Mitigating Hair Loss Among Scalp Laceration Repair Techniques: Review of the Literature

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Emergency room physicians treat approximately 11.5 million people for traumatic wounds annually; scalp lacerations constitute nearly 5% of these cases.^1,2 Scalp lacerations occur when blunt forces create a cut or tear in the scalp, most commonly to the level of loose areolar tissue that covers the pericranium and lies inferior to the musculoaponeurotic layer.^3,4 The high vascularity, relative inability to stretch the scalp skin over the calvarium, and tension on closure make scalp lacerations challenging to repair.³

The scalp's vascular supply originates from medium-sized vessels in the deep fat and aponeurosis that branch upward towards the skin surface, forming a rich network creating an extensive and well-developed vascular network. The high concentration of blood vessels in the tissue surrounding hair follicles suggests a complex vasculature that originates from horizontally disposed and branched arteries located in the deep dermis and superficial hypodermis.⁵ This robust network of blood vessels makes it possible to supply the high metabolic demands of follicles at varying depths and stages of growth.⁵ The ideal treatment for scalp laceration would indicate a swift procedure with minimal risk for complications that could deliver exceptional cosmetic outcomes while providing sufficient analgesia and hemostasis.⁶

The risk of hair loss in scalp lacerations poses a significant cosmetic complication, often leaving patients dissatisfied, as hair can conveniently serve to camouflage scars when follicles are effectively preserved.⁷ In a retrospective observational study that compared the hair apposition technique (HAT), suturing, and stapling for scalp lacerations, the most common side effects included redness, pain, and hair loss.⁸ The unique nature of the scalp hair structure makes it vulnerable to alopecia following lacerations.^7,9  Damage to the deeper hair follicle stem cells, which are crucial for hair growth, can result in complete hair loss; this reality underscores the need for effective wound closure techniques that  reduce this complication.^9,10 Consequently, minimizing hair loss through judicious wound closure techniques not only addresses cosmetic concerns but also acknowledges the broader impact on patients' mental health and quality of life.

Scalp lacerations present a significant challenge in emergency medicine and plastic surgery alike because of their prevalence and unique anatomical considerations.³ The complexity of these wounds, compounded by the risk of hair loss and resultant cosmetic dissatisfaction, warrants investigation into optimal effective closure techniques.¹¹ Traditional methods like sutures and staples have long been utilized, emerging techniques such as HAT to close primary defects and flap procedures on the scalp offer promising alternatives with the potential to mitigate hair loss and enhance aesthetic outcomes.^10,12,13 HAT is a method of wound closure that utilizes hair strands, typically sourced from the patient's scalp, as suture material. Weaving these hairs through the wound edges facilitates approximation and closure, serving as a low-cost and readily available alternative in situations where conventional sutures are not accessible or suitable.¹² By prioritizing patient comfort, optimal wound healing, and minimum long-term complications, healthcare providers can improve the overall quality of care for individuals presenting with scalp lacerations.

A literature search was conducted using PubMed (National Institutes of Health), Embase (Elsevier), and Google Scholar (Alphabet, Inc) databases from 1850 to 2023 for relevant English-language publications. Key search terms included scalp lacerations, wound closure, hair growth, suture, and staple. All retrieved publications were uploaded to Covidence (Veritas Health Innovation Ltd) for screening by the research team, and any duplicates were removed. The initial screening process was conducted by 4 individuals, and each paper required 2 votes to pass. A secondary screening process was conducted by the same 4 team members and involved identifying relevant inclusion and exclusion criteria, which will be discussed in depth in future sections.

Inclusion and exclusion criteria

Our systematic review selected studies based on defined criteria to ascertain the impact of various scalp laceration closure techniques on hair loss. We included peer-reviewed articles from 1850 to 2023 that provided clinical outcomes of scalp laceration repairs using sutures, staples, or HAT, with a specific emphasis on hair loss as a postoperative complication. Eligible studies comprised randomized controlled trials, cohort studies, case reports, case-control studies, and case series that reported the original primary data in English. Our exclusion criteria were precise: studies were omitted if they did not discuss hair or its associated loss in the context of scalp lacerations; if they described scalp injuries treated without sutures, staples, or HAT; if the defect was due to flap reconstruction; or if they targeted patient populations without scalp lacerations. Furthermore, we excluded textbooks, abstract-only publications, non-peer-reviewed literature, articles not published in English, studies without relevant primary data such as reviews, and studies detailing inappropriate outcomes or interventions. This selection methodology aimed to eliminate all but the most pertinent studies, ensuring that our analysis effectively evaluated the comparative implications of sutures, staples, and HAT on hair preservation following scalp laceration repairs.

Data collection process

Data extraction from the selected publications was performed. A standardized data extraction spreadsheet was developed to collect the relevant information from each study, which included study design, year of publication, author details, number of participants, participant demographics (age, gender), nature of scalp laceration, details of wound closure techniques (suturing, stapling, HAT), and outcomes with a specific focus on hair growth and hair loss. Complications and other notable findings were also documented when provided. The data extraction process was independently conducted by the research team for each article to ensure accuracy and consistency. Discrepancies in data extraction were resolved through discussion and consensus among all team members.

Each study was carefully analyzed to determine its relevance to our research question. The extracted data were then aggregated and synthesized to form the basis of our analysis.

The initial literature search yielded 21530 studies for screening. Covidence software identified and removed 2521 duplicates, leaving 19009 studies for title and abstract screening. Of these, 18627 studies were deemed irrelevant based on information provided in their titles or abstracts for the objectives of this literature review. Subsequently, 382 full-text articles were assessed for eligibility, out of which 371 were excluded for reasons such as non-mention of hair or hair loss in conjunction with staples or sutures (135), hair loss AND staples/sutures not mentioned (70), studies targeting the wrong patient population (60), textbook sources (38), abstract only (21), wrong study design (20), non-peer-reviewed literature (8), language other than English (7), wrong outcomes (6), wrong intervention (4), discussed flap reconstruction (4), and duplications (2). Ultimately, 7 studies satisfied all inclusion criteria and were included in the final analysis. The selection process is depicted in a PRISMA flow diagram below (Figure), and the data is represented in the Table.

Figure. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram of the study selection process.

Suture, staple, and hair apposition techniques: a case-based overview

We present a simplified case-based overview, highlighting the various closure techniques across the included studies. This summary encapsulates study demographics, laceration characteristics, complications, and final outcomes of each case, offering a concise yet comprehensive view of the application of closure techniques in clinical settings.

All of the included studies discussed the closure of a scalp laceration with sutures. The use of sutures, as demonstrated in research by Gür et al² and Ozturk et al,⁸ frequently correlates with increased instances of cosmetic dissatisfaction, pain, and occasional instances of hair loss. Additionally, when compared with HAT cases, the cases involving sutures typically involved the lengthiest durations of emergency department (ED) stays and displayed the highest rates of complications.

In contrast, the application of staples exhibited a somewhat different set of results. Five of the included studies assessed scalp wound closure with staples. According to the studies by Gür et al² and Bernstein et al,¹⁴ staples were associated with a modest decrease in cosmetic dissatisfaction compared with sutures, resulting in the most significant levels of pain among the 3 methods. Dermal sutures tie underneath the dermis, where the hair follicles sit, strangulating the follicles and potentially leading to increased hair loss. Staples, on the other hand, put less strain on the follicles, causing less trauma to these delicate hair-generating structures in the long run.¹²

On the other hand, HAT, which was discussed by 4 of the included studies, has been characterized by notably favorable outcomes. Findings from Gür et al,² Hock et al,⁶ and Karaduman et al¹⁵ consistently show that HAT leads to the shortest length of ED stays, the lowest rates of complications, and is associated with minimal cosmetic issues (ie, hair loss), all while maintaining similar or higher levels of patient satisfaction to those seen with sutures and staples.

Sutures are typically preferred in cases of profuse bleeding and short hair, offering strong wound closure irrespective of the wound's shape.⁸ When absorbable sutures are used, no removal is needed. However, sutures can be more invasive and painful, and may result in larger scars with hair loss.⁸ Staples are favored when the laceration has controlled bleeding and is confined to the dermis.⁸ This method is thought to have a decreased rate of hair loss and scar formation on the scalp.⁸ The hair apposition technique is a newer method that utilizes strands of hair on either side of the wound with glue to secure the closure. This method is suitable for patients with longer hair who have straight, small wounds (<10 cm).⁸

While sutures and staples have been conventionally used, our data supports HAT as a promising alternative, demonstrating shorter ED stays, lower complication rates, and minimal cosmetic issues such as hair loss. This underscores the importance of considering innovative approaches to optimize patient experiences and outcomes in scalp laceration repairs. However, it is crucial to address concerns that HAT might not be effective in all cases. Some physicians argue that trying to tie a patient's hair together in the ED and/or the operating room can lead to widened scars due to the lack of dermal approximation. Balancing these perspectives is essential to advancing our understanding and application of HAT in clinical practice. Further research needs to be conducted on the clinical applicability of HAT.

A significant limitation of our study is the insufficiency of long-term data regarding the outcomes of various scalp laceration repair techniques. While our data provides insights into patient satisfaction and cosmetic results within the first 7 to 14 days post-repair, it does not adequately address the potential long-term issues. For instance, with traumatic scalp wounds, patients may experience hair loss over 4 to 6 weeks due to follicle damage, and since hair cycles every 4 to 6 months, the full extent of hair loss might only become apparent after 6 to 12 months. The nature of the trauma population poses difficulty in reporting long-term follow-up. This gap in long-term data is crucial to comprehensively understand the efficacy and cosmetic outcomes of techniques like sutures, staples, and HAT. Future research should aim to include extended follow-up periods to better assess these long-term effects and provide a more complete evaluation of each method's impact on hair loss and overall aesthetic results.

The management of scalp lacerations poses a multifaceted challenge for ED physicians, predominantly stemming from the scalp's distinct anatomical features and rich vascularity. This systematic literature review critically examines the existing gap in research regarding the impact of various closure techniques, with a specific focus on sutures, staples, and HAT, and their implications for aesthetic complications, notably hair loss following scalp laceration repairs. Our findings suggest that a nuanced approach to scalp laceration management can contribute to elevated patient satisfaction, avoid complications, and enhance aesthetic results. Between sutures and staples, it would appear that staples offer the best results in terms of minimizing hair loss and reducing procedure time but can often lead to increased pain in the immediate post-procedure stages. HAT may be a viable option in certain patient populations but may lead to widened scars based on the relative lack of dermal approximation at the initial closure, which in turn leads to a decreased strength of closure over time. This research aims to guide healthcare providers in making informed decisions, ultimately improving the overall quality of care for patients with scalp lacerations.