While considered generally safe, local anesthetic agents used in hair transplant surgery can be toxic and extremity dangerous if administered inappropriately. Before considering going under the knife, confirm that all anesthesia is being administered by a licensed and experienced practitioner and that appropriate and legal monitoring will be in place during the entire surgery.

Daniel Danyo, MD: You know when I started in my training I was in general surgery and a resident who I really respected came up and said, any decision, any act that you do, you better be able to deal with the consequences. So, unless you have total supervision, and these people that are doing these injections that are non-physicians need to stop immediately. 

First of all, they can do an intravascular injection, and who knows what kind of rate or speed or actually dosage that they're injecting, and you get an intravenous bolus of lidocaine and possibly mixed with epinephrin you could have a cardiac event. You could have a stroke. You could have a seizure and possible death. 

The other thing is if they're doing it and there's no doctor around, who's going to resuscitate the patient? Who's going to give the proper medication treatment, let alone calling 911? But I mean, there's got to be something to prevent a further-

Spencer Kobren:  In some cases you have a matter of seconds to recognize things.

Daniel Danyo, MD: Yes.

Spencer Kobren: Now there's certain things, and again, I always have to preface this by saying that I'm not a physician but just based on being around this for basically all of my adult life. I can't believe how long I've been doing this but I started ... I got into this industry as young man and I've seen it all. I know where all the bodies are buried, no pun intended, and I know the drug addicts in the fields, the guys who have been institutionalized for mental disorders, the technicians who have been arrested for methamphetamine, everything that goes on in this field. I know what's happening.

Daniel Danyo, MD: Sure.

Spencer Kobren:  It scares the shit out of me, and that's one reason why, not that I wouldn't trust you or trust guys in the IHRS and their teams if I ever decide to transplant the back, which at this stage in my life I'm going to be 53 it's like, I'm fine with painting it for now. I'd rather save it for the front if I ever need it. 

Daniel Danyo, MD: Sure.

Spencer Kobren: But I want consumers and they are consumers because you guys, not you because this hasn't been your lifelong practice. 

Daniel Danyo, MD: Sure.

Spencer Kobren: You've been doing this for what? How many years now?

Daniel Danyo, MD: Since 2012 but I come from a pain management background.

Spencer Kobren: Right, but you're still ... Listen, you have more than enough cases when you apply to the IHRS, you've learned how to do it correctly and you're doing the entire procedure yourself, which is very, very, rare. And that's why I like talking to you so much. Coming from a pain management background, you also have the unique perspective on how easy it is to fuck somebody up.

Daniel Danyo, MD: Yeah.

Spencer Kobren: You know?

Daniel Danyo, MD: Well, let's go through some numbers here.

Spencer Kobren: Yeah.

Daniel Danyo, MD: So, the maximal dose is really based on body weight. So some higher, some lower, some people, to be totally conservative, say it's only 3.5 mg per kg. Some people say it's 5.5 or 6 mg per kg, but let's just say 5 mg per kg. I mean, 100 kg person, I don't know what the conversion would be, it would be a little over 200 lbs. So, most people are averaging, what? 175, that I see, I would imagine, or 180. So, we're talking about give or take 500 mg for that patient.

Now, when you add epinephrin, that number can go up, but when you take in all the other variables as far as their liver function, kidney function, everything else. It's 5 mg per kg, around 500 mg per day, with or without epinephrin. 

So, if you take a 20 CC bottle of 2% lidocaine, do you know how many mg that is? That's 400 mg. 

Spencer Kobren:  Sure.

Daniel Danyo, MD: And a lot of people think, oh, it's 2%. I'm gonna get great anesthesia control and I'm going to use that for the case and they're not gonna feel anything. Well, it's kinda like throwing gasoline on a fire instead of kerosine. 

Spencer Kobren: Well, it's like if I walk in, someone my size walks in, which, say you're in the 200 lbs range, or whatever. That would be too much for me. 

Daniel Danyo, MD: Yes. So, that would be 50 CC bottle of 1% lidocaine is 500 mg. I actually use .5% lidocaine. So a 50 CC bottle is 250 mg. 

Spencer Kobren: Now, I don't mean to cut you off, but what technician, even PAs, who are doing this and they are doing it legally, which is great, but who is telling this to the patient? Is the patient walking in with a list of information saying, okay, here, these are my stats. I'm 176 lbs, and according to these numbers, this is the amount of lidocaine that I feel safe having you guys administer. Can you try this first before we move any further? Now, that sounds silly, but I think we are, now, at a point in the field where patients need to be armed with this information and physicians and practitioners need to be able to answer them reasonably, and if they're not getting a reasonable response and people are just saying, well, we know what we're doing. You gotta walk the fuck out, because you may end up never walking anywhere again.