Patients and Methods
This work was conducted according to the ethical guidelines of the Declaration of Helsinki and its revisions and was approved by the institutional review board of Fayoum General Hospital. All patients in the case series provided informed consent to undergo the surgical procedures and to have photographs of their wounds/scars taken.
This case series consisted of all consecutive female patients who presented with traumatic facial wounds at our tertiary care hospital (Fayoum General Hospital) in Egypt and underwent wound closure by stitching with autologous human hair between 2009 and 2016. While this technique was performed with male patients as well, we selected this subset of patients for case series review.
Preoperative Wound Assessment
The wounds were assessed carefully during a physical examination, and the patient history was taken from the patient or guardian. During the physical examination, the length and depth of the injury were determined and the wound was assessed for injury to the nerves, blood vessels, ducts, muscles, and other structures. The presence or absence of hard tissue fractures was assessed by radiography. The patient or guardian was asked how the wounding occurred, with the aim of determining the risk of wound contamination. The patient or guardian was also asked whether the patient had any systemic conditions that could affect wound healing (eg, diabetes mellitus), whether previous wounds had left visible or abnormal scars, and whether the patient had a history of allergies or complications during anesthesia. The information that was retrieved during the physical assessment and discussion allowed the surgeon to determine the most suitable type of anesthesia and intervention. The patient or guardian was informed about the technique that would be used. The patient or guardian was also informed that it would be necessary to adhere to a rigorous follow-up regimen, namely, outpatient visits to the hospital every 3 days until the removal of the stitches, every 2 weeks in the first month thereafter, then every month for 2 months, and then every 3 months for at least 2 years. They were also told that photographs of their wound/scar would be taken at each visit. The patient or guardian was then asked to consent to the procedure and the taking of photographs. If the patient or guardian was literate, consent was obtained in writing. Alternatively, verbal consent was obtained.
The surgery involves the use of sterile latex gloves, narrow needles (27 or 30 gauge), mosquito or artery forceps, a micro needle holder, and small forceps (Figure 1a). All patients underwent stitching in an operating room to ensure the sterility of the procedure. Depending on the nature of their wound, the patients were given the most appropriate anesthesia, namely, local injection alone or combined with intravenous sedation or general anesthesia.
Tools needed for autologous hair-based suturing and the production of autologous hair ampoules. (a) The basic equipment needed for dermatologic microsuturing using hair filaments. (b-f) Production of an autologous hair ampoule. (b) The hair filament is passed through a 27-gauge insulin needle until it protrudes from the bevel end, after which the metallic part is separated from the plastic base by holding the metallic part with a mosquito or artery forceps and bending it from side to side until it breaks off the base. (c) If a 30-gauge insulin syringe is used instead of a 27-gauge insulin needle, the metallic needle can be separated from the syringe with a similar sawing method. (d) To anchor the hair filament to the metallic part of the needle, 1 mm of the needle base is crushed by using small mosquito forceps. (e) The view under loupe magnification (5.5×) of a 30-gauge needle with a hair filament anchored to it and grasped by a micro needle holder. (f) The hair filament is stretched straight, and the needle is grasped by the micro needle. The construct is now ready for cutaneous stitching.
Production of an Ampoule of Hair Thread
To generate the ampoule of hair thread, select long durable hair filaments from the scalp of the patient and separate them by scissors. Fed the filaments into the insulin needle (27 or 30 gauge) in a retrograde direction. Before or after that, separate the metallic needle from the attached plastic part (Figure 1b and Figure 1c). Leave a small part of the filament inside the needle. Crush 1 to 2 mm of the base of the needle by placing it between the 2 arms of the hinge of a mosquito, and compress the handles until the ratchets lock (Figure 1d). Now the hair filament anchored to the needle forming an ampoule for suturing is obtained (Figure 1e and Figure 1f).
Sterilization of the Ampoule of Hair Thread
The hair filament anchored to the insulin needle can be sterilized by immersing the ampoule in a small gallipot or container filled with alcohol alone or a mixture of alcohol and betadine for 10 to 30 minutes. It should be noted that the ampoule should be prepared in an infection-controlled environment to prevent infection.
After administering the anesthesia, the wound was washed by saline and antiseptic solutions such as povidone-iodine or chlorhexidine.[10,11] Foreign bodies were removed when they were found. The integrity of the adjacent vital structures was checked, and essential repair was performed as required. Unviable tissues were debrided meticulously and conservatively until healthy tissue was achieved. Hemostasis was ensured before starting wound closure.
Essential deep suturing techniques were applied in the wounds in some cases when needed by using 3–0/4–0 polydioxanon sutures (PDSII) and/or polyglactin sutures (Vicryl).[14,15] The wound was then closed with simple interrupted or continuous autologous hair sutures[16,17] that precisely approximated the wound edges. Thus, under surgical loupe magnification, the epidermis and the dermis were first gently penetrated with the straight insulin needle (30- or 27-gauge). Traction was applied on the thread to help pass all of the remaining part of the filament through the epidermis except for a few centimeters, which would be used later to generate the surgical knot. The opposite edge of the wound was then penetrated, placing traction on the thread and not the needle. This is because dragging the thread through the epidermis by continuous traction on the needle may cause the hair filament to detach from or break off at the needle base. The surgical knot was then easily generated by using a fine needle holder aided by fine forceps (toothed or untoothed). The proper alignment of the epidermal layer was checked under loupe magnification.
Wound Care After Surgery
Topical antibiotics were applied on the sutured wound to prevent infection, and the wound was covered with a sterile dressing. The patient was discharged from hospital and asked to return 3 days later. At the first visit, the dressing was removed so that the wound would be left exposed. The patient was asked to apply topical antibiotics daily and return to the hospital 3 days later. At that second visit, the wound was checked. If the wound had not yet healed reliably, the patient was asked to return to the hospital in another 3 days. This procedure continued until reliable healing was achieved. At that point, the stitches were removed.[19,20]
The patients were instructed to return to the hospital every 2 weeks in the first month and then every month for 2 months. Thereafter, the patients were asked to return to the hospital every 3 months for at least 2 years.
The stitched sites were evaluated at each visit by keen inspection with the naked eye, examination under a dermatologic lens, and examination under a surgical loupe at 5.5 × magnification. The photographs that were taken at each visit were also examined by using the photoviewer program at various magnifications (up to 10×).
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