To know the difference between single and double-layer wound closure.
The study was conducted in ten patients undergoing first session of hair restoration surgery by ‘strip method’ under local anaesthesia. Informed consent was obtained from all the patients. The length and width of the strip were marked pre-operatively. Three points were marked, one in the midline ‘O’ and one on either side, ‘A’&‘B’ at 8 cm from ‘O’. After removing the strip, five deep, interrupted, absorbable sutures were applied on left half but not on the right half. Lower edge trichophytic closure was performed with no undermining of the skin edges. A single continuous non-absorbable sutures was used to close the skin. The stitches were removed on the 10th postoperative day. The patients were assessed at 9 months interval postoperatively.
The mean age of the patients was 33.8 years. The average width of the strip removed was 15.1 mm. The average width of the scar on single-layer closure was 1.57 mm and 1.58 mm on the double-layer closure. The mobility of the scar was 7.9 mm on single-layer closure and 6.2 mm on double-layer closure. There was no statistical significance in the scar size and mobility of single-layer vs double-layer closure. The time of surgery was more in double-layer closure and the extra cost of the suture material.
There was no difference in scar quality. The extra time and money was saved in single-layer closure. The mobility of the scar was also found to be better in single-layer closure.
A surgical incision causes a scar which can lead to functional, cosmetic and psychologic problems. Scar tissue can be distinguished from normal skin by an abnormal colour, different thickness, decreased pliability, contraction or expansion of its surface area [
The following study was conducted to know the difference between single and double-layer closure.
The study was conducted in ten patients undergoing first session of hair restoration surgery by ‘strip method’. The procedures were carried out under local anaesthesia. All the patients were thoroughly explained about the procedure and informed consent was obtained. The length and width of the strip were marked pre-operatively according to the plan. Tumescent anaesthesia was used.
Three points were marked. The centre point (o) was marked in the midline. Two points (A and B) were marked on either side from point ‘O’ at 8 cm (
The mean age of the patients was 33.8 years (range, 28–46). The baldness pattern varied from type III to VII Norwood-Hamilton scale. The average width of the strip removed was 15.1 mm (range, 13–19 mm). The average width of the scar on single-layer closure was 1.57 mm and 1.58 mm on the double-layer closure (
Scar is an important sequelae of a hair transplant procedure. The scar maturation may take minimum of 6 months. The width of the scar is directly proportionate to the width of the strip removed and tension of the wound margins. The final scar is dependent on the pull exerted by the margins which may also be increased with muscular pull. As the donor scar is in the direction of the pull of scalp muscles, the ultimate scar is believed to stretch postoperatively. There are multiple factors which predict the final outcome. The final scar is dependent on various factors which include like the location of scar, the amount of width of scalp removed, the tension on wound margins etc. There have been controversy over the effectiveness of single-layer vs. double-layer closure of the donor strip in hair restoration surgery. There are certain pros and cons of each closure technique. The double-layer closure reduces the tension on the wound margins and decreases the dead space. It can result in buried suture material and can cause hair follicles damage. The one-layer closure has high possibility of ‘stitch marks’. If wider resection (more than 1.2 cm) is done, the scar may stretch due to elastic characteristics of the scalp. The location of the scar is very important. Any scar below the level of external occipital protuberance & superior nuchal line, is bound to stretch due to the muscular movements of neck muscles. Moreover, the anatomy above and below the level of external occipital protuberance and superior nuchal line is different [
The study by Mubashir et al. [
In the current study, there was no significant difference in scar width in two techniques. However a few observations were noted which could add to the evidence-based medicine, i.e., the mobility of the scar. The scar in double-layer closure side had about 20% lesser mobility as compared to the single-layer closure side. The other study by Israr and Stassen [
The main aim of double-layer closure is to decrease the scar. It is thought that the deeper stitches hold the scar long enough till the forces from sides start pulling the scar, resulting in stretch. The normal wound healing has three main stages, inflammatory, proliferative and remodeling [
The final quality of scar is dependent on the amount of width of the strip which is removed during the surgery. Thus preoperative scalp mobility is very important point. There are various methods of assessing the scalp mobility but the Mayer’s method is commonly used in which the compressibility is checked in horizontal direction. The method has a limitation as the donor wound closure is performed in vertical direction [
The duration in single-layer vs double-layer closure was not noted in the current study but Adeolu et al. [
There is no difference in quality of scar in single layer vs. double-layer closure. However, double-layer closure increased the overall cost and surgery time.
No potential conflict of interest relevant to this article was reported.
Patients provided written consent for the use of their images.
Surgical protocol.
Trichophytic wound closure.
Comparison of scars by single-layer vs. double-layer closure.
Patients’ data
Case no. | Age (year) | Type | Width of strip (mm) | Scar width (mm) |
Mobility (mm) |
Time taken in closure (second) |
||||
---|---|---|---|---|---|---|---|---|---|---|
1-layer | 2-layer | 1-layer | 2-layer | 1-layer | 2-layer |
|||||
Deep | Skin | |||||||||
1 | 29 | III | 19 | 1.9 | 2.0 | 5 | 4 | 205 | 45 | 200 |
2 | 31 | IV | 18 | 1.6 | 1.5 | 5 | 3 | 220 | 51 | 225 |
3 | 32 | IV | 15 | 1.3 | 1.3 | 4 | 4 | 220 | 59 | 215 |
4 | 34 | V | 14 | 1.4 | 1.3 | 8 | 6 | 230 | 64 | 232 |
5 | 39 | III | 13 | 1.0 | 1.0 | 13 | 9 | 232 | 62 | 234 |
6 | 30 | IV | 14 | 1.1 | 1.2 | 12 | 11 | 239 | 54 | 229 |
7 | 28 | III | 16 | 1.8 | 1.6 | 10 | 9 | 240 | 45 | 229 |
8 | 46 | VII | 15 | 1.6 | 1.7 | 7 | 5 | 224 | 43 | 230 |
9 | 35 | V | 13 | 1.9 | 1.8 | 8 | 6 | 215 | 54 | 229 |
10 | 34 | V | 14 | 2.1 | 2.4 | 7 | 5 | 211 | 64 | 234 |