Hair Tourniquet Removal

Hair tourniquet syndrome is a rare clinical phenomenon that involves hair, thread, or similar material becoming so tightly wrapped around an appendage that it results in pain, injury, and, sometimes, loss of the appendage.[1] Essentially, any appendage may be involved, including a toe, wrist, penis, scrotum, tongue, uvula, vaginal labium, ear lobe, umbilicus, or nipple.[2, 3, 4, 5, 6] In a meta-analysis review of 210 cases of hair-thread tourniquet syndrome, 44.2% involved the penis, 40.4% the toes, 8.6% fingers, and another 6.8% represented other sites.[7]

Human hair is extremely thin and, hence, easily overlooked, especially when a patient presents with a foreign body reaction and local swelling.[8] Once constricted over an appendage, reepithelialization may occur if the offending fiber is not removed in a timely fashion. This may further obscure the hair or thread below an overlying skin bridge, making recognition more difficult.[9] Hair has high tensile strength and the ability to stretch when wet and contract or tighten as it dries.[8] The wrapping of the offending fiber or hair around a digit is thought to be caused by repetitive movement of the appendage in a confined area, such as hands in mittens or feet in pajamas.[10] The tissue injury from constricting bands may be caused by ischemic compression of blood vessels and the direct cutting action of the tourniquet.[9] In addition to soft-tissue damage, this mechanism is even capable of disrupting bone.[7] Complications such as constrictive scarring, flexion deformity, and even urocutaneous fistulae may affect healing post release.[11]

Most cases of hair wrapping occur in young children. The most often observed age range of reported cases of finger wrapping is in the first days of life up to 19 months, and penile involvement is 4 months to 6 years.[12] Labial and clitoral wrapping have been described in an older age group (age 7-13 years).[13] Case reports have documented 80- and 84-year-old men with involved extremities.[14, 15] Hair tourniquet syndrome can be observed across all ages. The younger age group, especially infants younger than 4 months, is thought to be more at risk because 90% of mothers experience excessive postpartum hair loss, called telogen effluvium.[16] Most cases of hair tourniquet syndrome are deemed accidental, but intentional cases consistent with child abuse have been cited in the literature.[17]

Although the affected patient can present in several ways, the classic presentation is that of the inconsolable infant. The diagnosis can be made after identification of a swollen and painful appendage with sharp circumferential demarcation from normal tissue proximally. Hair tourniquet syndrome confers an inherent risk of loss of function and autoamputation. However, it is easily treatable and long-term effects are largely preventable with prompt diagnosis. Clinicians should maintain a high index of suspicion when confronted with such presentations.

Removal of the offending fiber is indicated in all cases of hair or thread tourniquet syndrome and should be implemented as early as possible.

Adequately visualized constricting bands with little or no tissue edema are good candidates for the unwrapping technique.

Cases associated with mild-to-moderate edema are candidates for the blunt probe cutting technique.

In cases in which other techniques have failed, when the swelling is so severe that the constricting band is not visible, or when epithelialization has occurred, the incisional approach should be implemented.

The use of depilatory creams is a safe alternative to instrumentation and can be done with minimal discomfort, while taking care and using caution on the application to the skin of the penis; it should be avoided when it involves the vagina and mucosal surfaces, as this could lead to burns or irritation.[18, 19]

Cases requiring surgical debridement have been described.[7, 20] When formation of excessive granulation tissue or involution under edematous skin is present, consider urgent surgical referral.

No absolute contraindications exist to the removal of a hair or thread tourniquet.  Conversely, removal is required to prevent morbidity.

Relative contraindications are approach-specific. Bleeding diathesis for the incisional approach and/or history of allergic reaction to depilatory creams are relative contraindications and may be an indication to choose one approach over another; however, this should never be a reason to withhold or postpone urgent treatment.

Topical agents, local infiltration of anesthetic, nerve blocks, and moderate sedation can be used singly or in combination.

The choice of technique may vary depending on the clinician’s skill, the appendage involved, the patient's age, and the patient's ability to cooperate.

Immobilization techniques may be required.

For more information on anesthetic administration techniques, see the following articles:

• Topical Anesthesia

• Infiltrative Administration of Local Anesthetic Agents

• Procedural Sedation

The necessary equipment for removal of hair or thread tourniquet is dictated by the method chosen by the practitioner. Individual circumstances may require alternative or additional equipment.

Equipment for the unwrapping method is as follows:

• Gloves
• Pincer instrument, if necessary (eg, fine-tipped forceps, hemostat)

Equipment for the cutting method is as follows:

• Gloves
• Local or regional anesthesia materials
• Scalpel blade, No. 11
• Povidone-iodine (eg, Betadine) solution
• Fine-tipped forceps
• Ear wax curette
• Fine-tipped hemostat
• Blunt probe
• Fine-tipped scissors

Equipment for the depilatory method is as follows:

• Gloves
• Commercial depilatory cream
• Water source for subsequent removal of depilatory cream

Positioning varies based on the anatomic part involved. A position that maximizes exposure of the involved appendage or body part while providing sufficient lighting is recommended; care should also be taken to maximize patient comfort.

Unwrapping method

This technique is likely to be successful in cases with minimal edema and clear access to the constricting fibers.

Look closely to identify a free end of the hair or thread.

Grasp the free end, then slowly pull and unwind the hair from the appendage using gloved fingers or a pincer instrument (eg, fine-tipped forceps, hemostat).

If no free end is visible, but a hair knot is visible, break the knot off the strand at one end using fine-tipped forceps, and then unwrap the hair as described.[9]

The unwrapping method may require multiple attempts, as the hair strand may break apart during removal or multiple hair strands may be involved.

Cutting method

Blunt probe method

This method is likely to be successful in cases in which the constricting band is not too deeply embedded in the soft tissue.

Gently wedge a blunt probe or metal earwax curette between the skin and the hair. Insertion is facilitated when performed in a proximal-to-distal direction while applying traction to the skin, allowing the hair to penetrate less deeply.[9] See images below.

Cut the hair with fine-tipped scissors or a No. 11 scalpel blade directed against the surface of the probe or curette so as to protect the underlying skin. Alternatively, lift a strand of hair gently away from the skin with the upturned scalpel blade until the hair is divided.[2]

Once divided, the hair can be removed using the simple unwrapping method described above.

Incisional approach for digital involvement

This approach is the most invasive and should be reserved for severe cases of digital involvement.

A digital nerve block is recommended.

The involved area must be adequately sterilized with povidone-iodine solution and then draped, with close adherence to sterile protocol throughout the procedure.

Once the area is anesthetized and prepared, make an incision using a No. 11 scalpel blade at either the 3- or 9-o'clock position of the digit. See image below.

The incision should be made longitudinally, with the blade perpendicular to the strand and skin surface, going from proximal to distal, and deep to bone to ensure incision of the fiber.[9]

Using the 3- and 9-o’clock positions tends to avoid the dorsal and ventral neurovascular bundles of the digits. See image below for cross-section.

An alternative incision site is along the dorsal aspect or 12-o’clock position (see image above).[12] A dorsal longitudinal incision parallel to the extensor tendon fibers is typically found to heal well with splinting and general wound care.[9]

Incisional approach for penile involvement

This approach is the most invasive and should be reserved for severe cases of penile involvement.

A dorsal nerve block with or without topical anesthetic is recommended.

The area involved must be adequately sterilized with povidone-iodine solution and draped, with close adherence to sterile protocol throughout the procedure.

The recommended site for the incision is the inferolateral surface at the 4- or 8-o’clock position, as these sites are ideal for minimizing risk of injury to the dorsal neurovascular structures of the penis. See image below.

The incision should be made longitudinally, staying in the deep penile fascia between the corpus cavernosum and spongiosum.[21]

The deep fascia of the penis is relatively tough. In light of this, the clinician may elect to make light incisions along the initial incision, slightly deeper with each stroke, with the goal of cutting the constricting band without penetrating the fascial layer into the lumen of the corpora.[9]

Depilatory method

Although such use is off-label, chemical depilatories are easy and painless to use, relinquishing the need for anesthetic agents.[18]

A 2015 single center retrospective study showed that 64% of the 81 patients enrolled had successful treatment of the hair tourniquet with one or two treatments. None had success past two applications.[22]

Chemical depilatories should not be used on broken skin or with any sign of tissue necrosis. Exercise caution using these creams on the skin of the penis so as to avoid the meatus; limit application to the shortest time necessary. Depilatory creams should be avoided all together on the vaginal area or any area near a mucosal surface, and the clinician then should proceed with mechanical removal.[19]

Standard chemical depilatory agents (eg, NairTM) are thioglycolate-based and work to disrupt the chemical bonds of hair keratin, causing the hair to break in half. Consequently, their use is limited to hair tourniquets and will not be of utility in removal of thread tourniquets. 

The manufacturer’s instructions recommend that a small site be tested before use 24 hours prior to the main application to assess for irritation or allergic reactions. This should not preclude the use of depilatory creams in emergent situations.

Apply the depilatory cream to the region of the hair tourniquet, with specific attention to the knotted area, and wait the time indicated on the product (typically, 3-10 min) for complete hair breakage.[2] A second application can be applied 10-15 minutes after the initial application.[22]

After the specified time has passed, wash off the depilatory cream with soap and water.

Always document neurovascular status, tendon function, or both after the procedure.

If the skin or distal structures have been lacerated or compromised by the tourniquet or its removal, appropriate tetanus wound prophylaxis should be provided.

A urology consultation should be obtained immediately in all cases of hair tourniquet that involve the penis.  

Surgical consultation may be necessary in cases involving significant tissue edema, distorted anatomy, necrosis, or uncertainty about the completeness of the removal.

Antibiotic therapy should be considered for patients who are immunocompromised, have diabetes, or have contaminated wounds.[2]

Very young, preverbal children with constricting bands should be evaluated for child neglect or abuse.[17]

Urgent follow-up is required, and patients should be discharged with wound care instructions and return precautions.

Prolonged ischemia, the cutting action of the tourniquet, or the removal incision may all cause damage to the neurovascular structures of the involved appendage. The incisional approach is most fraught with risk for the complication of injury and poses the additional risk of damage to underlying structures. Incisional removal of hair tourniquets from the penis could damage the corpus callosum, corpus spongiosum, or urethra. The incisional approach on the digits may involve injury to the dorsal or palmar neurovascular bundles or flexor tendons when using the 3- or 9-o’clock incisions. Although the dorsal incision alternative should spare these digital structures, the extensor tendon or the tendon sheath may be damaged, with the latter potentially resulting in tenosynovitis.[9]

As with all procedures, if the skin is penetrated, either by the constricting band or an incision, bleeding and infection are known risks.

The use of commercial depilatory cream to remove a hair tourniquet may provoke local skin irritation or contact dermatitis.

Among the methods described, the simple unwrapping approach carries the least risk for iatrogenic complication.

Depending on the degree and duration of the constricted appendage, necrosis of distal structures may ensue.