Many surgeons, including Dow Stough, Griffin, Arnold, Mangubat, and Seager prefer staples for skin closure. Most practitioners, however, continue to prefer sutures. There is no doubt that staple closure is faster, that staples cause very little tissue reaction and in most instances result in comparable scars to that produced by suturing, but the degree of patient discomfort continues to be debated. In our experience, sutures are less uncomfortable post-operatively, and at the time of suture or staple removal. Mangubat has studied staples vs. sutures on contralateral sides of the donor area and had no complaints regarding discomfort from the staples on a post-operative questionnaire he had his patients complete at their follow-up visits. Interestingly, his patients did say the staples were more uncomfortable, but they "accepted" them because he believes, and tells them that "the results are worth it". (He also does not undermine his wound edges; instead placing towel clamps on the edges to produce mechanical creep, and removes them as he comes to them with the advancing staples). The staples are removed in 10 to 14 days. Cole and Unger have both tried similar studies but discontinued them because there was so much patient complaint about the stapled side. Shiell has twice performed a 10-patient study comparing 4-0 Nylon to staples in closing 8 mm wide donor wounds on contralateral sides. He found no difference in the cosmetic results between staples and sutures, but almost all his patients claimed the staples were much more painful to remove at seven days. Bernstein performed a 22 patient study where he compared staples to Monocryl.⁸⁰ Bernstein’s study found that 14 of 22 patients preferred the Monocryl side, 1 patient preferred the staple side, and 7 of 22 had no preference. The most common complaints with the staples were inconvience, postoperative discomfort, and occasional pain associated with their removal. The average scar width on the staples side measured 1.78 mm compared to 1.42 mm on the suture side. It is hard to explain this difference in patient acceptance of staples except in the context of the power of suggestion by the surgeon.

The need for galeal, subcutaneous, or dermal sutures in donor wound closure is another area of controversy. Dow Stough, Shiell, Bernstein, Unger, and most hair restoration surgeons, in general, find no benefit from using double layer closures.^, Bernstein believes that in situations where there is no undue tension there is no need for buried sutures.⁸⁰ Scars that are wider than 1 mm wide occur, for example, in less than 2% of Unger’s patients; the majority has scars that are 0.2 – 0.5 mm wide or less and are difficult to find unless one knows where to look. Thus, two-layered closures, at least in wounds that close with minimal or no tension, appears to be superfluous unless there is prior history of unexpectedly wide scars without tension. In addition, buried sutures may cause a tissue reaction resembling an infection, that frightens patients, is annoying to treat and usually produces worse scars than normal. Such suture reactions are uncommon, and generally occur only at the point of a buried knot, but if they are unnecessary in the first place, it seems unwise to add another possible complication to the surgery. At three months post-operative check-ups, Shiell found there was rarely any difference between the patients who were closed in two-layers and those who were closed in one-layer. He does, however, employ a two-layer closure if closing tension is greater than average and for patients with existing wide scars. He believes that wide donor scars are more a result of "genetic predispositions" than tight closures and occur more frequently in individuals of Mediterranean and African origin. Cole agrees there is a genetic predisposition to wide donor scars. He finds they are more common in individuals with dark pigmented, coarse, often wavy hair. He also generally finds that wide scars in those genetically predisposed to them tend to recur, regardless of the method of closure (staples, two-layer, one-layer, or alteration in suture material), and are widest when incisions are made in the inferior occipital area and, least common, superior to the ears. Unger and Cole find that wide scars, paradoxically, are most likely to occur in those individuals with extremely lax scalps. Cole recommends that you consider evaluating the patient for hyper-extensibility of the joints, when the scalp is significantly looser than average and the patient has dark, coarse hair. Unger postulates that maturation of the scar is somehow delayed in such individuals and, therefore, leaves his sutures in place for a minimum of 14 days instead of his usual 7 to 10 days. This frequently, but not always, leads to more usual scar widths. In addition, he sometimes employs galeal sutures as well as superficial ones in these patients.

Beehner, Limmer, and Parsley use interrupted deep Vicryl sutures in their two- layer closure of the donor area. Beehner’s technique for inserting deep sutures is to place interrupted 3-0 Vicryl sutures in the tough fibrous portion of the dermis, rather than the galea.⁷⁸ For his longer incisions he uses five to six sutures, and for the shorter ones (7-9 cm) he employs three sutures. He found that 2-0 Vicryl resulted in a considerably greater frequency of suture reactions than 3-0. He also decreased the number of knots from three to two for each interrupted suture. He inserts the needle in the subcutaneous fat just below the bulbs. The needle is passed to the upper dermis and exits just below the epidermis. He then enters the opposite margin just below the epidermis and passes the needle into the subcutaneous fat. The knot is tied in the superficial subcutaneous fat. He cuts the suture flush with the skin, and closes with a simple running 3-0 Prolene suture that is removed six to seven days later. The resulting donor scar is rarely greater than 1–1.5 mm and he says he rarely excises the old scars in subsequent procedures because of this.

Limmer and Parsley have a different method of using interrupted 3-0 Vicryl sutures.^76,77 They first place 4-0 catgut vertical mattress sutures every 3 cm while using a towel clamp to approximate the skin edges. Between each of these sutures they tie a 3-0 Vicryl suture similar to Beehner, with the knot in the subcutaneous tissue or deep dermis.(Fig. 16) Parsley also does not feel the subcutaneous tissue is of value for placing donor area sutures. He, too, prefers the holding strength of the deep reticular dermis. Moreover, he is careful to keep the Vicryl at 1 to 2 mm below the epidermis to minimize the possibility that the suture will "spit". He closes the epidermis with a 4-0 plain catgut suture in a running lock stitch.⁷⁶* The suture dissolves within 10 to 14 days.

Cole also believes that subcutaneous sutures help to improve the width of the donor scar. His two-layer technique is completely different than those of Beehner, Limmer, and Parsley. Cole uses either 0 Vicryl or 4.0 monocryl in the subcutaneous plane just deep to the papillae.(Fig. 17) Cole believes that some patients will produce wider scars regardless of technique and even his two-layer closure is minimally effective. To eliminate the suture reaction, the initial knot is tied on the surface 1 cm lateral to the incision margin. The needle is then passed into the subcutaneous tissue from the surface of the skin, where it remains until he reaches the other end of the wound ;margin or another desired point along the suture line. He has never seen "spitting" when this technique is employed. Cole prefers to bury the first knot of his two layer closure, however due to the amount of tension is greater on it. (Fig. 18) The second knot is buried or passed outside the wound. Cole feels that "spitting" occurs in the minority of patients and he has not observed "spitting" with monocyrl suture.

As for what type of suture is best, Cole generally closes his wounds that are 6 mm or less in width with a running 4-0 Supramid suture. He leaves these sutures in place for seven days. With wider wounds he uses a 3-0 Nylon or Supramid suture, or 2-0 chromic suture. He may leave these sutures in place for 12 to 14 days. Placing the suture superficially in the upper dermis least impairs blood supply to the wound, but may result in a greater incidence of post-operative bleeding and wider scars in the subcutaneous fat because of the open space that must fill with scar tissue. Cole, therefore, runs his sutures into the subcutaneous fat deep to the bulbs. Unger, after trying numerous types of suturing techniques and sutures, has also settled on a deep but single-layer closure and usually uses 2-0 Supramid on a CL-20 reverse cutting needle. He would use a 3-0 or 4-0 Supramid suture, similar to Cole, but the length of the suture and size needle he prefers is only available with 2-0 Supramid.

Despite the foregoing, because a significant number of Cole’s patients come from a long distance, he often closes with an absorbable suture, 2-0 Chromic, 4-0 Monocryl or a combination of 4-0 Chromic with a buried suture. This has the benefit of insuring the suture will not require removal. Many times, a local physician, friend, family member, or spouse removes the sutures of the visiting patient. Even local physicians are prone to miss a running suture within the long hair of the donor region. Using an absorbable suture insures the missed suture will eventually dissolve without consequence. One must choose a suture that will last long enough to insure healing without lasting so long that it is annoying to the patient. The disadvantages of most absorbable sutures are the length of time it takes for them to dissolve and their greater irritability or tissue reactivity. Patients look forward to the day their sutures are removed. After the seventh day, the donor region becomes increasingly pruritic, yet absorbable sutures are often still present for 21 days. This results in an extra 11 to 14 days (or more) of discomfort, over that experienced with non-absorbable sutures that are usually removed at 7 to 10 days. Despite this, Cole cannot think of a single patient who did not want the absorbable sutures for subsequent procedures. Table #9 -- lists a variety of absorbable sutures and the time required for them to dissolve.

Shiell routinely closes with a 4-0 monofilament nylon using a continuous interlocking "blanket" stitch for the donor site.* He removes the sutures in 7 to 10 days.* His loops are 8 mm apart and 4 mm deep. For those patients who come from other cities, he prefers 3-0 plain catgut.⁷⁹*

Bernstein uses 4-0 and 5-0 Monocryl sutures. He states that Monocryl Monocryl is stronger and produces less tissue reaction than chromic or Vicryl sutures. He also advocates a simple running stitch, keeping the sutures a maximum of 1.5 mm from the wound edge with approximately 0.5 cm between each loop. He advances the suture on the surface rather than below the skin* (Fig.#). Email 6/13/00. Cole warns that the knot unravels more easily with Monocryl so the surgeon must insure a proper, firm tie. In addition, since Monocryl maintains only 20 to 30% of its tensile strength at two weeks, Monocryl may not be the ideal buried absorbable suture.

As can be seen from the preceding, different practitioners have found different techniques for donor wound closure to be optimal in their hands. The novice may be left confused but should in some respects be reassured by these differences in opinion. As is commonly the case, there is no single "best way". There are many factors that must be considered when one is deciding on how to "best" close a wound. These include how wide a strip is typically being taken, where its greatest width is, if there are other scars present inferior and/or superior to the current donor site and whether the tumescent fluid - if any - contains epinephrine or not. Each of these factors, and probably others, will have an effect on the optimal method of closure. For example, with multiple donor area scars, and wider typical strips and therefore greater wound closing tensions, it may be more advantageous to use a double-layer closure and/or superficial interrupted sutures or staples. Unger’s usual two relatively narrow, usually contralateral donor sites (see below), are easily closed with single-layer sutures. In addition, there is, at most, only one scar superior or inferior to any donor area no matter how many sessions have been carried out. The result is the routine production of excellent scars and minimal discomfort. He has learned to take less, rather than more, from any area, and to close with minimal tension. Over the years his patients’ problems have only rarely been in the recipient area – most commonly they have occurred in the donor area when he attempted to take just "a little more" tissue in order to produce more grafts for an anxious patient. For out-of-town patients, he may sometimes use 2-0 to 4-0 Vicryl rapide instead of Supramid, but generally prefers not to do that because, as noted earlier, all "dissolving" sutures cause more irritation than non-dissolving ones. Frequently, either he or the patient knows someone competent to remove them, who practices within a reasonable distance from where they live. These sutures are also used for the galea, on those rare occasions when double-layer closure is deemed advantageous because of unexpected closing tension, or a past history of wider than usual scars, despite no closing tension.