Hair Style Can Impact Intubation

Healing Little Heroes director dressed as Darth Vader at Ronald McDonald House, San Diego

Our Healing Little HeroesFoundation  founder dressed as Darth Vader at Ronald McDonald House, San Diego

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way.

Chris Whitten as Queen Amidala with Healing Little Heroes Foundation at San Diego Children's Hospital

Chris Whitten as Queen Amidala with Healing Little Heroes Foundation at San Diego Children’s Hospital

Hairstyle Can Make Intubation Difficult

In many hospitals, including mine, we often meet our patients for the first time in our preoperative areas in the hour before surgery. By the time I get my first chance to talk to my patient, he or she is often already in hospital gown, with their hair covered by an OR cap.

An intricate hair bun can interfere with your ability to tilt the patient's head into a god sniffing position.

An intricate hair bun can interfere with your ability to tilt the patient’s head into a good sniffing position. It would also be difficult to quickly take apart in the middle of an intubation

Sometimes that OR cap and hide one of the many large and involved hairstyles popular today, including ponytails, buns, dreadlocks, weaves, and wraps. If the bulk of the hair is placed toward the occiput or nape of the neck, it may be difficult to tilt that patient’s head backward to place the head into the optimal sniffing position for intubation. If you don’t notice this before you start, you can be unpleasantly surprised mid-intubation.

Have a high index of suspicion for odd lumps and bumps under the cap. Don’t hesitate to have your patient remove the cap during the airway exam. Or simply place your hand on the back of the head and neck as the patient tilts their head into extension.

When there is a potentially problematic hairstyle see what you can do the resolve it before induction. Often you can quickly resolve the problem by strategically moving or removing a rubber band.

If the hair has been extensively braided or woven into a complex and firm mound, the style may be difficult to deconstruct and other solutions may be needed.The most common is to position the bun or mound of hair into the hole of a foam donut or the hole in a Shea headrest. If you lack a foam donut you can make one by coiling a towel or blanket into a donut shape. Whatever you use must help your ability to position. Don’t make it so high or bulky that your intubation aide itself amplifies the problem.

Ramp the patient appropriately using blankets to lift their shoulders and torso higher, leaving room to tilt back the head. Clearly it’s much better to recognize the potential for hair problems and ensure that the patient can tilt their head back before induction than it is to wait until after and have to resolve the issue on the fly.

Bobby Pins and Clasps

Bobby pins and clasps are very firm objects and they can easily cause pressure points if positioned under the weight of the patient’s head. They can also be dangerous if your patient is about to enter an MRI scanner.

Pressure Alopecia (Loss of Hair)

The other potential problem with hairstyle is the risk of postoperative pressure alopecia. Pressure alopecia is a rare, and often-preventable complication caused by excessive pressure inducing local ischemia during the procedure, resulting in the loss of hair. Patients typically present within the first month after surgery with either swollen or raised area or with actual hair loss. It can be temporary or permanent.

Predispositions include prolonged anesthesia (greater than 3 hours), hypotension, hypotension, trendelenburg positioning, and obesity. However, anything that causing point pressure over an area for an extended period of time can cause localized ischemia. This potentially includes big hair underlying the weight of the head.

If you have a patient at risk for postoperative alopecia you should consider periodically repositioning the head and massaging the scalp, if that’s possible with the procedure being performed.  If you do have a patient you consider to be at risk, tell them.

Traction Alopecia


You can easily remove, loosen or slide a rubber band to better position the head, to avoid excessive point pressure, or to decrease traction on the scalp. But you have to know it’s there.

I also look at how tightly the hair is pulled back. Traction alopecia has certainly been reported with very tight weaves and braids left in for prolonged periods of time. Could a tight pony tail or hair weave, combined with a prolonged anesthetic with intraoperative hypotension increase this risk? I haven’t seen it reported but I could see how it could happen.


It’s easy to forget hair as both a risk factor for difficult intubation as well as a risk factor for anesthetic complication. However,  it’s important to recognize that even the little things we take for granted in life can sometimes cause harm.

May The Force Be With You

Christine Whitten MD,

Author of Anyone Can Intubate 5th Edition

Photo of Dr. Chris Whitten dressed as Queen Amidala

Chris Whitten as Queen Amidala wishes that the Force Be With You


Further Reading

  2. Davies KE,  Yesudian P. Pressure alopecia, Int J Trichology , 2012, vol. 4 (pg. 64-80)
  4. Healing Little Heroes Foundation


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