Introduction: Understanding Surgical Skin Closure Options
Surgical skin closure technique directly determines healing speed, infection risk, scarring severity, and patient satisfaction. Poor technique can extend healing by weeks and significantly increase surgical site infection rates. With over 6 million surgical procedures performed annually in the US and more than 1.10 million cesarean sections in the European Union, selecting the right closure method affects millions of patients each year.
Surgical skin staplers deliver 3 to 7 times faster wound closure than traditional suturing. However, this speed comes with documented trade-offs:
- Higher infection rates in certain procedures
- Visible "railroad track" scarring from puncture sites
- Patient discomfort during staple removal
- Additional appointment and cost for removal
These limitations have pushed development of bioabsorbable closure systems that match stapler speed while eliminating removal procedures and improving cosmetic outcomes.
TLDR: Key Takeaways About Surgical Skin Staplers
- Staplers close wounds 5-7 times faster than manual suturing, saving critical operating room time
- Best for linear incisions in non-cosmetic areas (scalp, extremities, trunk) where speed is prioritized
- Traditional metal staplers require removal 7-14 days post-op, causing patient discomfort
- Bioabsorbable systems eliminate removal needs while maintaining speed
- Proper technique minimizes infection, dehiscence, and scarring complications
What Are Surgical Skin Staplers? Types and Mechanisms
Surgical skin staplers are mechanical devices that deliver metal or absorbable fasteners to bring wound edges together. Unlike internal staplers used for organ and tissue closure during abdominal or thoracic surgery, skin staplers work externally or subcutaneously to close the dermal layer.
The basic mechanism bends metal staples into a "B" or rectangular shape, holding skin edges together without knot tying.
The global surgical stapling devices market reached $5.30 billion in 2023 and is projected to grow to $9.89 billion by 2030, driven by increasing surgical volumes and infection control protocols favoring single-use devices.
Disposable vs. Reusable Staplers
Disposable staplers dominate the current market. These single-use devices offer several advantages:
- Come pre-loaded and sterile, ready for immediate use
- Eliminate cross-contamination risks between patients
- Remove sterilization costs and equipment maintenance
- Align with CDC protocols that encourage disposable devices to control pathogen spread
Reusable models are increasingly rare in modern surgical settings.
Traditional Metal Staplers vs. Bioabsorbable Systems
Traditional metal staplers use stainless steel or titanium fasteners that pierce the external skin surface. Standard staples utilize 0.51 mm diameter wire with approximately 10 mm span before closure.
These require removal 7-14 days post-operatively.
Bioabsorbable stapler technologies use materials that the body naturally absorbs over time. Systems using polylactic acid (PLA) and poly(lactic-co-glycolic acid) (PLGA) eliminate removal procedures entirely.
The SubQ It! bioabsorbable closure system places fasteners subcutaneously rather than piercing the external skin, maintaining 80% of their strength for 21 days before gradual absorption.
Clinical Indications for Surgical Staplers: When to Use Them
Staplers excel in emergency and trauma settings requiring rapid closure, high-volume surgical environments, and procedures where speed directly impacts patient outcomes.
They're particularly valuable when operating room time costs $30-$46 per minute, making the 5-10 minutes saved per closure financially significant.
Surgical Specialties and Procedure Types
Common stapler applications include:
- Scalp lacerations (emergency department standard)
- Orthopedic incisions (hip and knee arthroplasty)
- Cesarean sections (though sutures may be preferable for wound separation risk)
- General abdominal surgery
- Thoracic procedures
- Trauma wound management
Studies confirm staplers are quicker and easier than sutures for selected emergency department lacerations without compromising healing outcomes.
Anatomical Considerations
Location selection depends on tissue characteristics and cosmetic requirements.
Ideal locations for staplers include flat, non-tension areas with adequate subcutaneous tissue:
- Scalp
- Back
- Extremities
- Abdomen
Avoid staplers in areas requiring precise cosmetic results:
- Face and neck
- Hands and feet
- Joints and high-mobility areas
- Thin or fragile skin
Bioabsorbable closure systems like SubQ It! address some cosmetic limitations by eliminating external puncture marks and reducing visible scarring compared to traditional metal staples.
Patient Factors Affecting Stapler Selection
Patient characteristics influence closure method selection:
- Skin thickness and quality affect staple formation success
- Wound tension levels determine dehiscence risk
- Bleeding disorders may complicate placement and removal
- Immunocompromised status potentially increases infection risk
- Follow-up reliability for removal appointments (bioabsorbable systems eliminate this concern)
Contraindications and When NOT to Use Staplers
Understanding contraindications prevents complications and poor outcomes.
Absolute contraindications:
- Infected or contaminated wounds
- Areas of poor perfusion or tissue viability
- Very thin, fragile, or atrophic skin
Relative contraindications:
- Keloid-prone patients
- Wounds under high tension
- Patients with limited healthcare access for removal
- Pediatric patients (removal anxiety)
- Areas requiring optimal cosmetic outcome
Surgical Stapling Technique: Step-by-Step Overview
This overview describes traditional metal stapling technique for educational purposes and is not a substitute for hands-on training. Technique varies by device manufacturer and clinical setting.
The following steps outline the standard approach to surgical skin stapling.
Wound Preparation and Assessment
Proper preparation ensures successful closure:
- Achieve hemostasis (bleeding control) — stop all active bleeding completely
- Irrigate and debride — remove contaminants and non-viable tissue
- Assess depth — determine if deeper layer closure is needed
- Ensure proper alignment — verify wound edges match anatomically
Stapler Positioning and Application
Correct stapler technique prevents complications and optimizes healing:
- Position perpendicular to the skin surface
- Capture equal tissue depth on both sides of the wound
- Maintain 6-8 mm spacing between staples for optimal wound oxygenation (research shows 6 mm or more prevents tissue hypoxia)
- Evert skin edges during stapling to prevent inversion
- Avoid excessive pressure which embeds staples too tightly
Assessing Staple Placement Quality
Evaluate each staple immediately after placement:
- Both staple legs penetrate dermis adequately
- Crown sits just above skin surface (not embedded)
- Wound edges approximate evenly without overlap or gaps
- No excessive tissue compression (prevents ischemia)
Post-Application Care and Documentation
Immediate care:
- Cleanse wound gently
- Apply appropriate dressing
- Instruct patient on keeping area clean and dry
Documentation requirements (critical for surgical training and patient safety):
- Number of staples used
- Anatomical location
- Any complications during application
- Scheduled removal date (typically 7-14 days)
Advantages and Limitations of Surgical Staplers
Key Advantages
Speed of application represents the primary benefit. Mean closure time for staples was 7.17 minutes versus 13.93 minutes for sutures in abdominal surgery.
| Closure Method | Time Required | Speed Advantage |
|---|---|---|
| Stapler closure | 30-60 seconds | Baseline |
| Suture closure | 5-10 minutes | 7x faster with staplers |
| Orthopedic applications | Variable | Up to 7x faster |
Beyond speed, staplers offer:
- Reduced tissue handling and trauma
- Easier to learn than suturing (shorter training curve)
- Cost-effective in high-volume settings when OR time savings are considered
- Decreased anesthesia time for trauma patients
Primary Limitations
While speed advantages are substantial, traditional metal staplers present several drawbacks that affect patient outcomes.
Cosmetic concerns top the disadvantage list:
- Visible "railroad track" scarring from staple entry/exit points
- Wider scars compared to subcuticular sutures
- Patient dissatisfaction with appearance, particularly in visible areas
Infection and dehiscence (wound separation) data shows mixed results. A systematic review of 42 RCTs found sutures resulted in fewer overall wound infections (4.90%) compared to staples (6.75%). In orthopedic surgery specifically, staples showed significantly higher SSI risk (relative risk 2.05).
Patient discomfort during removal creates additional challenges:
- Requires return visit (compliance issues)
- Painful removal process (particularly with multiple staples)
- Anxiety in pediatric patients
These limitations have driven development of alternative closure methods, including bioabsorbable subcutaneous systems that eliminate removal-related pain and cosmetic concerns while maintaining speed advantages.
Clinical Scenarios Where Limitations Become Critical
Traditional metal stapler disadvantages outweigh speed benefits in specific patient populations and surgical contexts:
- Pediatric patients (removal anxiety and cooperation issues)
- Cosmetically sensitive areas (face, neck, décolletage)
- Patients with limited healthcare access for removal appointments
- Wounds requiring extended healing time (>14 days)
- Keloid-prone individuals
Alternatives to Traditional Surgical Staplers: A Comparative Analysis
No single closure method is universally superior. Selection depends on wound characteristics, anatomical location, patient factors, and clinical priorities.
Traditional Suturing Techniques
Types and approaches:
- Interrupted sutures — allow individual adjustment at each stitch point
- Running sutures — faster application for linear closures
- Superficial sutures — approximate skin edges
- Deep (subcuticular) sutures — provide superior cosmetic outcomes
Advantages:
- Superior cosmetic results, especially with subcuticular technique
- No removal needed with absorbable sutures
- Better for irregular wounds and high-tension areas
- More versatile for complex closures
Disadvantages:
- Time-consuming (5-10 times slower than staplers)
- Requires greater technical skill and training
- Higher material costs per closure
Tissue Adhesives and Surgical Glues
Cyanoacrylate-based adhesives (Dermabond, Histoacryl) polymerize on contact with skin moisture, creating a flexible film that holds wound edges together.
Ideal uses:
- Small, clean lacerations (< 5 cm)
- Pediatric patients (reduces procedural anxiety)
- Low-tension wounds
- Supplemental closure over deep sutures
Limitations:
- Not suitable for high-tension areas or joints
- Weaker tensile strength than staples or sutures
- Cannot be used in areas exposed to moisture
- Allergic contact dermatitis occurs in 0.5-14% of patients
A prospective comparative study published in JASSM found tissue adhesives consistently score better on cosmetic scales compared to both staples and sutures.
Adhesive Strips and Tapes
Steri-Strips and similar products serve as minimally invasive options for superficial wounds or supplemental closure. They reduce tension on suture lines and support healing after staple or suture removal.
However, these products cannot serve as primary closure for most surgical incisions.
Bioabsorbable Subcuticular Closure Systems
Advanced closure technologies combine the speed advantages of staplers with the cosmetic benefits of subcuticular sutures.
The SubQ It! system uses bioabsorbable dermal fasteners placed beneath the skin surface, eliminating external skin piercing entirely. This subcutaneous placement addresses the primary limitations of traditional metal staplers while maintaining procedural efficiency.
Clinical characteristics:
- No removal required (absorbed by body)
- Minimal scarring without "train track" marks
- Application 7 times faster than manual sutures
- Each fastener weighs 0.0064 grams
- Deployment time approximately 7 seconds per fastener
- The system holds FDA clearance for abdominal, thoracic, gynecologic, orthopedic, and plastic surgery procedures
Comparison Table: Creating a Decision Matrix
| Closure Method | Application Time | Removal Required | Cosmetic Outcome | Cost Considerations | Best Use Cases | Contraindications |
|---|---|---|---|---|---|---|
| Metal Staplers | 30-60 seconds | Yes (7-14 days) | Fair (railroad tracks) | Low device cost, removal visit adds expense | Emergency trauma, scalp, trunk, extremities | Face, neck, cosmetically sensitive areas |
| Absorbable Sutures | 5-10 minutes | No | Excellent (subcuticular) | Moderate material cost, high OR time cost | All areas, especially cosmetic | None specific |
| Non-Absorbable Sutures | 5-10 minutes | Yes (7-14 days) | Good to Excellent | Low material cost | High-tension wounds, precision closure | Infected wounds |
| Tissue Adhesives | 1-2 minutes | No | Excellent | Moderate device cost | Small lacerations, pediatrics, low-tension | High-tension areas, joints, moisture exposure |
| Bioabsorbable Closure Systems | 1-2 minutes | No | Excellent | Higher device cost, OR time savings | MIS, laparoscopic, cosmetic priority | Infected wounds, very thin skin |
Best Practices and Considerations for Surgical Closure Selection
Selecting the optimal closure method requires balancing wound characteristics, patient factors, and procedural constraints. This framework helps guide evidence-based decisions at the point of care.
Clinical Decision-Making Framework
Apply this systematic approach:
Assess wound characteristics
- Depth and tissue layers involved
- Tension on wound edges
- Contamination level
- Length and shape (linear vs. irregular)
Consider anatomical location
- Cosmetic importance to patient
- Mobility and tension in area
- Tissue thickness and quality
Evaluate patient factors
- Age and healing capacity
- Compliance with follow-up
- Anxiety level (especially pediatric)
- Patient preferences regarding scarring
Weigh procedural priorities
- OR time constraints
- Surgeon experience with methods
- Cost considerations
- Available resources
Preventing Complications Across All Closure Methods
Universal principles for successful closure:
- Adequate hemostasis before closure prevents hematoma formation
- Appropriate deep layer closure relieves tension on skin closure
- Avoid excessive tissue compression — don't overtighten closure devices
- Ensure proper edge eversion for optimal scar formation
- Use prophylactic antibiotics when indicated (contaminated wounds, high-risk patients)
These foundational techniques apply regardless of closure method chosen. Looking ahead, emerging technologies continue to refine these principles.
Future Trends in Surgical Closure Technology
Innovation continues to reshape the closure landscape:
- Smart sutures with embedded sensors monitor wound pH, temperature, and infection markers
- Antimicrobial-coated materials reduce SSI risk (triclosan-coated sutures already recommended by ACS and SIS)
- Robotic-assisted closure systems for precision and consistency
- Bioabsorbable technologies that eliminate removal procedures and reduce healthcare system burden
The shift toward patient-friendly technologies reflects growing emphasis on patient-centered care, cosmetic outcomes, and total cost of care rather than just device cost.
Frequently Asked Questions
What are surgical skin staples made of?
Traditional surgical staples use surgical-grade stainless steel or titanium for biocompatibility, strength, and corrosion resistance. Bioabsorbable alternatives use polylactic-co-glycolic acid (PLGA) that naturally degrades over time.
How long do surgical staples stay in?
Typical removal timeframes are 7-10 days for most body areas, 3-5 days for face and neck, and 10-14 days for back or high-tension areas. Exact timing depends on wound healing progress and surgeon preference.
Are surgical staplers better than sutures?
Neither method is universally superior. Metal staplers offer speed (3-7 times faster) but traditional sutures provide better cosmetic results. Bioabsorbable subcuticular systems like SubQ It! combine stapler speed with superior cosmetic outcomes.
Do surgical staples hurt when removed?
Removal typically causes brief discomfort or pinching sensation as each staple is extracted. Pain level varies by individual tolerance, staple location, and number of staples. Removal anxiety is common, especially in pediatric patients.
What are the complications of surgical staples?
Potential complications include infection (rates comparable to sutures in most studies, though some data shows 6.75% vs. 4.90% for sutures), wound dehiscence under excessive tension, allergic reactions (rare with stainless steel/titanium), and tissue necrosis if staples are too tight.
Can surgical staples cause scarring?
All closure methods create scars, but metal staples often produce wider "railroad track" scars due to external placement. Subcuticular techniques and bioabsorbable systems result in finer, less noticeable scars.
