Perspectives

James R. Van Dellen, M.D.

Professor, Department of NeurosurgeryQueen Elizabeth Medical Center

Birmingham University Hospitals NHS Foundation Trust

Barber Surgeon, or Surgeon Barber?

Commentary on:Outpatient-Based Scalp Surgery withoutShaving and Allowing Use of Shampooby Hwang et al. pp. 391-393.

James R. Van Dellen

T he definition of a barber (Latin barba � beard) has beengiven as someone, most often male, whose occupation isto shave or trim the beards of men and to cut hair. Priests

and medicine men in the very early periods were recorded asbeing barbers. In Europe during the Medieval and into the MiddleAges, the barbers often served as surgeons and dentists, per-forming bloodletting and leeching, fire cupping, enemas, and theextraction of teeth. In 1163, the medieval Roman Catholic churchafter the Council of Tours under Pope Alexander III banned clergyfrom the practice of surgery and, from about then, “physicians”also became clearly separated. Surgery was thereafter not gen-erally conducted by physicians but by barbers and they werefurther charged with looking after soldiers or sailors during orafter a battle that earned them the name barber surgeons. Thebarber pole (although the exact colors and configuration remainunder debate), associated with the service of bloodletting, origi-nally had a brass wash basin at the top, in which leeches werekept, and another at the bottom, to receive the blood and the polerepresented the staff the patient gripped to encourage bloodflow. British barbers were even recorded to have received higherpay than surgeons until surgeons were assigned to war ships. Inmost countries, the trade or craft guild system was increasinglyput under pressure by the medical profession. For example, theCompany of the Barber-Surgeons of London, formed in 1540 bythe union of the Company of Barbers and the Fellowship ofSurgeons, split in 1745, the surgeons from the barbers, andformed the Company of Surgeons, which, in 1800, became theRoyal College of Surgeons.

Textbooks recommend preoperative shaving for cranial neurosur-gical procedures and the practice remains widespread in mostneurosurgical units.

Key words:� Dressings� Scalp mass� Shaving� Wound healing

WORLD NEUROSURGERY 77 [2]: 293-295, FEBRUARY 2012

IS THE REMOVAL OF HAIR NECESSARY, AND DOES IT STANDUP TO THE SCRUTINY OF MODERN EVIDENCE EVALUATION?

The extent and nature of shaving, ordinarily performed beforeneurosurgical operations, varies in extent as well, the mostsevere being of the whole scalp. It is ostensibly performed toprevent perioperative intracranial infection, but, is it not merely apersistence of another early nonscientific “tradition,” epitomizedperhaps by the past practice of using elegant, but very difficult todo, and probably unnecessary, “turban dressings” after cranialsurgery—now virtually never used?

We, as neurosurgeons, clearly need to consider whether shavingof the hair and neurosurgical procedures are almost inseparablyconnected issues and whether this applies to scalp and skullprocedures (2) or to intracranial procedures as well. Many pa-tients who have lost their hair, find it embarrassing to return tosociety and naturally prefer to keep their full head of hair toenhance self-image during the postoperative period. This hasbeen an issue of great contention in my past practice, especiallyfor young girls. As well as cosmesis, patient esteem and facili-tation of their return to a normal life, as pointed out in the articleby Hwang et al. (2), it is also an effort to improve patientconfidentiality. Patients react very positively to an option thatallows them to enjoy the psychologic benefits of undisturbedbody image while recovering from major surgery and this can aidin a rapid rehabilitation. It may be important in certain circum-stances to avoid the stigmatizing effect of a totally or partiallyshaved head with openly visible signs of a head operation.However, cultural and social factors clearly need to be taken intoaccount. For example, within the Buddhist community shaving isone of the traditional procedures for cleanliness and purification.Knowledge by a surgeon of a patient’s social attitudes toward

Department of Neurosurgery, Queen Elizabeth Medical Centre, BirminghamUniversity Hospitals NHS Foundation Trust, Birmingham, United Kingdom

To whom correspondence should be addressed: James R. Van Dellen, M.D.[E-mail: profjvandellen@btinternet.com]

Citation: World Neurosurg. (2012) 77, 2:293-295.DOI: 10.1016/j.wneu.2011.02.043

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shaving, or, not shaving, for cranial neurological surgery has clearimplications when implementing true informed consent.

Although performed to prevent perioperative contamination andlater wound and potential intracranial infection, there has been,and there currently is published, no clear scientific basis for thispractice. Interestingly the first “scientific challenge” to thispractice was published only as recently as 1992 (8).

A recent review (3), using key words in search engines andreferences lists of studies published in English, between 1992and 2009, examined the relationship between skin preparationand the development of surgical site infection in patients whohad cranial surgery. Although not all studies had control groups,there had been no statistically valid differences reported whenthere had been a control group. There is, therefore, great needfor well-designed, randomized controlled studies, and then alsoassessing the impact on patient “well-being” and return to anormal life, unfortunately not done in the study of Hwang et al.(2). In the many studies available, including a Cochrane review(6), there has been no report as yet indicating that shaving of thehair has led to a decreased incidence of infection. The need toshave in contradiction has not been clearly enunciated, but it hasbeen in one study (4) proposed in an immunocompromisedpatient, the presence of infectious diseases, surgery with foreignmaterial insertion, multiple operations within 1 month, and thepresence of a traumatic wound around the operative site.

What has become evident is that the “removal” of hair, includingthe timing of this event, can, however, have a significant impact onthe instigation of infection and other complications. Use of a razor,as opposed to disposable clippers, has clearly documented delete-rious effects. The use of depilatories, as an alternate, has hadreported significant side effects. In further contradiction there arereports, including the method described by Hwang et al. (2), ofmany practical methods of managing and excluding hair in relation-ship to surgical wounds for surgery and postoperatively.

An additional issue relating to surgical wounds has been thepreparation of the surgical area using varying forms of skin antisep-sis. Although no clear guidance is available on the use of alcohol-based, chlorhexidine, or iodine-containing surgical site antimicrobialand cleansing substances, it would appear on common sensegrounds to be a positive step before an incision. Neither is thereclear support for pre-emptive, preoperative skin preparation; butonce again reduction of potential skin and hair contamination wouldappear to be a simple and sensible precaution, especially if by asimple means as a shampoo. The use of shampoo in the patients inthe study by Hwang et l. (2) was regarded as very beneficial beforeand during the early postsurgery.

The benefit of perioperative antibiotic prophylaxis is well docu-mented, but whether this needs to be continued postoperativelyas proposed by Hwang et al. (2) has not been determined.

Finally, the method of skin closure in the circumstance of anunshaved wound needs to be considered. Despite the surprisingrecent report on the negative effect of staples in orthopedicpractice (5), the cosmetic result and benefits of a monofilament-

type, easily applied, metallic skin closure method has much to

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recommend its use (2), including no risk of accidental needle-stick injury and therefore safer for the user.

The method of dressing the closed surgical wound has also beendiscussed and it provides an optimal environment for rapidhealing, to protect against further trauma and exposure toharmful substances (2). The ideal has been established, which isa moist but clean wound, and, when there is no shaving at all, theuse of an antibiotic ointment along the wound line appears tobe a safe and practical method of skin incision management.There have been variations of dressing discussed depending onthe extent of hair removal (2, 7). The use of gauze in theimmediate postoperative period to collect minor blood oozingfrom the wound appears to be beneficial. Early “shampooing” is,as reported by Huang et al. (2), beneficial and not risky as woundsare sealed to bacterial invasion within a few hours of closure (9).

My origins are from an absolutely traditional neurosurgical back-ground, even to the extent of having worked in a unit where a barberwas employed specifically, the preceding evening, to completelyshave the heads of patients undergoing intracranial and skull sur-gery. My current practice has evolved to separating the hair using acomb/brush and then, using a disposable clipper, to remove a verynarrow strip of hair on either side of the line of the incision and thenpostoperatively the use of a very narrow strip of sterile standardsticky dressing, but, I have had experience in major intracranialcases with no shaving at all and with only an antibiotic ointmentdressing. I also immediately before marking the incision and aftercompletion of the surgery use a chlorhexidine shampoo to the areaand surrounding hair before applying the surgical wound dressing. Igenerously apply sterile aqueous gel to the hair surrounding theincision to keep it slicked down. I advise patients that a gentle fingertip shampoo a day or so after surgery, avoiding scratching or pickingat the wound, provides a helpful circumstance for the patient. Theuse of the water-based gel in the hair surrounding the woundassists also in cleaning the hair around the wound area immediatelypostoperatively as well as later.

It would also appear that there is no evidence to support the needto shave pediatric patients (including shunt procedures, or for theseoperations in adult patients). Nonshaved cranial surgery, as inwhites/Asians, can also be safely carried out in black Africans, butwith some attention to details in the perioperative care of theincision sites (1).

THEREFORE, A CLEAR SCIENTIFIC CHALLENGE EMERGES WITHRESPECT TO OUR ROLE, AND WHETHER WE NEED TOCONTINUE TO BE BARBERS AS WELL AS SURGEONS?

As stated by Iyiguni et al. (3), there is undoubtedly a need forwell-designed, randomized controlled studies that show whethershaving or not shaving in the skin preparation of a surgical area inpatients having cranial surgery has a statistically significantimpact on the infection rate; whether antimicrobial shampoos(preoperative and early postoperative) have a statistically signifi-cant effect on surgical site infection rates; whether the mode ofdressing the surgical wound statistically alters surgical siteinfection rates; and finally, whether shaving has an impact on

patient well being and their return to their previous routine life.

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REFERENCES

1. Adeleye AO, Olowookere KG: Nonshaved cranial sur-gery in black Africans: a short-term prospective pre-liminary study. Surg Neurol 69:69-72, 2008.

2. Hwang S-C, Kim S-K, Park K-W, Im S-B, Shin W-H,Kim B-T: Outpatient-based scalp surgery withoutshaving and allowing use of shampoo. World Neuro-surg 77:391-393, 2012.

3. Iyiguni E, Ayhana H, Tastan S, Kose G: The effect ofunshaved skin preparation in cranial surgery on de-

velopment of surgical site infection: systematic re-view. J Neurol Sci (Turkish) 27:185-196, 2010.

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. Ratanalert S, Saehaeng S,Sripairojkul B, Liewchan-pattana K, Phuenpathom N: Nonshaved cranial neu-rosurgery. Surg Neurol 51:458-463, 1999.

. Smith TO, Sexton D, Mann C, Donell S: Sutures ver-sus staples for skin closure in orthopaedic surgery:meta-analysis. BMJ 16:340, 2010.

. Tanner J, Woodings D, Moncaster K: Preoperativehair removal to reduce surgical site infection. Co-chrane Database Syst Rev 2006;3:CD004122.

. Vermeulen H, Ubbink D, Goossens A, de Vos R,Legemate D: Dressings and topical agents for surgi-

cal wounds healing by secondary intention. Co-chrane Database Syst Rev 2004;2:CD003554. A

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. Winston KR: Hair and neurosurgery. Neurosurgery31:320-329, 1992.

. Winston KR, McBride LA, Dudekela A: Bandages anddressings and cranial neurosurgery. J Neurosurg 106:450-454, 2007.

itation: World Neurosurg. (2012) 77, 2:293-295.OI: 10.1016/j.wneu.2011.02.043

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