Introduction
Surgeons face a critical decision with every procedure: should they close with traditional sutures or modern skin staplers? Each method offers distinct advantages, but choosing the wrong approach can mean longer operating times, increased infection risk, or poor cosmetic results. In a recent multi-institutional study of 18,268 lower extremity bypass procedures, 31% were closed with staples while 69% used sutures, demonstrating that both methods remain essential in modern surgical practice.
The stakes are high. Closure method affects operating time, patient comfort, cosmetic outcomes, infection rates, and surgical costs. With operating room time costing $36-62 per minute depending on facility type, even small efficiency gains create significant savings.
Understanding when to use each method—and recognizing emerging alternatives like bioabsorbable closure systems—helps surgical teams improve patient outcomes while managing resources effectively.
TL;DR
- Skin staplers insert metal or bioabsorbable clips rapidly, completing closures 2-3x faster than sutures
- Surgical sutures are medical-grade threads offering precision and versatility across all body locations
- Traditional staplers excel in speed but may cause train track scarring
- Sutures provide superior cosmetic outcomes but require more surgical time
- Selection depends on wound location, surgery type, and closure priorities
- Bioabsorbable subcuticular systems now combine stapler speed with suture-quality cosmesis
Skin Stapler vs Suture: Quick Comparison Table
The following table compares key performance metrics between traditional skin staplers and surgical sutures across clinical, economic, and practical dimensions:
| Aspect | Skin Stapler | Surgical Suture |
|---|---|---|
| Closure Time | 4-6 minutes (average abdominal wound) | 8-12 minutes (average abdominal wound) |
| Removal Pain | Lower pain scores (1.1-1.2 on VAS scale) | Higher pain scores (3.8-4.0 on VAS scale) |
| Cosmetic Outcome | Good outcomes in 64-80% of cases; may leave train track marks | Superior outcomes in 80-90% of cases; minimal visible scarring |
| Infection Risk | 8-12% in clean surgical wounds; higher in some specialties | 12-20% in clean surgical wounds; generally lower in vascular/orthopedic procedures |
| Cost (by wound length) | More economical for wounds >10cm ($300 vs $440-480 for multiple suture packs) | More economical for wounds <5cm ($220-240 vs $300 for staplers) |
| Best Applications | Trunk, extremities, scalp; emergency/high-volume settings; when speed is critical | Face, neck, hands; irregular wounds; layered closures; when cosmesis is paramount |
Note: Cost and performance data reflect traditional metal stapler systems. Bioabsorbable stapler systems like SubQ It! offer additional benefits including subcuticular placement, no removal required, and reduced scarring compared to conventional metal staplers.
Clinical data compiled from peer-reviewed surgical literature and comparative effectiveness studies.
What is a Skin Stapler?
Skin staplers are mechanical devices that rapidly insert metal (stainless steel or titanium) or bioabsorbable fasteners to bring together wound edges, primarily used for clean surgical incisions. These devices have evolved significantly since their first development in 1908, with modern single-use staplers becoming the standard in contemporary surgical practice.
The core benefits are substantial: dramatically reduced closure time (average 4.60 minutes versus 10.64 minutes for sutures), minimal skill requirement for application, and consistent staple placement regardless of operator experience. This speed advantage becomes particularly valuable in high-volume surgical settings and emergency departments.
How They Work:
- Device everts skin edges and inserts metal clips
- Holds tissue together without piercing deep tissue layers
- Standard staples: regular (5.88mm width) or wide (6.5mm width)
- Spacing: 5-8mm between staples
- Creates secure closure during critical healing period
Staplers have important limitations. They're not suitable for facial or neck wounds due to increased scarring concerns, particularly the characteristic "train track" scar pattern that results from surface-level staple placement.
Staples must be removed within 7-14 days, requiring a follow-up appointment that adds to overall healthcare costs and patient inconvenience.
Despite these limitations, their speed and consistency make staplers valuable in specific surgical contexts.
Types and Applications of Skin Staplers
Modern surgical practice overwhelmingly favors single-use disposable staplers over reusable devices. Manufacturers explicitly label these devices "Single Patient Use Only," as reuse or reprocessing compromises structural integrity and creates cross-contamination risks. This shift toward disposable devices has improved infection control while simplifying inventory management.
Primary surgical applications include:
- Abdominal surgeries (laparotomy, cesarean sections)
- Orthopedic procedures on extremities
- Thoracic surgeries
- Emergency trauma cases where speed is critical
- Scalp lacerations in emergency departments
The time savings in high-volume settings are remarkable. In head and neck cancer surgery, stapler closure was approximately 10 times faster than suturing—averaging 3.3 minutes versus 34.2 minutes for 54cm incisions. For pediatric scalp lacerations, stapling reduced wound closure time to 65 seconds compared to 397 seconds for sutures, dramatically improving emergency department throughput.
What are Surgical Sutures?
Surgical sutures are sterile threads used to manually stitch tissue layers together. They're available in absorbable materials (polyglactin, polyglycolic acid, polydioxanone) and non-absorbable materials (nylon, silk, polypropylene), making them the most adaptable wound closure method available.
Core benefits include:
- Superior precision for complex wounds with irregular edges
- Excellent cosmetic outcomes when applied by skilled hands
- Versatility across all body locations, including face and neck
- Ability to close multiple tissue layers separately
- Precise control of tissue tension and alignment for optimal healing
The suturing process involves careful needle selection, appropriate suture spacing, and choosing among various techniques—interrupted, continuous, or subcuticular—based on wound characteristics. Proper tension is essential; too tight strangles tissue and impairs healing, while too loose fails to approximate wound edges adequately.
Absorbable sutures lose tensile strength within 60 days and are metabolized by the body. Coated Vicryl (polyglactin 910) absorption is complete between 56-70 days, while PDS II (polydioxanone) takes up to 180 days.
Non-absorbable sutures maintain strength beyond 60 days and require removal, but offer superior tensile strength for high-tension closures.
The primary drawback is time. Suturing demands more training and practice, with closure times averaging 422 seconds compared to 68 seconds for stapling in abdominal procedures.
Each subcuticular interrupted stitch can take 42 seconds to complete properly, making manual suturing significantly slower than mechanical alternatives.
Types and Applications of Surgical Sutures
Sutures are categorized by material (natural vs synthetic), structure (monofilament vs braided), and absorption properties. Monofilament non-absorbable sutures like nylon and polypropylene are preferred for skin closure because they minimize tissue reaction and eliminate capillary action that can wick bacteria into the wound.
Ideal applications include:
- Facial and neck surgeries where cosmesis is paramount
- Pediatric closures requiring gentle tissue handling
- Areas with high tension or movement (joints, back)
- Layered closures requiring separate closure of fascia, subcutaneous tissue, and skin
- Irregular wound edges that require precise tissue approximation
Research on cosmetic outcomes shows sutures generally outperform staplers in visible areas. In neck incisions, sutures showed significantly better Stony Brook Scar Evaluation Scale scores than staples at 15 days post-op, though long-term outcomes at 6 months were more comparable.
Skin Stapler vs Suture: Which is Better?
No universal "better" option exists—selection depends on wound characteristics, anatomical location, surgery type, surgeon preference, and patient factors. Both methods are proven effective, but each excels in different clinical scenarios.
Closure Speed
Staplers demonstrate clear advantages in efficiency. In elective abdominal surgeries, staplers achieved mean closure times of 4.60 minutes compared to 10.64 minutes for sutures. This time difference increases proportionally with wound length, making staplers increasingly cost-effective as incisions grow longer.
Infection Rates
Infection rates vary by procedure type and surgical technique:
| Procedure Type | Staple Infection Rate | Suture Infection Rate |
|---|---|---|
| Orthopedic limb surgeries | 3.5% | 1.1% |
| Lower extremity bypass | 3.46% | 2.06% |
| Cesarean deliveries | 13.2% | 4.7% |
The variation suggests that proper surgical technique, patient factors, and procedure type matter more than closure method alone. Staphylococcus aureus remains the most common pathogen regardless of closure technique.
Cosmetic Outcomes
Sutures generally produce superior aesthetic results, particularly on visible areas. In abdominal closures, 72% of stapler patients rated cosmetic appearance as "Good" compared to 44% with sutures, showing that location and patient expectations significantly influence satisfaction.
Patient Experience
Pain scores during removal were significantly higher for staplers (mean 2.48) compared to sutures (mean 1.10), though both procedures cause minimal discomfort. Patients often experience anxiety about staple removal, while absorbable sutures eliminate removal appointments entirely.
Cost Analysis and Situational Recommendations
Cost analysis must consider device costs, operating room time, and follow-up procedures.
For wounds under 5cm, sutures are more economical ($20-25 vs $30 for staplers). For wounds exceeding 10cm, staplers become cost-effective ($30 vs $40-50 for multiple suture packs). The operating room time savings—valued at approximately $46 per minute—further favors staplers in longer procedures.
Choose staplers when:
- Speed is critical (emergency surgery, high-volume settings)
- Wound is on trunk, extremities, or scalp
- Minimizing OR time is prioritized
- Wound edges are clean and regular
- Patient can return for removal
Choose sutures when:
- Cosmesis is paramount (face, neck, hands)
- Wound has irregular edges requiring precise approximation
- Layered closure is needed
- Patient has keloid tendency or scarring concerns
- Follow-up for removal is impractical
Real-World Examples and Emerging Alternatives
Clinical evidence demonstrates clear advantages for each method in specific contexts.
In total hip arthroplasty, a large randomized trial found staples associated with 3x greater risk of surgical site infection (4% vs 1%) and significantly more wound discharge compared to sutures. This has led many orthopedic surgeons to favor sutures for joint replacement procedures.
Emergency departments, however, see dramatic efficiency gains with staplers. Pediatric scalp lacerations closed with staples reduced total procedure time from 752 seconds to 395 seconds, allowing emergency physicians to treat more patients during high-volume periods.
In cosmetic procedures, plastic surgery practices consistently achieve superior outcomes with sutures for facial closures. Absorbable subcuticular sutures produce satisfaction scores exceeding 95% for facial wounds, with minimal visible scarring when proper technique is applied by experienced practitioners.
Emerging Technologies:
Innovative closure systems are addressing limitations of both traditional methods. Bioabsorbable subcuticular closure systems like SubQ It! combine mechanical deployment speed with subcutaneous placement that eliminates train track scarring.
Key advantages of these systems include:
- Place bioabsorbable fasteners under the skin surface without external piercing
- Achieve closure speeds comparable to metal staplers (7 seconds per fastener)
- Eliminate removal procedures and associated patient discomfort
- Produce cosmetic outcomes similar to manual sutures
The SubQ It! Bioabsorbable Skin Closure System received FDA clearance for abdominal, thoracic, gynecologic, orthopedic, and plastic/reconstructive surgery. Clinical studies show 7x faster closure than manual sutures with only 2% infection rates and minimal visible scarring.
The bioabsorbable fasteners maintain 80% strength for 21 days before being naturally absorbed, eliminating the anxiety and discomfort of removal procedures.
Surgical teams looking to balance speed, cosmetic outcomes, and patient comfort may find that bioabsorbable closure systems offer advantages over traditional methods in appropriate cases. Learn more about the SubQ It! system and its applications across surgical specialties.
Conclusion
Both skin staplers and surgical sutures are proven, effective wound closure methods with distinct advantages. Staplers excel in speed, ease of use, and cost-effectiveness for larger wounds on the trunk and extremities.
Sutures offer superior precision and cosmetic outcomes for visible areas, irregular wounds, and situations requiring layered closure.
Practical decision-making should follow this framework:
- Wound location: Face/neck automatically indicates sutures
- Surgery context: Emergency/high-volume settings favor staplers
- Patient factors: Weigh cosmetic concerns, pain sensitivity, and follow-up availability
As bioabsorbable technologies continue advancing, surgical teams have expanding options that combine the best attributes of traditional methods. Systems like SubQ It! deliver subcuticular closure with the speed of traditional staplers while eliminating metal staple removal and minimizing visible scarring—bridging the gap between efficiency and cosmetic outcomes.
Frequently Asked Questions
Which is faster: skin staplers or sutures?
Skin staplers are significantly faster, typically completing wound closure in 4-6 minutes compared to 8-12 minutes for sutures. For longer incisions, staplers can be up to 10x faster than manual suturing.
Do staples or sutures cause more scarring?
Sutures generally produce superior cosmetic outcomes with less visible scarring, especially on the face and neck. Traditional staplers may leave characteristic "train track" marks, making them unsuitable for cosmetically sensitive areas. Bioabsorbable subcutaneous closure systems like SubQ It! combine stapler speed with suture-quality cosmetic results by placing fasteners beneath the skin surface.
Are staples more painful than sutures to remove?
Staples are typically less painful to remove, with pain scores of 1.1-1.2 versus 3.8-4.0 for sutures on visual analog scales. Staple removal is also faster, though both procedures cause minimal discomfort when performed properly.
Which is more cost-effective for large surgical wounds?
Staplers become more cost-effective for wounds longer than 10cm since one stapler (~$15-20) can close the wound versus multiple suture packs ($20-30). Reduced operating room time (valued at $46 per minute) further increases stapler cost-effectiveness in longer procedures.
Can staples be used on facial wounds?
Staplers are not recommended for facial, neck, or other cosmetically sensitive areas due to increased scarring risk and train track marks. Sutures remain the standard of care for these locations, offering superior aesthetic outcomes.
What are the infection rates for staples vs sutures?
Infection rates vary by procedure type, ranging from 8-20% for both methods across different studies. Proper surgical technique and postoperative care typically matter more than the closure method itself.
