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Cutaneous Neuroma causing neurological symptoms after hair
Khurram Jehangir Khan, MD; Soma Sahai-Srivastava, M.D
University of Southern California Department of Neurology, Los Angeles, California, USA
This is a case report and review of
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Published online 2009 May 28. doi: 10.1016/j.jhsa.2009.04.003
ISHRS Practice Census: 2011
•Hair restoration is one of the most
exciting and innovative surgical fields
in aesthetic surgery today.
•Hair transplantation is the treatment
of choice for hair loss, preferred by
60% of men and 10% of women.
•In 2010 alone, there were 101,252 hair
restoration surgeries in the US, an
increase of 3% from 2008.
•Major complications as a result of
surgery is rare, Minor complications
include delayed healing, infection,
scarring, or graft rejection.
•Scar neuroma pain has been described
as a complication of craniotomy (16%),
but not in the setting of hair transplant
•Some may present with the classic Tinel
sign or scar dysesthesia with radiating
pain. This may be due to entrapment
of cutaneous nerve in the surgical scar.
Local injection with local anaesthetics
are often used for both diagnostic and
therapeutic purposes .
•Scar neuroma injection with local
anesthetic and steroids are reported to
result in complete remission of
headache in postcraniotomy setting
1. Hair transplant patients with Headache
should be evaluated for scar neuromas
including palpation in order to recreate pain
2. We hypothesize that the unrelenting barrage
of nerve impulses from injured peripheral
nociceptors increases the excitability of
adjacent uninjured pain-transmitting neurons
in the trigeminal nucleus caudalis resulting in
central sensitization and vague, diffuse poorly
localizable chronic head pain resulting in
3. Scar Neuroma treatment is safe, effective and
can be successfully performed in an outpatient
clinic by injection of local anesthetics and
•32 year old male presents with history of chronic daily
headache for 10 years after hair transplant surgery, in the
right temporal, throbbing, radiating to the right shoulder,
neck and right arm. He also had some photophobia and
autonomic signs ipsilateral to the pain. Triggers for
exacerbation included weather changes, alcohol, sleep
deprivation, lifting weight and pressure to the posterior
temporoparietal region.. He reported significant emotional
and psychological distress due to pain and and was being
treated with antidepressants.
•Physical examination including neurological examination
was nonfocal except for presence of a curvilinear surgical
scar in the right temporoparietal area, measuring 8cms.
Palpation of the scar revealed underlying firm bead like
thickening, in certain areas which triggered radiating his
usual HA. Workup including MRI of head without
contrast was unremarkable.
•Treatment : Previously failed anticonvulsants,
Nonsteroidal anti-inflammatory drugs and pain. He was
treated with injection at the most painful points of the scar
at 3 distinct locations with a solution of lidocaine 2% (1.5
mL) and dexamethasone 10 mg/2 mL (0.5 mL). He was
also started on amitriptyline 10 mg PO at bedtime for
insomnia and to treat the neuropathic components of his
pain. After the injection, he reported significant
improvement in headache by over 75% both in intensity
and frequency and has maintained this status for 6
4. Scar after Hair Transplant Surgery