Q: I’ve heard that healing after a hair transplant requires stitches. How long will they stay in? — S.R., Cresskill, N.J.
A: In a Follicular Unit Transplant (FUT), the surgeon removes a thin strip of scalp from the patient’s donor area that supplies the follicular unit grafts for the hair transplant. After the strip is removed we use either sutures (stitches) or staples to close the wound.
We now close most wounds in the donor area with staples, rather than sutures, because we have found that staples cause less injury to the remaining hair follicles compared to sutures; therefore, more hair will be available for future hair restoration sessions. For more about sutures vs. staples, see Why We Changed from Sutures to Staples in FUT Hair Transplants.
Q: I hear you leave staples in sometimes up to three weeks after a hair transplant. Why do you leave staples in that long? – M.C., Boca Raton, FL
A: My reason for leaving some staples in longer is that the tensile strength of the wound continues to increase (significantly) during the first three week period after surgery — actually, it will continue to gain strength for up to one year post-op. To give the wound the best chance to heal, on average, I take out alternating staples at 10 days and the remaining staples at 20 days.
Although patients do complain that they are uncomfortable, removing half at 10 days offers enough relief for those who are bothered by them. The advantage of leaving the staples in longer is that the wound heals with a finer scar. And for patients who are very active, it allows them to resume activities more quickly. For each patient, I modify the time left in by surgery, length of incision, tension, and also the patient’s needs and ability to have them removed.
In contrast to sutures, staples do not leave any track marks and do not need to be removed as quickly. Sutures can also damage the surrounding hair by strangulating the follicles. Staples are interrupted (placed individually), so they don’t cause damage to the follicles adjacent to the wound edge.
Read more details about our use of surgical staples on the Donor Area page.
Q: How soon after the hair transplant procedure do I have to get them out? — T.J., Fort Lee, NJ
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.
Q: Do you currently prefer sutures or staples to close the donor area? — O.C., Dallas, TX
A: Staples, because they conserve more hair.
Q: I recall that you wrote an article about Monocryl for the donor closure in hair transplants. Why are you now using staples? — R.S., Park Slope, NY
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, 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 at 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.
Q: Can you please comment on the use of sutures verses staples in hair restoration procedures? — S.S., Prospect Park, NY
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.
Q: I have heard that staples are uncomfortable after the hair transplant, why do doctors use them? — B.E., Great Falls, V.A.
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.
Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples? — D.B. Fort Lauderdale, Florida
A: Yes. Although the staples that we use to close the donor area after hair transplant or restoration procedures are made of stainless steel, they are too small to be picked up by metal detectors.
I generally prefer staples, as they are superior to sutures in preserving donor hair.
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