Updated Recommendations for Control of Surgical Site Infections

J. Wesley Alexander, MD, ScD; Joseph S. Solomkin, MD; Michael J. Edwards, MD


Annals of Surgery. 2011;253(6):1082-1093. 

In This Article

Hair Removal

The dogma of preoperative shaving was challenged by a prospective randomized study in 1971 when it was documented that when hair was removed by a razor the wound infection rate was 5.6%, almost 10 times higher than when a depilatory was used (0.6%) or when no hair was removed (SDC-27). Two years later, a very large observational study of factors related to wound infections in 18,090 clean cases, revealed that patients who were shaved had an infection rate of 2.3% compared to 1.7% when hair was removed by clipper and 0.9% when no hair was removed (SDC-28). A prospective randomized trial involving preoperative shaving vs. clipping was published in 1983, involving 1,013 patients. Including stitch abscesses, the overall rate of infection in patients prepped with a razor was 4.6% compared to 2.5% in those prepped with clippers.[4] The best infection rate (1.8%) was found in the group prepped with a clipper on the morning of the operation. The benefit of clippers vs. the razor is supported by other studies in coronary artery bypass patients (OR = 3.25) (SDC-29). Neurosurgical patients are of particular interest because of the large amount of hair involved. Several studies have now shown than removal of hair by shaving compared to no shaving had no benefit on the incidence of postoperative infection (SDC-30-35). Two recent reviews using the Cochrane Database (SDC-36) and other methods of searching (SDC-37) have concluded that hair removal by clipper was superior to removal by a razor, but the infection rates were best when no hair was removed. There have been no prospective randomized trials, which compared clipping to the use of a depilatory cream.


It seems logical that the incidence of wound infection would increase when hair gets into a surgical wound. However, all of the evidence suggests that not removing hair is associated with the least infection. When it is deemed by the surgeon that hair should be removed, shaving should never be used. Clipping the hair with care to avoid skin damage seems to be the most satisfactory method. Most studies support hair removal done immediately before operation.


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