Preserving dignity—and hair—in brain surgery | Rupa Juthani | TEDxEmory

0:01 [applause] >> Hi everyone. I am so incredibly honored to be here today and I'm excited to talk to you about the importance of compassion in medicine through the lens of hair sparing in neurosurgery. Now when you hear the words brain surgery, what image comes to mind? For most people who are not neurosurgeons, it's not a brain scan or a microscope. It's the image of a sick, frail patient.

0:31 A shaved head, a long scar, a white head wrap in an unresponsive patient. This visible flashing sign that says, "I am sick and it is serious." Now for decades, patients have been told that losing their hair is just a small price to pay for a life-saving brain operation. But as a neurosurgeon who has operated on countless patients with brain tumors and other life-threatening conditions, I challenged myself to ask, "Does it have to be a choice?"

1:06 I want to redefine successful surgery here to include one that preserves dignity, identity, and leverages the power of psychosocial healing. Now let me start with the story we all know. And bear in mind, I am fresh off of a week-long trip to Disney with my kids, so I am brainwashed, so to speak. In the classic fairy tale of Rapunzel, her strength and identity live in her hair. When it is cut, her magic is extinguished. The story is not subtle.

1:38 Her power and identity and selfhood, that is how Rapunzel identifies herself in the world. Now this is a fantastical tale, yes, but in my operating room, I have learned that these fantasies are actually pointing to something real. The reflection we see in the mirror tells the story and reality of who we are. This is a patient of mine returning to work soon after surgery feeling strong and powerful.

2:09 Now, I have the great privilege and responsibility of operating on this organ that identifies ourselves and defines our sense of self. Your memories, your language, your ability to move, to laugh, your ability to love and chase your dreams. And for a long time, neurosurgery has been defined by a fairly narrow scorecard. Did we remove the tumor? Stop the bleeding. Preserve movement. Restore vision.

2:41 Did we save function? These things all matter and they matter profoundly, but they only tell part of the story. Because after surgery, the patient looks in the mirror and their brain can either tell them, "I am sick." Or it can tell them, "I am whole and I am me." This is a patient of mine just days after a 12-hour brain surgery where we worked to remove a tumor while preserving the nerve that controls movement to the face.

3:16 In this surgery, physical appearance is one of the top priorities. Now, the pride in looking in the mirror with your family after that and smiling is absolutely priceless. Hair loss after brain surgery is not just for the individual, though. It broadcasts vulnerability and changes how other people treat you and how you treat yourself. A visible scar can turn even a small errand into a conversation you just did not want to have. Every glance in the mirror becomes a reminder of this challenging ordeal that you've been through. These are conscious and unconscious cues that tell your brain how you're doing.

3:57 And when patients look into the faces of all the people they love, they see reflected back all of their emotions. Gratitude, but sometimes pity, fear, and sadness. And instead, when they see joy that their loved one looks like themselves, that is more powerful than any pill or IV that we can give them. It makes the patient more likely to stand up, to walk around, to be independent, and get back to the activities of their daily living.

4:31 Because people don't then see a sick patient. They see a strong one. Now, I've met patients who are brave about their diagnosis, about the risks, and prepared for the recovery that comes afterwards. But invariably, the conversation shifts to how to prepare their family for what they will look like. Sometimes they joke and say, "I needed a haircut anyways." Or they ask if they should just shave their hair. I had a young mother who was worried her children would be afraid of her if half of her head was shaved.

5:03 They often apologize right afterwards, as though confessing that they care about their appearance is somehow vain and superficial in light of something as life-altering as brain surgery. Or even worse, sometimes they'll tell me to just do whatever makes it easier for me. A remarkable thought to think about my convenience when their comfort is the one that matters. Now, when patients apologize for wanting dignity, it tells us we are doing something wrong in delivering care as a society.

5:40 Because it is not superficial, and asking for dignity is not vain. I had a female patient who suffered from a severely recessed hairline, which would make the scar to remove a large brain tumor even more visible. Instead, I worked with a plastic surgery colleague to correct her hairline at the same time. So now not only would the scar be invisible, but we were correcting a lifetime insecurity. This had almost as much impact on her as removing the tumor and giving her her vision back. It is the difference between feeling like a person who had surgery and thrived and one who became defined by their illness.

6:22 Now even patients who say they don't really care about their hair are actually immensely grateful afterwards, maybe in ways that they never admitted to themselves. And it doesn't actually matter if they're balding or have short hair or long one. It's about coming out of surgery looking the same as you did going in. Now my practice has changed and evolved in the 8 years since I have been practicing since training. I always tried to shave as little hair as possible, but not always in emergencies and maybe with variable degrees of cleansing afterwards.

6:56 Early in my career, I had a young female patient about the same age as me at that time who had curly hair. I did a minimal shave to remove a brain tumor and I even washed the hair afterwards. But when she came back to my clinic, she said she suffered from so many tangles that her friend had to cut her hair because it was just too painful to brush it with a fresh incision. She came back to my clinic with her long locks now cropped short and sparse.

7:26 I had another patient who came back with a thick blood clot still attached to her incision that I had to remove painfully bit by bit. Now these cases devastated me even though the surgery had gone perfectly. And I became determined to do better. I started making my shave smaller and smaller until eventually I eliminated it entirely. And I advocated not only to get shampoo, but conditioner and combs available for all of my surgeries. People initially made fun of me and called it Salon Jutani.

8:00 But quickly, the OR staff became as invested in this process as I was. Because that is what patient care is all about. It's about finding ways to improve a patient's life in both big ways and small ones. I also from personal experience can tell you that wounds heal better when they're clean. The blood and debris from surgery can prevent critical oxygen flow to the incision. And cleaning it with sterile water and shampoo afterwards is a great way to avoid that.

8:33 As I became more experienced, I increasingly used hidden incisions and small dressings instead of head wraps. And I'm always looking for ways to make the patient care experience even more painless. But I am not just relying on my own experience here. There is peer-reviewed literature looking at the psychosocial impact of hair shaving. In a study on brain surgery, the authors found that a greater extent of hair shaving was associated with lower body image directly related to self-esteem.

9:05 So why then, might you ask, would a surgeon ever shave hair? Well, in training, we're taught that hair is a risk of infection. And even the most well-intentioned of surgeons really struggle to unlearn this. But the truth is hair can be cleansed and prepped in much the same way as skin. Albeit with a little extra time and care. Large reviews have actually failed to show any difference in infection rates or other complications with complete hair sparing. And even studies with implants, which carried the highest rates of infection, have shown that hair sparing doesn't actually increase the risk of infection.

9:48 So then, what arguments are left? People would say, "It adds time." But the average brain surgery is 3 to 5 hours, some upwards of 12 to 14 hours. So I ask you, does 5 to 15 minutes really meaningfully change the risk? Except in rare emergencies, the answer is no. So then we are left with one hard truth. That it is inconvenient and a nuisance for the surgeon.

10:21 But 15 minutes of a surgeon's time can translate into better healing and a lifetime of benefit for the patient. And the inconvenient truth is that even in trauma, if you just make it part of your practice, you can bestow the same dignity without compromising care. Now, if you are sensitive, please note the following slide does contain a real brain picture. In the case of one of the most deforming types of surgery we do, we sometimes emergently have to remove half the skull to relieve the pressure and save a patient's life. In these cases, patients are left with a severely concave head, sometimes for 6 to 12 weeks after surgery. Now, in almost all of these cases, because it's an emergency, surgeons justify shaving half of the head, making a deforming surgery even more devastating.

11:15 But even in traumas, I began doing a minimal hair shave right along the hairline to avoid the extra time of combing and prepping, while also preserving nearly all the hair. And with the most emergent of conditions, where we place a small hole called burr hole, and pass a thin tube to relieve pressure in the brain, often at the bedside due to emergency. I rejected the traditional practice of shaving a quarter of the head, and I instead made my incision no bigger than a centimeter.

11:47 And what happened? Did patients not get the care that they needed? No. What happened was that they and their loved ones thanked me for this small but meaningful dignity. Now, let me take you to an evolution happening in the field of neurosurgery. Minimally invasive cranial neurosurgery has expanded dramatically. Non-invasive and keyhole approaches using natural corridors such as through the nose, smaller openings, and more targeted ways to reach even the deepest of brain regions have largely replaced traditional open approaches.

12:23 In minimally invasive surgery, we ask ourselves, what is the least invasive way we can have the best outcome? Now, we know that these small approaches have advantages including a shorter length of stay and lower operative time in experienced hands. Now, I want to be clear, not every patient is a candidate for these procedures. Anatomy matters. Experience matters. Safety is always the foundation. But what I'm arguing for here is a broader definition of successful neurosurgery. One that takes into account the whole human and picks an approach that best suits the needs of that patient.

13:06 And this is where we challenge old ideas about healing. As surgeons, we're used to treating things as a mechanical problem. Fix the picture, send the patient home. But we are now realizing that healing is complicated, and it starts from the inside out. Stress, inflammation, lifestyle, stability, functioning in society, are all critical to a successful outcome. So, what does this end up looking like in real life?

13:37 It looks like a surgeon asking more questions during the planning. How can I help the patient recover as quickly and painlessly as possible? I think about how I can make my incision less conspicuous. Can I avoid shaving? And can I choose a closure that maximizes safety and healing? These are technical decisions, yes, but they are also acts of compassion. And I challenge you to think about compassion not as separate from surgical excellence, but rather as a critical and essential surgical skill.

14:16 And one that we're just not very good at teaching. Because without the human touch, we're really no different than a robot, and we are losing out on an immensely powerful tool. Now, we already accept the impact of mental health in many other areas of medicine. So, why would we treat something as fundamental as appearance and identity as irrelevant, especially when it's brain surgery, the organ that constructs our identity?

14:48 So, here is a cultural shift I want to invite. To patients and families, you do not have to apologize for caring about how you will look and recover after surgery. You are human, and you are protecting that which makes you feel human. And to surgeons and health care teams, it is time to stop dismissing appearance as superficial, and start using it as the powerful adjunct to physical healing that it actually is.

15:19 And yes, we need to stop hiding behind claims of safety as a cover for convenience. So, let's now return to fairy tales. Believing in Rapunzel's story is not magical thinking. It is aligning surgical care with evidence-based ways we know people actually heal. The most incredible invention of all time was the human brain. So, why don't we work with it instead of against it?

15:51 In modern neurosurgery, choosing minimally invasive and maximally effective approaches, with attention to how patients look and feel, allows patients to preserve their sense of dignity and sense of self. And when a patient can recognize themselves, their brain can shift from survival mode to recovery and healing. That is the kind of magic I believe in. Not fairy tale magic, human magic, the magic of compassion, of kindness, of empathy and thought, the true act of caring for another individual.

16:29 That is where science and compassion meet. Because the future of brain surgery is not only in how precisely we operate, it is in how completely we heal. And I challenge us all to change how we think about healing and to be uncompromising in our quest for compassion. Thank you so much for your time. I'm incredibly honored to be here and wouldn't be here if it weren't for my husband and children and my amazing parents and friends who are here to support me. Thank you.

17:02 >> [applause]