Pressure alopecia following robotic gynaecological surgery: Lessons from a case series on a preventable complication.

This retrospective, observational case series included patients who had scalp swelling and localised alopecia following robotic pelvic surgeries performed at a tertiary care hospital between 2020 and 2024. Data was extracted from anaesthesia records, surgical logs, and post-operative follow-up notes after institutional approval. Relevant clinical and perioperative details are summarised in details [ Table 1 ]. Case studies POD: Post-operative day, SBP: Systolic blood pressure; DBP: Diastolic blood pressure Six patients who underwent robotic pelvic procedures during the study period developed occipital pressure-related complications, including transient swelling, prolonged soreness, and hair loss. PA diagnosis was clinically based on the typical pattern: well-circumscribed, non-tender alopecic patches over pressure points. All procedures were performed in steep Trendelenburg (40°–45°) position with no reposition of the head after robotic docking. Operative durations ranged from approximately 3 to 6 h, and intra-operative haemodynamics, including blood pressure, were maintained within acceptable limits. Estimated blood loss remained within routine expected ranges. None of the patients had psychiatric or autoimmune history. Patients 2, 3, 5, and 6 presented with occipital swelling and tenderness on post-operative day 1, resolving spontaneously within 4–14 days. Patient 5 experienced persistent soreness for approximately 2 weeks. Patients 1 and 4 [ Figure 1 ] developed localised occipital alopecia noted between post-operative days 14 and 25, with complete regrowth observed over the following months. No patient experienced permanent alopecia. Alopecia over occipital area at 3 weeks in patient no: 4. no: Number Although prolonged surgical duration is considered the primary risk factor for PA, five of six cases in this series occurred after procedures lasting less than 4 h. These findings highlight that steep Trendelenburg positioning and prolonged unrelieved occipital pressure along with localised scalp oedema rather than duration alone may play a critical role in the development of post-operative scalp ischaemia during robotic pelvic surgery. The present series highlights the need for proactive pressure-relief measures in patients placed in steep Trendelenburg position.

Pressure alopecia (PA), also known as post-operative alopecia, a relatively unknown and under-reported complication amongst anaesthesiologists, occurs due to prolonged pressure on the scalp, leading to local ischaemia and temporary hair loss. While generally reversible, it may occasionally lead to permanent scarring alopecia. Traditional literature links PA to surgeries exceeding six hours,[ 1 ] cardiac operations,[ 2 3 ] reconstructive breast surgeries,[ 4 5 6 ] and prolonged intensive care unit (ICU) stays. However, the increasing use of robotics in surgery has introduced new risk factors. Robotic pelvic surgeries require steep Trendelenburg positioning leading to scalp oedema and potentially longer durations of time, increasing susceptibility to PA. Although isolated case reports[ 7 ] exist, a detailed case series specifically analysing PA in robotic pelvic surgeries is not reported. This series presents six cases who had developed post-operative occipital pressure-related findings and elaborates on the possible perioperative contributors.

PA is an under-recognised post-operative complication with important cosmetic implications especially in young females presenting for gynaecological procedures. Robotic pelvic surgeries amplify the risk due to steep Trendelenburg positioning, headrest pressure, and restricted repositioning once docking occurs. Importantly, PA can occur even after moderately long surgeries (<4 h), suggesting that ischaemia-related factors, headrest choice, and haemodynamic stability may play a larger role than duration alone. Deidentified data may be requested with reasonable justification from the authors (e mail to the corresponding author) and shall be shared after approval as per the author’s institution’s policy. During the preparation of this work, the author(s) used Chatgpt and Grammarly to assist in improving grammar, clarity, and academic tone of the manuscript. After using this tool, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication. TD was involved in conduct of cases, acquisition, data literature search, data analysis, definition of intellectual content, manuscript preparation, editing, review. ARA was involved in data acquisition, data analyses, literature search, manuscript preparation, editing, review. IH was involved in conduct of cases, literature search, manuscript preparation, editing, review. NB was involved in conduct of cases, literature search, manuscript preparation, editing, and review. All the authors have participated in the review, drafting and final approval of the manuscript. There are no conflicts of interest.

PA represents a classic example of a preventable perioperative complication that presents due to limited awareness and inconsistent monitoring of pressure points. This case series highlights several critical aspects relevant to modern anaesthetic practice during robotic surgery. Prolonged scalp compression results in localised vascular occlusion and subsequent tissue hypoxia, which leads to follicular apoptosis and alopecia. Mild ischaemia manifests as a reversible anagen-to-telogen shift and presents clinically as non-scarring alopecia.[ 8 ] However, severe ischaemia can cause irreversible follicular matrix destruction, dermal fibrosis, and permanent scarring alopecia. In the present series, complete recovery in all six cases supports the likelihood of sub-threshold ischaemic insult without permanent follicular compromise. Robotic pelvic surgeries are uniquely high risk for perioperative pressure alopecia because of positioning and physiological factors. The steep Trendelenburg position produces an increase in contact pressure between the occiput and the headrest, accentuated by the cephalad shift of body weight, resulting in traction on the hair shaft and follicles. After the robotic arms are docked, repositioning the patient becomes difficult, unlike open or laparoscopic surgery where head adjustments are possible. These procedures may also be prolonged because of learning curve of the surgeons. Pneumoperitoneum increases intra-abdominal pressure, reduces venous return, and may impair microcirculation of the scalp, predisposing tissues to ischaemia.[ 9 ] This is accentuated by scalp oedema due to the dependent position. PA was first described in 1959.[ 10 ] Despite being recognised for over 6 decades, awareness among anaesthesiologists remains low. It is briefly mentioned in anaesthesia textbooks[ 11 ] as a pressure complication. Davies and Yesudian[ 1 ] reviewed over 100 cases and found that pressure alopecia occurred in lengthy surgeries under general anaesthesia and extended stay in the ICU. PA has been described in prolonged breast reconstructive surgery,[ 4 5 ] paediatric urological surgeries, and cardiac procedures.[ 2 3 ] Lawson et al .[ 2 ] were the first to report permanent alopecia following surgery and believed that the duration of surgery was directly correlated with the probability of the alopecia being permanent. In this series, 29 patients who developed permanent alopecia had been intubated on average 10 h longer than 31 patients whose alopecia was temporary. Sharma et al .[ 7 ] in 2023 reported two cases of PA in robotic surgeries lasting 6–6.5 h, respectively. In the present series, five of six cases occurred in procedures of less than 4 h duration, suggesting that the risk is not solely duration-dependent. Rather, the contribution of steep Trendelenburg, scalp oedema, headrest type, and restricted repositioning may exert a greater effect than operative duration alone. Clues favouring a diagnosis of PA include the precise localisation of hair loss over pressure-bearing sites, typically the occiput where contact with the headrest occurred during surgery. The onset usually becomes evident within the first post-operative week, correlating with the timeline of ischaemic follicular injury.[ 12 ] Preventive strategies include proper head positioning. Rigid, doughnut-shaped headrests should be replaced with gel, viscoelastic, or horseshoe-shaped supports that ensure neutral alignment without hyperflexion or rotation. Intra-operative position checks should be performed after placing patients in the Trendelenburg position, with efforts made to reduce traction forces on the scalp—especially before robotic docking, when adjustments are still possible—to prevent prolonged focal ischaemia. Maintaining haemodynamic stability is critical; keeping the mean arterial pressure above 65–70 mmHg and preventing hypothermia help support the scalp microcirculation. Minimising both, the degree and duration of the Trendelenburg tilt and streamlining docking time help avoid unnecessary delays. Finally, patients should be counselled pre-operatively regarding the rare but possible occurrence of post-operative alopecia in relevant cases.