We read with great interest the randomized controlled trial accessing wound complication rates of subcuticular suture and staples for skin closure at cesarean delivery, reported by Basha et al. This study brought new discussion in what concerns skin closure at cesarean delivery. The authors showed that women whose skin incisions were closed with staples were more likely to have a wound separation than women whose incisions were closed with 4-0 Monocryl (Ethicon, Juarez, Mexico) subcuticular sutures, even after adjustment for potential confounders. Since staples were removed between days 3-4 after surgery, we wonder if the procedure took place too early. When we consider the 4 stages of wound healing described by Schultz, which includes hemostasis, inflammation, proliferation and repair, and remodeling, perhaps the best time for staple removal would be later on. The first stage is usually completed within hours. Inflammation, the second stage, begins soon after hemostasis and is finished usually in the first 24-72 hours after injury; however, it may last as long as 5-7 days after lesion. Proliferation and repair, the third stage, typically occurs 1-3 weeks after skin aggression, and it is in this stage that wound tensile strength begins to develop, with collagen production between days 5-15. The final stage, remodeling, begins approximately 3 weeks after injury and could take from months to several years to achieve physiologic completion.

Thus, it is important to note that although the skin seems intact within days after injury, the tissue underneath is still vulnerable to damage as it undergoes the final stage of wound healing. If removal of staples had occurred between days 6-7, like Gaertner et al described, probably the rate of wound complications would be similar to that of subcuticular suture.

We suggest a randomized controlled study to access if the rate of wound separation is similar to that of subcuticular suture, when staples are removed later.