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Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study
Surgical Neurology 69 (2008) 69 – 72 www.surgicalneurology-online.com
Technical Note
Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study Amos Olufemi Adeleye, MBBS, FWACS4, Kayode G. Olowookere, MBBS Division of Neurosurgery, Department of Surgery, Lagos State University Teaching Hospital, P.M.B. 21105 Ikeja, Nigeria Received 19 December 2006; accepted 13 February 2007
Abstract
Background: Many studies on white populations have shown the absence of any scientific, or even beneficial, basis for the traditional preoperative ritual of shaving the operative field. We were not able to lay our hands on any document regarding this subject on any black African population. Methods: We prospectively performed 17 cranial procedures in nonshaved fields in 15 selected black Africans in the Lagos State University Teaching Hospital, Ikeja, Nigeria. Results: There was no serious complication recorded over a short-term follow-up of 2 to 6 months. The short, curly, crimpy, and densely knotted black African scalp hairs however did pose some unique perioperative challenges to us. Conclusions: Nonshaved cranial surgery, as in whites/Asians, can also be safely carried out in black Africans. This however demands some attention to details in the perioperative care of the incision sites. We found this caveat to be particularly more imperative in black Africans because of their unique anthropological scalp hair characteristics. D 2008 Elsevier Inc. All rights reserved.
Keywords:
Nonshaved cranial surgery; Black Africans; Nigeria
1. Introduction Preoperative shaving of hair-bearing surgical incision sites is a long established practice aimed, in conjunction with other preoperative rituals, at controlling infective complications of surgeries. There are a growing number of contemporary studies, however, showing that there is no scientific basis to this practice [15,22,23], and that elective and emergency cranial surgeries are safely carried out in nonshaved fields [2,7,9,12,15,18,21]. Some workers have actually documented reduced rates of wound infections in surgeries in shaveless groups [5,6,17]. We pioneered a new neurosurgical service in a young teaching hospital, the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, in January 2005 and selected some uncomplicated cranial procedures for shaveless surgeries. This is a preliminary short-term outcome of our prospective survey in which we seek to show the 4 Corresponding author. Department of Neurosurgery, HadassahHebrew University Medical Centre, POB 12000, Ein Kerem, Jerusalem 91120, Israel. E-mail address: [email protected] (A.O. Adeleye). 0090-3019/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.02.046
prospects and the challenges of nonshaved cranial surgery in a black African population. It appears that this is the first document on this subject in our patient population. 2. Materials and methods Over a 7-month period from July 1, 2005, to January 30, 2006, all cranial surgeries in hair-bearing scalps of patients with no confounding comorbidities were carried out in nonshaved fields. These included emergency and elective cranial procedures. For the sake of this analysis, we looked at the patients’ demographics (hospital number, age, sex, and date of procedures); nature of surgery (emergency or elective); classification of the procedures: minor (scalp incisions/excision of scalp masses with no skull opening), moderate (ventricular shunting, minimal skull openings [burr-holes placements]), and major (repair of large encephaloceles and major intracranial works); duration of postoperative hospital stay and time of operative stitches removal in days; duration of perioperative antimicrobial prophylaxis; postoperative complications, infectious and others; and lengths of follow-up.
70
A.O. Adeleye, K.G. Olowookere / Surgical Neurology 69 (2008) 69 – 72
Cases of cerebral abscess, ventricular shunt surgeries in cases of raw septic spinal bifida with associated hydrocephalus, and surgeries in non–hair-bearing scalps were excluded from our shaveless surgery protocol.
3. Results There were 17 nonshaved cranial surgeries in 15 patients: 2 patients had 2 surgeries each (Table 1). There were 11 males and 5 females (male/female ratio, 2.2:1) with age range from 1 to 75 years. According to our classification in Materials and methods, there were 2 minor (day cases really), 6 moderate, and 9 major (including extensive brain tumor resections) procedures; 9 electives; and 8 emergencies. Antimicrobial prophylaxis in our unit was with thirdgeneration cephalosporins: 1 dose at induction of anesthesia and 2 to 4 doses postoperatively. The length of follow-up was 2 to 6 months. 3.1. Outcome measures Patients’ acceptance was good. Two patients, during the preoperative conference, actually expressed some misgiv-
ings at the prospects of immediate postoperative baldness until they were assured that we could offer them nonshaved surgery. 3.1.1. Preincision operative site preparation There were 2 male patients (cases 11 and 12, Table 1) with thickset mats of scalp hairs in whom it was difficult to part the hairs along the proposed incision line. A 1-cm strip of scalp along the incision line was therefore shaved. Not infrequently, many broken, loose strands of hairs found their way into the operative fields. These sometimes constitute nuisance effects and need meticulous care to retrieve them. Preincision operative site scrubbing using the traditional initial soapy lotions, povidone iodine followed by surgical spirits requires that the initial soapy lotions be mopped dry before the iodine solutions are applied. This mopping process consumes much more surgical gauze materials in the nonshaved scalps. 3.1.2. Wound complications One patient (patient 8, Table 1) developed frontal flap tip necrosis after unilateral frontal and parietal burr-hole
Table 1 Profiles of the nonshaved cranial surgical procedures, complications, and lengths of follow-up S/N
Date
Minor surgery 1 23/08/05 2 29/11/05 Moderate surgery 3 26/07/05
Sex/Age (y)
Surgical procedure/operative time (h)
Complications
Male/40 Female/5
Excision of scalp mass (0.5) Excision of scalp mass (0.5)
Nil Nil
5 8
5 2
Male/65
Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0) Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0) Ventriculoperitoneal shunt (0.75) Ventriculoperitoneal shunt (0.75) Shunt revision, cerebrospinal fluid fistula (0.5) Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0)
Nil
6
6
Nil
6
5
Nil Nil Nil
6 6 10
4 4 4
Frontal flap tip necrosis, cerebrospinal fluid seroma
12
2
Nil Wound seroma
8 14
6 5
6
3
10
3
Nil
7
3
Nil
7
3
Nil
7
3
Nil
6
3
Nil
9
2
4
06/09/05
Male/75
5 6 7
13/09/05 27/09/05 06/10/05
Female/3 Male/1 Male/1
8
13/12/05
Male/42
Major surgery 9 06/07/05 10 25/08/05
Female/0.5 Female/17
11
13/10/05
Male/27
12
14/10/05
Male/19
13
28/10/05
Male/25
14
29/10/05
Male/25
15
29/10/05
Male/25
16
03/11/05
Male/50
17
23/11/05
Female/7
Repair of occipital encephalocele (2.0) Temporal craniotomy, anterior temporal lobectomy, tumor excision (6.5) Temporoparietal craniotomy, open depressed skull fracture debridement, acute epidural hematoma evacuation (2.25) Redo parietal craniotomy, brain tumor excision (6.0) Parietal craniotomy, open depressed skull fracture debridement, traumatic intracerebral hematoma evacuation (2.0) Parietal craniotomy, evacuation of acute epidural and intracerebral hematoma (1.5) Debridement parietal open comminuted linear skull fracture (0.5) Evacuation /hemostasis, acute epidural hematoma (1.5) Suboccipital craniectomy, excision of brain tumor (5.0)
Nil
Wound seroma
Stitch removal (postoperative day)
Follow-up (mo)
A.O. Adeleye, K.G. Olowookere / Surgical Neurology 69 (2008) 69 – 72
drainage of chronic subdural hematoma. It appeared that the underlying frontal subgaleal cerebrospinal fluid collection that he developed contributed largely to this frontal flap tip necrosis, which responded to wound dressing augmented with oral ciprofloxacin. The uncomplicated parietal scalp wound had healed with primary intention, and his postoperative hospital stay was not affected by this event. There was no other surface or deep infectious complication recorded. 3.1.3. Other complications Two other patients developed cerebrospinal fluid seroma under their scalp flaps after extensive tumor resections. One resolved spontaneously, the other resolved after one round of aseptic cyst aspiration. 3.2. Stitch removal Stitches were removed on postoperative days 5 to 14, and these varying durations were dictated, especially in the most prolonged cases, by the underlying seroma. However, we found it more tasking removing stitches in nonshaved scalp wounds in our black patients. Although the stitches are cut quite long, and brightly colored suture materials like blue prolene or nylon are chosen for nonshaved scalp wound closure, 1 or 2 stitches are easily lost at suture removal, and the incidence of chronic stitches complication may thus rise. 4. Discussion In this short-term prospective preliminary series, we have attempted to study the feasibility of nonshaved cranial surgery in an indigenous black African population. Our results were comparable with the rest of the literature in some respects and unique in others. Since the pioneering large series by Winston [23] in 1992, more and more reports have documented (i) that there is no scientific basis to the long established surgical, more particularly neurosurgical, rituals of preoperative shaving of hair-bearing incision sites [13,15,22]; (ii) that wound infection rates in nonshaved cranial surgeries are no worse than in the shaved cases [2,17,22]; and (iii) that preoperative shaving of surgical incision sites, especially using the traditional surgical blade, as compared with hair clippers [1,13,22] is injurious to the operative site epidermal layer [1,20] and may actually promote rather than prevent postsurgical infections. Because of socioeconomic reasons, preoperative hair shaving, when desired, continues to be done with surgical blade and scalpel in our unit. This was the basis of our attraction to the nonshaved option, and we have thus successfully carried out minor, moderate, and major surgical procedures in both elective and emergency situations, sparing our patients immediate postoperative alopecia. Acceptance of this protocol was good in our patients. A few of them actually expressed pleasant surprise at our ability to thus allay their fear of inevitable
immediate postoperative alopecia. Although there was a case of mild superficial wound infection, we have not recorded any untoward case of deep infection in this short-term series. Nonshaved cranial surgery however demands some practical measures in order not to be counterproductive. These include preincision scalp hair grooming to delineate the incision line, keeping of loose hairs out of the operative fields, and the need for a very rigorous operative site scrubbing. Although these issues were documented in many series on whites [2,14,19] and addressed extensively in the seminal works of Winston [23], 1992, the issues appear to carry even more practical implications in black Africans with their unique anthropological scalp hair characteristics [24]. Compared with whites and/or Asians, the scalp hairs of a black African (without any prior physical or chemical grooming) are more curly (with much shortened functional length) [4,8,16], exhibit more kinks (sudden constrictions along their lengths) [4], and have more crimps (the number of times the direction of hair curvature changes per unit time) [4,8]. They are thus more susceptible to breakage [4] and as such are probably more likely to be found in the operative fields with greater nuisance effects, if not more chances of long-term inflammatory/infective complications. Furthermore, black African scalp hairs are not only shorter, making them more difficult to keep out of the wound [10,11,23], but they also form dense mats of tightly interwoven, complexly knotted hair shafts [4,11]. These sometimes, but not forbiddingly, make preoperative grooming and the delineation of the incision line a little more challenging. They also sometimes demand more meticulous care in postoperative stitch removal in order not to leave any stitch behind. Black- and gray-colored stitches are particularly notorious in this respect. We have found that shaving a thin strip of scalp along the incision line [15] and closing the skin wound with brightly colored sutures like prolene or nylon, which are cut fairly longer than usual after knotting, help forestall some of these drawbacks. The limitations of our study include the fact that it is a one arm, uncontrolled, small series and its preliminary nature, with only a short-term follow-up. We realize that a controlled study with much larger series and long-term follow-up is needed to verify some of our findings and to establish general guidelines for clinical practice. This study is only an initial exploration of a subject that is already much researched in white populations, but has hardly ever been mentioned in the black African race. 5. Conclusions Nonshaved cranial surgery, as already documented in the white populations, is not impossible for black Africans. The immediate postoperative wound events are comparable to those in the traditional methods. There are unique anthropological characteristics of the natural scalp hairs of the black African that demand some extra care in the performance of nonshaved cranial surgery. There is need
71
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for large long-term controlled studies to verify the main findings of this short-term small survey. In the meantime, the choice of this procedure should be tailored to each patient’s clinical and anthropological characteristics [3]. References [1] Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair removal methods on wound infections. Arch Surg 1983;11:347 - 52. [2] Bekar A, Korfali E, Dogan S, Yilmazlar S, Baskan Z, Aksoy K. The effect of hair removal on infection after cranial surgery. Acta Neurochir (Wien) 2001;143:533 - 6 [discussion 573]. [3] Camarata JC, Wang PT. Hair sparing techniques and scalp flap design. Neurosurg Clin N Am 2002;13:411 - 9. [4] Franbourg A, Hallegot P, Baltenneck F, Toutain C, Leroy F. Current research on ethnic hair. J Am Acad Dermatol 2003;48(6 Suppl): S115 - 9. [5] Gil Z, Cohen JT, Spektor S, Fliss DM. The role of hair shaving in skull base surgery. Otolaryngol Head Neck Surg 2003;128:43 - 7. [6] Horgan MA, Piatt Jr JH. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 1997;26:180 - 4. [7] Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med 1988;6:7 - 10. [8] Hrdy D. Quantitative hair form variation in seven populations. Am J Phys Anthrop 1973;39:7 - 18. [9] Iwami K, Takagi T, Arima T, Takayasu M. Cranial surgery without hair shaving: practice and results in our hospital. No Shinkei Geka (Jpn) 2006;34:901 - 5. [10] Khumalo NP. African hair length: the picture is clearer. J Am Acad Dermatol 2006;54:886 - 8. [11] Khumalo NP, Doe PT, Dawber RPR, Ferguson DJP. What is normal black African hair? A light and scanning electron-microscopic study. J Am Acad Dermatol 2000;43:814 - 20. [12] Miller JJ, Weber PC, Patel S, Ramey J. Intracranial surgery: to shave or not to shave? Otol Neurotol 2001;22:908 - 11. [13] Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal-a systematic literature review. AORN J 2003;75: 928-38, 940 [14] Kretschmer T, Braun V, Richter HP. Neurosurgery without shaving: indications and results. Br J Neurosurg 2000;14:341 - 4.
[15] Kumar K, Thomas J, Chan C. Cosmesis in neurosurgery: is the bald head necessary to avoid postoperative infection? Ann Acad Med Singapore 2002;31:150 - 4. [16] Porter CE, Diridollou S, Barbosa VH. The influence of AfricanAmerican hair’s curl pattern on its mechanical properties. Int J Dermatol 2005;44(Suppl 1):4 - 5. [17] Ratanalert S, Musikawat P, Oeasakul T, Saeheng S, Chowchuvech V. Non-shaved ventriculoperitoneal shunt in Thailand. J Clin Neurosci 2005;12:147 - 9. [18] Ratanalert S, Saehaeng S, Sripairojkul B, Liewchanpattana K, Phuenpathom N. Nonshaved cranial neurosurgery. Surg Neurol 1999;51:458 - 63. [19] Sheinberg MA, Ross DA. Cranial procedures without hair removal. Neurosurgery 1999;44:1263 - 5. [20] Siddique MS, Matai V, Sutcliffe JC. The preoperative skin shave in neurosurgery: is it justified? Br J Neurosurg 1998;12:131 - 5. [21] Tang K, Yeh JS, Sgouros S. The influence of hair shave on the infection rate in neurosurgery. A prospective study. Pediatr Neurosurg 2001;35:13 - 7. [22] Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2006;(2): CD004122. [23] Winston KR. Hair and neurosurgery. Neurosurgery 1992;31:320 - 9. [24] Wolfram LJ. Human hair: a unique physicochemical composite. J Am Acad Dermatol 2003;48(6 Suppl):S106 - 14.
Commentary Adeleye et al have written an article that is interesting and important for us all. The authors must be congratulated for challenging standards that have been in use for so long—without any scientific validation. Jens Haase, MD Department of Neurosurgery Aalborg University 9220 Aalborg, Denmark
Technical Note
Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study Amos Olufemi Adeleye, MBBS, FWACS4, Kayode G. Olowookere, MBBS Division of Neurosurgery, Department of Surgery, Lagos State University Teaching Hospital, P.M.B. 21105 Ikeja, Nigeria Received 19 December 2006; accepted 13 February 2007
Abstract
Background: Many studies on white populations have shown the absence of any scientific, or even beneficial, basis for the traditional preoperative ritual of shaving the operative field. We were not able to lay our hands on any document regarding this subject on any black African population. Methods: We prospectively performed 17 cranial procedures in nonshaved fields in 15 selected black Africans in the Lagos State University Teaching Hospital, Ikeja, Nigeria. Results: There was no serious complication recorded over a short-term follow-up of 2 to 6 months. The short, curly, crimpy, and densely knotted black African scalp hairs however did pose some unique perioperative challenges to us. Conclusions: Nonshaved cranial surgery, as in whites/Asians, can also be safely carried out in black Africans. This however demands some attention to details in the perioperative care of the incision sites. We found this caveat to be particularly more imperative in black Africans because of their unique anthropological scalp hair characteristics. D 2008 Elsevier Inc. All rights reserved.
Keywords:
Nonshaved cranial surgery; Black Africans; Nigeria
1. Introduction Preoperative shaving of hair-bearing surgical incision sites is a long established practice aimed, in conjunction with other preoperative rituals, at controlling infective complications of surgeries. There are a growing number of contemporary studies, however, showing that there is no scientific basis to this practice [15,22,23], and that elective and emergency cranial surgeries are safely carried out in nonshaved fields [2,7,9,12,15,18,21]. Some workers have actually documented reduced rates of wound infections in surgeries in shaveless groups [5,6,17]. We pioneered a new neurosurgical service in a young teaching hospital, the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, in January 2005 and selected some uncomplicated cranial procedures for shaveless surgeries. This is a preliminary short-term outcome of our prospective survey in which we seek to show the 4 Corresponding author. Department of Neurosurgery, HadassahHebrew University Medical Centre, POB 12000, Ein Kerem, Jerusalem 91120, Israel. E-mail address: [email protected] (A.O. Adeleye). 0090-3019/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.02.046
prospects and the challenges of nonshaved cranial surgery in a black African population. It appears that this is the first document on this subject in our patient population. 2. Materials and methods Over a 7-month period from July 1, 2005, to January 30, 2006, all cranial surgeries in hair-bearing scalps of patients with no confounding comorbidities were carried out in nonshaved fields. These included emergency and elective cranial procedures. For the sake of this analysis, we looked at the patients’ demographics (hospital number, age, sex, and date of procedures); nature of surgery (emergency or elective); classification of the procedures: minor (scalp incisions/excision of scalp masses with no skull opening), moderate (ventricular shunting, minimal skull openings [burr-holes placements]), and major (repair of large encephaloceles and major intracranial works); duration of postoperative hospital stay and time of operative stitches removal in days; duration of perioperative antimicrobial prophylaxis; postoperative complications, infectious and others; and lengths of follow-up.
70
A.O. Adeleye, K.G. Olowookere / Surgical Neurology 69 (2008) 69 – 72
Cases of cerebral abscess, ventricular shunt surgeries in cases of raw septic spinal bifida with associated hydrocephalus, and surgeries in non–hair-bearing scalps were excluded from our shaveless surgery protocol.
3. Results There were 17 nonshaved cranial surgeries in 15 patients: 2 patients had 2 surgeries each (Table 1). There were 11 males and 5 females (male/female ratio, 2.2:1) with age range from 1 to 75 years. According to our classification in Materials and methods, there were 2 minor (day cases really), 6 moderate, and 9 major (including extensive brain tumor resections) procedures; 9 electives; and 8 emergencies. Antimicrobial prophylaxis in our unit was with thirdgeneration cephalosporins: 1 dose at induction of anesthesia and 2 to 4 doses postoperatively. The length of follow-up was 2 to 6 months. 3.1. Outcome measures Patients’ acceptance was good. Two patients, during the preoperative conference, actually expressed some misgiv-
ings at the prospects of immediate postoperative baldness until they were assured that we could offer them nonshaved surgery. 3.1.1. Preincision operative site preparation There were 2 male patients (cases 11 and 12, Table 1) with thickset mats of scalp hairs in whom it was difficult to part the hairs along the proposed incision line. A 1-cm strip of scalp along the incision line was therefore shaved. Not infrequently, many broken, loose strands of hairs found their way into the operative fields. These sometimes constitute nuisance effects and need meticulous care to retrieve them. Preincision operative site scrubbing using the traditional initial soapy lotions, povidone iodine followed by surgical spirits requires that the initial soapy lotions be mopped dry before the iodine solutions are applied. This mopping process consumes much more surgical gauze materials in the nonshaved scalps. 3.1.2. Wound complications One patient (patient 8, Table 1) developed frontal flap tip necrosis after unilateral frontal and parietal burr-hole
Table 1 Profiles of the nonshaved cranial surgical procedures, complications, and lengths of follow-up S/N
Date
Minor surgery 1 23/08/05 2 29/11/05 Moderate surgery 3 26/07/05
Sex/Age (y)
Surgical procedure/operative time (h)
Complications
Male/40 Female/5
Excision of scalp mass (0.5) Excision of scalp mass (0.5)
Nil Nil
5 8
5 2
Male/65
Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0) Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0) Ventriculoperitoneal shunt (0.75) Ventriculoperitoneal shunt (0.75) Shunt revision, cerebrospinal fluid fistula (0.5) Frontoparietal burr-hole evacuation of chronic subdural hematoma (1.0)
Nil
6
6
Nil
6
5
Nil Nil Nil
6 6 10
4 4 4
Frontal flap tip necrosis, cerebrospinal fluid seroma
12
2
Nil Wound seroma
8 14
6 5
6
3
10
3
Nil
7
3
Nil
7
3
Nil
7
3
Nil
6
3
Nil
9
2
4
06/09/05
Male/75
5 6 7
13/09/05 27/09/05 06/10/05
Female/3 Male/1 Male/1
8
13/12/05
Male/42
Major surgery 9 06/07/05 10 25/08/05
Female/0.5 Female/17
11
13/10/05
Male/27
12
14/10/05
Male/19
13
28/10/05
Male/25
14
29/10/05
Male/25
15
29/10/05
Male/25
16
03/11/05
Male/50
17
23/11/05
Female/7
Repair of occipital encephalocele (2.0) Temporal craniotomy, anterior temporal lobectomy, tumor excision (6.5) Temporoparietal craniotomy, open depressed skull fracture debridement, acute epidural hematoma evacuation (2.25) Redo parietal craniotomy, brain tumor excision (6.0) Parietal craniotomy, open depressed skull fracture debridement, traumatic intracerebral hematoma evacuation (2.0) Parietal craniotomy, evacuation of acute epidural and intracerebral hematoma (1.5) Debridement parietal open comminuted linear skull fracture (0.5) Evacuation /hemostasis, acute epidural hematoma (1.5) Suboccipital craniectomy, excision of brain tumor (5.0)
Nil
Wound seroma
Stitch removal (postoperative day)
Follow-up (mo)
A.O. Adeleye, K.G. Olowookere / Surgical Neurology 69 (2008) 69 – 72
drainage of chronic subdural hematoma. It appeared that the underlying frontal subgaleal cerebrospinal fluid collection that he developed contributed largely to this frontal flap tip necrosis, which responded to wound dressing augmented with oral ciprofloxacin. The uncomplicated parietal scalp wound had healed with primary intention, and his postoperative hospital stay was not affected by this event. There was no other surface or deep infectious complication recorded. 3.1.3. Other complications Two other patients developed cerebrospinal fluid seroma under their scalp flaps after extensive tumor resections. One resolved spontaneously, the other resolved after one round of aseptic cyst aspiration. 3.2. Stitch removal Stitches were removed on postoperative days 5 to 14, and these varying durations were dictated, especially in the most prolonged cases, by the underlying seroma. However, we found it more tasking removing stitches in nonshaved scalp wounds in our black patients. Although the stitches are cut quite long, and brightly colored suture materials like blue prolene or nylon are chosen for nonshaved scalp wound closure, 1 or 2 stitches are easily lost at suture removal, and the incidence of chronic stitches complication may thus rise. 4. Discussion In this short-term prospective preliminary series, we have attempted to study the feasibility of nonshaved cranial surgery in an indigenous black African population. Our results were comparable with the rest of the literature in some respects and unique in others. Since the pioneering large series by Winston [23] in 1992, more and more reports have documented (i) that there is no scientific basis to the long established surgical, more particularly neurosurgical, rituals of preoperative shaving of hair-bearing incision sites [13,15,22]; (ii) that wound infection rates in nonshaved cranial surgeries are no worse than in the shaved cases [2,17,22]; and (iii) that preoperative shaving of surgical incision sites, especially using the traditional surgical blade, as compared with hair clippers [1,13,22] is injurious to the operative site epidermal layer [1,20] and may actually promote rather than prevent postsurgical infections. Because of socioeconomic reasons, preoperative hair shaving, when desired, continues to be done with surgical blade and scalpel in our unit. This was the basis of our attraction to the nonshaved option, and we have thus successfully carried out minor, moderate, and major surgical procedures in both elective and emergency situations, sparing our patients immediate postoperative alopecia. Acceptance of this protocol was good in our patients. A few of them actually expressed pleasant surprise at our ability to thus allay their fear of inevitable
immediate postoperative alopecia. Although there was a case of mild superficial wound infection, we have not recorded any untoward case of deep infection in this short-term series. Nonshaved cranial surgery however demands some practical measures in order not to be counterproductive. These include preincision scalp hair grooming to delineate the incision line, keeping of loose hairs out of the operative fields, and the need for a very rigorous operative site scrubbing. Although these issues were documented in many series on whites [2,14,19] and addressed extensively in the seminal works of Winston [23], 1992, the issues appear to carry even more practical implications in black Africans with their unique anthropological scalp hair characteristics [24]. Compared with whites and/or Asians, the scalp hairs of a black African (without any prior physical or chemical grooming) are more curly (with much shortened functional length) [4,8,16], exhibit more kinks (sudden constrictions along their lengths) [4], and have more crimps (the number of times the direction of hair curvature changes per unit time) [4,8]. They are thus more susceptible to breakage [4] and as such are probably more likely to be found in the operative fields with greater nuisance effects, if not more chances of long-term inflammatory/infective complications. Furthermore, black African scalp hairs are not only shorter, making them more difficult to keep out of the wound [10,11,23], but they also form dense mats of tightly interwoven, complexly knotted hair shafts [4,11]. These sometimes, but not forbiddingly, make preoperative grooming and the delineation of the incision line a little more challenging. They also sometimes demand more meticulous care in postoperative stitch removal in order not to leave any stitch behind. Black- and gray-colored stitches are particularly notorious in this respect. We have found that shaving a thin strip of scalp along the incision line [15] and closing the skin wound with brightly colored sutures like prolene or nylon, which are cut fairly longer than usual after knotting, help forestall some of these drawbacks. The limitations of our study include the fact that it is a one arm, uncontrolled, small series and its preliminary nature, with only a short-term follow-up. We realize that a controlled study with much larger series and long-term follow-up is needed to verify some of our findings and to establish general guidelines for clinical practice. This study is only an initial exploration of a subject that is already much researched in white populations, but has hardly ever been mentioned in the black African race. 5. Conclusions Nonshaved cranial surgery, as already documented in the white populations, is not impossible for black Africans. The immediate postoperative wound events are comparable to those in the traditional methods. There are unique anthropological characteristics of the natural scalp hairs of the black African that demand some extra care in the performance of nonshaved cranial surgery. There is need
71
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Commentary Adeleye et al have written an article that is interesting and important for us all. The authors must be congratulated for challenging standards that have been in use for so long—without any scientific validation. Jens Haase, MD Department of Neurosurgery Aalborg University 9220 Aalborg, Denmark