A: We remove every other staple at 10 days post-op.

The remaining staples are generally removed at 20 days post-op. This varies based upon the patients scalp laxity and the width of the donor strip.

A: Staples, because they conserve more hair.

A: I have been using staples in almost all of our follicular unit hair transplants since the beginning of 2006. When we published the Sutures vs. Staples study in 2001, some doctors were still not convinced. Because of this I continued to look at the issue, not in a bilaterally controlled experiment, but just looking at my cases done with the 5-0 Monocryl and those with staples that I continued to use from time to time. After doing hundreds of additional cases, I was still convinced that the overall the suture line looked better with the 5-0 Monocryl sutures than with the staples.

However, it occurred to me that perhaps we were looking at the wrong thing. I began to think that perhaps we should be looking a hair preservation, rather than cosmesis alone.

The problem with the appearance of stapled closures is that it results in a very well demarcated, geometric line. Monocryl sutures, on the other hand, results in a much softer, more smudgy line – the characteristic that made it look better in the study.

This effect is produced by two things. The first is that the very fine 5-0 Monocryl sutures placed very close to the wound edges allow perfect wound edge approximation. However, the running suture actually destroys some hair as it makes its spiral course through the skin, destroying some hair and producing this smudgy appearance. We had felt that suturing very close to the would edge, using fine suture caliber 5-0 Monocryl, advancing the running stitch on the surface rather than in the SC space, and the mechanism of action of Monocryl absorption (via hydrolysis rather than by an inflammatory reaction) would all mitigate against any hair loss – but there was still some. It seemed that although the overall look was better with sutures, it might be at the expense of some hair loss.

To test this, I began to look at the hair yields in the donor strips of second hair transplant procedures where the new harvest completely encompassed the old scar. It seemed, at least anecdotally, that the strip containing an old incision that had been sutured closed contained slightly less hair than that from one that was stapled closed, even if the former looked better. Although I did not do a rigorous study, this was my “sense.”

In addition, I realized that staples could be left in the scalp for 3 weeks after a hair transplant without causing excessive inflammation (patient discomfort not withstanding) and this gave me more flexibility in using staples in patients with slightly tight scalps without having to rely on subcutaneous sutures. I began to take out alternate staples at 7 to 10 days and the remaining staples at 18-21 days post-op.

With the issue of hair preservation, rather than just the cosmetic benefit, as the main goal and with the added flexibility of being able to leave in alternate staples for up to 3 weeks, I started using staples routinely in almost all of our hair transplants.

A: Sutures are great on non-hair bearing skin and allow perfect approximation of the wound edges, but on the scalp they can cause damage to hair follicles below the skin’s surface. The reason is that a running (continuous) suture traps hair follicles and when the skin swells (as it normally does after hair transplants) the trapped follicles can strangulate and die.

Since staples are placed individually – about ½ cm apart – they don’t strangle the tissue. This allows the blood supply to flow freely to the wound edge permitting the blood’s oxygen to reach the follicles in the stapled area and minimizing the risk of any hair loss. The unimpeded blood flow also facilitates wound healing and can sometimes result in a finer scar, particularly in a tight scalp.

For these reasons, we now use staples in most of our hair transplants.

A: Staples are used for two main reasons.

The first is that being made of stainless steel; they don’t react with the skin and, therefore, cause little inflammation.

The second is that, unlike sutures which are used with a continuous spiral stitch, each staple is separate and this causes minimal interruption to the blood supply. The combination of little inflammation and minimal interference with the blood flow facilitates healing and minimizes damage to hair follicles.

Although sutures are generally more comfortable after the hair transplant, the doctors who choose to use staples do so because they are the least injurious to the hair in the donor area.