Beyond Staples -- New Sutures in Hair Restoration Surgery
For a number of years, hair transplant surgeons have used either metal staples or
, more commonly, a running suture of Surgilene (or Nylon) to close the donor wound. However, neither type of closure was completely satisfactory.
Metal staples were uncomfortable and disliked by many patients and they often left a fine, but very distinct line in the donor area. On the other hand, Surgilene sutures (made of a non-absorbable, synthetic, mono-filament) were more difficult to remove. More importantly, when there was any wound tension, or if there was significant post-op edema, the running suture could strangulate follicles and result is localized hair loss around the suture line.
To minimize any potential loss of the hair that was incorporated within the running suture, hair restoration surgeons began to place the sutures closer to the wound edge. Although this minimized the amount of trapped hair, it also made the sutures even more difficult to remove, as they became buried within days after the procedure.
In an effort to produce the best and most comfortable results for the patients, hair transplant surgeons have tried using various absorbable sutures, such as Chromic and Vicryl. Unfortunately, these were also not perfect solutions, producing too much tissue inflammation. The fact that they did not need to be removed did not offset the increased risk of follicular damage from the inflammation.
A New Suture
At the American Academy of Dermatology Annual Meeting in 1997, Johnson and Johnson introduced a new absorbable suture called Monocryl. The suture, made of Poliglecaprone 25, a synthetic, monofilament suture was touted as being easy to tie, very strong and preserving most of its tensile strength for up to three weeks post-op. Most importantly, it was broken down by hydrolysis rather than needing an active inflammatory response of the body to degrade the suture. This seemed to be the answer to the problem.
Hair restoration centers started using 3-0 Monocryl in a running stitch, placing it relatively close to the wound edge. Doctors quickly learned that 4-0 and even 5-0 was sufficiently strong to hold the entire wound together. With the finer sutures, hair transplant surgeons could place the stitches as close to the wound edge as 1.5 mm and still obtain a secure closure.
One of the tricks doctors learned was that advancing the suture on the surface rather than under skin (as surgeons traditionally did) had two advantages. It minimized the amount of suture that crisscrossed the follicles under the skin and allowed the clipped hair at the edge of the wound (that the suture did cross over on the surface) to keep the sutures from becoming buried too quickly -- if at all. This new suture and suturing technique soon became the closure method of choice.
The Study
To test the usefulness of this new technique, hair transplant surgeons conducted a bilateral controlled study comparing staples to the new Monocryl sutures. Although 4-0 sutures were used in the study, the research also used the finer 5-0 as the work-horse diameter, as this allowed the most precise control of the wound edges and the least tissue reactivity.
In the study, hair transplant doctors made objective measurements on the dimensions of the resulting donor scars and took subjective responses from the patients in the study. The two groups were evaluated with regard to healing, post-operative discomfort, resultant surgical scar, and closure material preference.
The average scar width on the staples side measured 1.78mm compared to a 1.42 mm on the sutures side. Fourteen of the 22 patients in the study preferred Monocryl for future procedures; one preferred staples and 7 had no preference. Of those that preferred sutures, post-operative discomfort from the staples and the inconvenience and occasional pain associated with their removal was responsible for their decision.
Based on this study, many hair transplant surgeons now use Monocryl sutures for the majority of donor incision closures. However, some cases occasionally require the use of staples in select patients, particularly in those with very high hair density and loose scalps.
Beyond Staples -- New Sutures in Hair Restoration Surgery
By: Robert M. Bernstein, MD, F.A.A.D.
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