Co-editors’ Messages

Complications in hair restoration don’t occur very often, but when they do, it gives me a reason to educate myself. One such complication occurred in a patient undergoing an FUE procedure a few weeks ago. The problem he developed was intra- and post-operative hiccups. Although I was aware of this side effect with surgery, and knew that it was thought to be a side effect of drugs, I wasn’t sure about exactly what the mechanism was that was occurring. I must say that after some investigation I am not much the wiser.

The case itself was very straightforward: 2,500 grafts over two days in a man in his late 30s with no medical problems and on no medications. The patient was pre-medicated with 10mg diazepam and 35mg prednisolone orally. Intra-operatively drugs used included lidocaine 1%, bupivacaine 0.5%, and triamcinolone with epinephrine 1:100,000 in a tumescent solution. Vital signs were normal throughout. It was noted on the first day at the patient’s lunch break that he had intermittent hiccups. These were not distressing to him and continued after his food and after drinking water. At the end of day 1, the hiccups still persisted intermittently and on returning the next morning were still occasionally present. The second day progressed in much the same manner as the first day. On the third day at check-up hiccups were still present; however, the patient reported no problems with sleeping. As the patient was not in any distress and was due to fly overseas to his home country, I decided not to treat with medication but to wait to see if they resolved spontaneously.

Persistent hiccups are described as lasting 48 hours or more and intractable as lasting more than 1 month. A hiccup is an involuntary contraction (myoclonic jerk) of the diaphragm that may repeat several times per minute. The medical term is synchronous diaphragmatic flutter or singultus, which is Latin for the act of catching one’s breath while sobbing.¹ A reflex arc causes a strong contraction of the diaphragm followed about 0.25 seconds later by closure of the vocal cords, which results in the classic “hic” sound. At the same time, the normal peristalsis of the esophagus is suppressed.

On looking at the hair transplant literature, there was not much information on the cause and treatment of this condition as it relates to hair transplant surgery. It is reported as being a side effect most commonly of diazepam and associated occasionally with irritation of the vagus nerve in strip surgery.² In the past, we have had a very rare occasion where a patient has developed hiccups during the course of the procedure, but this has always been a short-lived event with no specific treatment required. A case report of herpes zoster, as described by Cotterill, also had hiccups as a complication.³

In the wider literature, causes of hiccups have been attributed to several things: phrenic/vagus nerve stimulation, drugs, metabolic conditions, electrolyte imbalance, direct stimulation/irritation of the diaphragm (e.g., in intra-abdominal surgery), infection, CNS disorders, arrhythmias, coughing, and alcohol.¹ The incidence in hair transplantation is very low having been described in one case series as 0.2%.⁴ In the general population, incidence is described as equal amongst the sexes but intractable hiccups are more common in men for unknown reasons.¹

Treatment of choice for sustained hiccupping is chlorpromazine, a potent anti-psychotic that also has anti-emetic properties. Side effects of chlorpromazine include sedation and for this reason I chose to wait and not treat this patient as he was flying overseas. It was not an ideal situation to be sending the patient on a plane under the influence of a strong sedative and carrying anti-psychotic drugs into another country. Instead I gave the patient the name of the drug and told him to contact his own physician if the hiccups hadn’t resolved in a couple of days. Fortunately, at follow-up after 4 days, the patient reported resolution without treatment.