Hair Tourniquet Removal Technique

Updated: Mar 11, 2019
  • Author: David Muncy, DO; Chief Editor: Erik D Schraga, MD  more...
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Technique

Approach Considerations

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.

The blunt probe method. The blunt probe method.
This illustration shows removal of a penile tourni This illustration shows removal of a penile tourniquet using the blunt probe method.

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.

In this figure, the blade is in the 9-o'clock posi In this figure, the blade is in the 9-o'clock position. The dorsal alternative approach is also indicated.

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.

This cross-section of the finger illustrates the 3 This cross-section of the finger illustrates the 3- and 9-o'clock positions as well as the alternative dorsal approach for digital tourniquet removal.

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.

To avoid the deep structures, the incision must be To avoid the deep structures, the incision must be kept within the deep fascia of the penis. This figure illustrates the importance of the 4- and 8-o'clock positions. The dorsal neurovascular bundle is not compromised by these approaches.

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.

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Pearls

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.

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Complications

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.

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