it’s because of the use of unlicensed personel to administer, and monitor patients (besides performing the procedure) during the hair transplant surgery. Listen to IAHRS accepted member Daniel Danyo, M.D. discuss the real danger of lidocaine toxicity from the perspective of a former pain management specialist with an intimate understanding on how these medications interact with the body as well as other medications patients are taking during the time of surgery.

Dan Danyo, MD: Well, lidocaine toxicity is an issue, and particularly with hair transplant. When you look at the duration of time of the initial blocks to the donor site, and then you might maybe add tumescence to that, and then you're going ahead and doing some nerve blocks and brain blocks ...

Spencer Kobren: Well, it's ... I don't mean to cut you off. It's more of an issue than I think a lot of potential hair transplant patients really understand. There have been a few deaths this year in the US because of lidocaine toxicity. This is the type of stuff that happens around the world on a more regular basis, but the fact that I am seeing it now more here in the US really, I think, speaks to how the field is devolving. Everyone is ... They're setting up these pop-up, turnkey hair transplant mills and they are having unlicensed personnel inject anesthetic.

Dan Danyo MD: Yes. Lidocaine is very toxic at toxic levels but, even at sub-toxic levels, people can have issues. We treat a wide range of patients. Some may have liver toxicity, maybe they drink too much. They won't process lidocaine quite as well. They may be very skinny or they don't have a lot of fat that actually absorbs a lot of the blood lidocaine level so that they have more acute lidocaine issues. They may be older, have cardiac toxicity, maybe on anti-depressants. The other thing is people use Valium and Xanax, both benzodiazepines, which is great for sedation but terrible for lidocaine toxicity because they compete at the same liver pathway, and that is called cytochrome P450 3A4.

Spencer Kobren: Also, what a lot of patients think they can do is ... Usually, a physician or the clinician will provide some sort of sedative, maybe a Valium. I don't know what you're providing your patients.

Dan Danyo, MD: I do Ativan because it's not processed through that particular pathway.

Spencer Kobren: Ativan. Okay. A lot of guys will come in and they will take their own. They have their own prescription and they, before ... They're so nervous that day that they decide to sedate themselves even before they walk into the OR, and they may not even be telling the doctor.

Dan Danyo, MD: Oh, yeah. What happens ... All of this has to be kept in mind, that you could have a forest fire that essentially starts out as a campfire and then becomes just a massive problem. I think anyone who has done enough hair transplant cases has had issues of at least mild lidocaine toxicity. It creeps up. People will say, "My tongue feels numb, my teeth are buzzing, I have a headache," or they start getting more sedated. Generally, it's in the afternoon, after you've done the donor site, you're now onto the recipient site. 

They can also develop signs of what's called tachyphylaxis, where the liver has really kind of been up-regulated and processing, getting rid of the lidocaine, and it actually over-processes. You will get acute loss of anesthesia. The knee-jerk reaction is, "Hey, let's give more," or, "Let's do super juice and give double strength epinephrine."

Spencer Kobren: That's funny, that is a knee-jerk reaction. You hear about that a lot. I've heard ... Guys have written about this on Bald Truth Talk message forums, written us directly, and, really, the best course of action ... Again, I'm not a physician, but just from ... You correct me if I'm wrong, is sometimes you guys just have to kind of stop for a while.

Dan Danyo, MD: Yes. I had ... Actually, one of my good friends, I did a 2000 graft procedure. It was one of those days where the extraction was difficult because he had kind of tethered grafts. It took longer. He had a lot of popping while we were placing, as well, just the size of the graft. We do pin implantation. We lost the anesthesia control. We got to that point ... In my calculations, I felt like I was if not at a toxic level or close to it. Since we used HypoThermosol with ATP, I said, "We're done today." We had about 600 more grafts to place. I had him come in at 8:00 in the morning the next morning. We kept the grafts refrigerated. The next morning, I used a different agent. We numbed him up, got him in, no problems, and he had great growth. 

There are times you have to pull the plug. This is not a race to completion.