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The Shave And Prep In Surgery

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I am writing this as a wet shaver and a general surgeon with an interest in history. Surgeons split off from barbers, the original shavers, to follow armies at war, thus learning the management of wounds.
As late as the Renaissance, surgeons were referred to as Mister, while the “ doctors” ministered as priests, never touching blood. It was only the drainage of an abscess by a French surgeon on a Royal’s Buttock, that elevated European surgeons to the title of Doctor. To this day, as a rejection of all things French, British surgeons are still referred to as Mister!

The very aspects of hair, that make it great material for shaving brushes (air space) is what makes hair a risk for a surgical patient. That water and heat retention occur means there are many small spaces for bacteria to hide in hair, so it’s got to go, (except in special cases). Bacteria counts correlate well to wound infection rates.
This means that shaving is healthful and prevents disease/complications.
In the mid 20th century double-edged blades, and cream from a small aerosol can were still used in preparation for surgery. Those razors loaded with med tech blades soon morphed into plastic replicas of double-edged razors with a single edge blade inserted in the plastic at each edge. Sometimes the shaves were field style or dry. Then plastic cheap razors infiltrated the hospitals from the emergency rooms up. Now a safety razor cannot be found in an American hospital.
In the late 1980’s a single journal article, poorly crafted, swung the tide toward electric razors. The research stated that a sharp edged shave the night before surgery caused more infections than an electric clipper at the time of surgery Sadly, they never compared the electric clipper to a shave at the time of surgery!
Since that time, hair removal in the operating room is by electric clipper, and, by the way wound infection rates have risen. Any wet shaver can explain it. The electric razor leaves stubble, which is residual hair, and hair contains hidden bacteria!
Face shaving for cosmesis (DFS/BBS), meant many people knew how to shave, so pre operative shaves were performed by skilled shavers. The proliferation of disposable and electric razors in the general population means fewer of the operating room staff today, knows how to wet-shave and that promotes continued use of the electric with increasing wound infection rates over the past 20 years.
Generally a small area of skin is shaved in the region of a planned incision. Since a man’s beard is far hairier than most body parts in most people, there is not much skill needed to perform a pre-operative shave. The need to do it properly however is reuniting barbers and surgeons after a centuries long estrangement!
Larry Isaacs, MD

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12 thoughts on “The Shave And Prep In Surgery”

  1. In my practice, the nurses and surgeons or residents shave depending on the institution.
    Please address the shaving of the groin area. This is a diffucult site to clip. Lots of different anatomy and creases, not to mention very delicate skin.
    Many tims the patient is shave from pubis to inner thigh bilateral.

  2. Great article! Never really thought about that kind of shaving. One thing the article doesn’t mention is that when you shave with a DE/Straight, you also remove a tiny layer of skin, and as we all know there is also a lot of bacteria on the skin as well, so you’re not only removing all that hair, but also the top layer of skin, and all the bacteria on it.
    Now, all they need is an alcohol aftershave (I suggest a bay rum) and the patient is looking good, smelling good, and ready for surgery! 🙂
    I wonder if surgery wings would be interested in hiring skilled wetshavers for pre-surgical shaves…?

    1. The pro electric clipper folks cite this as the reason shaving increases the infection rate, since skin is injured by the blade, and then incised by scalpel. Many things are operator dependent and I am sure my barber can deliver a close atraumatic shave, so there’s no reason a skilled OR nurse couldn’t also do it. They used to. The skin is prepared with appropriate antiseptic agents so there are virtually no bacteria on it at the time of incision.

  3. A single study may have started the trend towards clippers over razors for preoperative hair removal, but there have been multiple studies, including in laparotomies and bypass surgeries, showing increased infection rates when hair removal is performed with razors versus clippers. The issue is that the razor blades create cuts in the skin that reduce its protective barrier against infection, whereas the clippers should be less traumatic too the skin. The prospective, comparative trial of clippers versus shaving that you thought would be desirable has already been done, and was published in 1992 in the Annals of Thoracic Surgery. This study had almost 2000 patients undergoing bypass surgery, and they were randomized to manual shaving versus electric clippers. Infection rates were three times higher in the manual shaving group. So how you remove the hair is important. As a dermatologic surgeon, I perform surgeries on hair-bearing skin daily. Like most dermatologic surgeons, I never shave the skin before surgery. In areas of dense hair growth, we simply trim the hair with scissors. On rare occasion, for large scalp surgeries, we will use electric clippers. But for the most part, preservation of the epidermal barrier is more important than removal of hair. In a surgical incision, hair that remains external is unlikely to introduce organisms into a surgical wound, unless your surgery introduces bacteria-colonized hairs into the wound itself.

    1. Dear Doctor:
      For purposes of my continuing surgical education, could you provide me with those citations? I would like to review the articles. Thanks.

      1. I have reviewed the literature, and it supports your position. However as an observer, granted anecdotal, I have seen a consistent rise in surgical infections in many hospitals with multiple surgeons since the demise of the blade shave.
        (All wound infections are reviewed in hospital).
        I wonder how you would explain this observation over time. After all if the SCIP research and guidelines worked, the rates of wound infection should be lower. I do not believe this is so.

        1. Another intangible is the skill of operating room personnel. When I started operating the OR nurses were uniformly men, usually with military backgrounds, who themselves were skilled double edged wet shavers. Over 30 plus years the staffs have been progressively women, with much less shaving experience. The increasing number of surgical site infections (SSI) made SCIP programs necessary. In this case I chose to believe my lying eyes over 30 years of observation than any number of studies. BTW what is a dermatologic surgeon precisely?

  4. As a pro barber in the UK, I found this to be a great read!
    I would be interested to know if we, in the UK, still prep for surgery using electrical equipment rather than the much cleaner and smoother wetshave? I have an Anaesthetist as a customer – I must ask him……….

  5. Great history lesson. I always wondered if learning to shave with a DE and/or cut throat should be a mandatory learning module at med schools? It’s a great way to learn steadiness of hand, soft touch, precision, and manual dexterity (manipulating blade angle, etc.). Not to mention, I’m not sure how comfortable I feel with someone who isn’t confident enough to take a single blade to their own face cutting me open…

      1. I wouldn’t preclude the ladies, they could apply single blade to the legs… As a cyclist, I do shave my legs, and most of the time I do it with my safety razor (unless in a rush, I still have a mach 3), so it’s still a valid field of play for learning the skills…

    1. It would beunlikely that the surgeon would bedoing the shaving him/herself. It is more likely that a nurse or at best a resident would be responsible for any shaving.

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