In Follicular Unit Transplantation (FUT) a thin strip of hair is taken from the back and/or sides of the scalp. This is called the "donor strip" and the individual hair follicles that are used in the hair transplant are harvested from it. Once the donor strip is removed, the area where the strip was taken from is sewn closed.

While the scar from the incision is usually undetectable, due to the density of the hair where the strip is taken and the skill of the hair transplant surgeon, it is still important to provide the best possible closure -- both for aesthetic purposes and for the comfort of the patient. In the history of hair restoration procedures, this incision has typically been closed by either metal staples or a nylon suture. Although both are effective, each present specific disadvantages. Metal staples can be uncomfortable while nylon sutures are difficult to remove and can strangulate follicles and result is localized hair loss around the suture line.

In 1997, hair transplant surgeons were presented with an alternative: a relatively new absorbable suture called Monocryl. This suture is a synthetic, monofilament suture that is strong and easy to work with. Additionally, Monocryl is broken down by hydrolysis (other sutures require an active inflammatory response from the body).

One of the things many hair restoration centers like about Monocryl is that its tensile strength lasts about three weeks. Many surgeons feel that this, in conjunction with better control over wound edge apposition, accounts for the noticeably finer scar left by Monocryl sutures.

New techniques with staples have also produced more favorable results. Although staples are generally removed at 7 to 10 days, they might be left in longer, or at least some might be left in longer, particularly when the wound edges are closed under tension. With this in mind, for patients with all but the loosest scalps, many hair restoration centers remove alternating staples at 10 days and then the remainder at 18 to 20 days. At other times, 2 of every 3 staples are removed at the 10 day mark and the remaining 1/3rd at 18-20 days. This routine seems to have two advantages. First, leaving in staples for a longer period of time seemed to result in a finer scar and second, hair restoration surgeons feel more comfortable allowing active patients to resume physical activities sooner after hair transplant surgery.

Of course, in these cases, patients have the inconvenience of having the staples in longer and need to return to the hair restoration center office twice for their removal.

Although there is data showing that Monocryl sutures produce a slightly finer donor scar than staples -- on average 0.34 mm -- the look of the sutured closure is even harder to detect than would be predicted by this number alone. When one looks at a sutured incision and compares it to a stapled closure, one notes a "smudgier," softer and less defined line. In contrast, the stapled closure is more defined and often more easily identified through hair.

The paradox is that the smudgy look of the sutured closure is due to the fact that a running synthetic suture actually destroys tiny bits of hair along its path. Thus, the very thing that makes the sutured incision look more natural -- focal hair loss along the suture line -- was the very problem the patient and hair restoration surgeon are trying to address: hair loss. In other words, although the actual suture line produced by the synthetic closure is fine, there is some spotty hair loss from the suture making this line less distinct, but also causing a net loss of hair (albeit small). In contrast, the slightly wider scar of the staples represents a small amount of stretch (due to wound edges that are not as well apposed during the closure) rather than from the destruction of hair follicles.

New advance in wound closure continue to surface, including the Trichophytic Closure. Although initially used with sutures, the Trichophytic Closure allows stapled closures to heal with a less detectable scar as well. Because it is slightly more difficult to control the wound edges with staples, in contrast to sutures, some hair restoration centers have been experimenting with trimming both the upper and lower edges -- but removing less tissue at each edge than if only one edge were trimmed. Regardless of the specific technique, the Trychophytic closure is one more argument in favor of returning to stapled closures.

Many patients, who have had both stapled closures and absorbable Monocryl sutures, have been adamant in requesting the sutures again, due to the convenience and comfort they provide. However, many hair transplant surgeons feel that the potential to conserve donor hair outweighs any discomfort during the healing process and makes using staples worthwhile. After all, the ultimate goal of any hair restoration procedure starts with conservation.