Clean vs Sterile in Low-Risk Surgery: Rethinking Infection Risk and Surgical Costs

It seems imprudent to consider using sterile versus nonsterile gloves in a surgical procedure, as the decision could potentially impact postoperative infections and patient safety. Sterile gloves guarantee aseptic conditions, although at a significantly higher cost, while nonsterile gloves are more economical but may theoretically compromise aseptic conditions.

However, the safety of this intervention has been studied and established in the dermatological surgery literature for decades. This study aims to provide a comprehensive theoretical cost analysis of sterile versus nonsterile glove use in an established hair restoration practice, drawing on longstanding precedent and the extensive body of evidence on perioperative infection rates reported in the dermatological Mohs micrographic surgical literature.

Procurement of medical supplies constitutes a meaningful expense within medical practices. While essential for certain procedures, sterile gloves represent a significant cost. This analysis investigates the financial implications of substituting nonsterile gloves for sterile gloves when appropriate. This study will focus exclusively on the cost analysis of such an intervention within a cosmetic surgical practice. However, subsequent studies will be necessary to determine the safety of such intervention.

There is ample evidence of an evidence-based shift from sterile to nonsterile gloves, with no significant change in perioperative infection rates in the dermatological surgery literature and occasionally in other low-risk procedures, such as laceration repair. These findings are comparable to those in hair transplantation, where the blood supply reduces the risk of infection.^1-3 This evolution has been driven by the aim of balancing the highest degree of patient safety with efficient management of operational expenses.

Sterile gloves have traditionally been reserved for use during sterile surgical procedures to mitigate the risk of postoperative infections, while nonsterile gloves have been used during examinations and nonsterile procedures, where a lower perceived risk of infection is present. While sterile gloves can ensure aseptic conditions, their significantly higher cost compared with nonsterile gloves has prompted a judicious evaluation of the evidence-based cost-benefit ratio of this measure. Extrapolating the assumptions learned from years of shifts in Mohs micrographic surgical practice, the prevailing theoretical assumption is that the scalp’s robust blood supply can inherently diminish the risk of infection.

This topic, well-explored in the dermatological surgery (Mohs surgery) literature, shows many practices now favor a “clean” over a sterile technique without compromising post-operative outcomes, thereby enhancing cost-effectiveness. The articles were selected for procedural similarity to surgical hair restoration, given the robust blood supply and the associated low infection rates of these procedures.

A 2006 study by Rhinehart et al. found no significant differences in infection rates between sterile and nonsterile gloves during Mohs excisions and reconstruction procedures. Of 1810 Mohs patients, 1239 met the study criteria; of these, only 25 infections were identified, all associated with cartilage fenestration and a secondary diagnosis of malignant melanoma, indicating no statistically significant difference between sterile and nonsterile gloves.⁴ Since this study, many practices have switched to using nonsterile gloves for these procedures, reporting comfort with the switch and no changes in postoperative course or patient care, all with a significant gain in cost-effectiveness.

While the switch from sterile to nonsterile gloves has been observed mainly within dermatological settings, the question has been raised across different surgical specialties. An article focused on complications in the emergency department when using sterile versus nonsterile gloves for repairing uncomplicated lacerations found no statistical difference in infection rates. This study included 816 individuals randomized to have their wounds repaired with either sterile or nonsterile gloves.³

Tatiana Humphreys, MD, et al, published a commentary article stating her practice changed to a “clean” technique rather than a sterile procedure because of the mounting body of evidence showing no significant difference in postoperative infection rates when using nonsterile vs. sterile gloves. The author states that she has adapted her practice to use nonsterile gloves for surgical reconstructions and reports significant cost savings, with no corresponding changes in postoperative infection rates or medical outcomes.²

Hair transplantation is an effective treatment for male pattern hair loss, also known as androgenetic alopecia. There are 2 general types of surgical techniques: Follicular unit extraction (FUE) and follicular unit grafting (FUG). Both procedures transplant hair follicles, typically from the occipital region of the scalp (and for FUE, occasionally from other areas of the body if needed), into the areas of concern. The FUE procedure is usually preferred, allowing for a high number of available donor grafts in combination with a better, more natural outcome and a less noticeable degree of scarring. The procedure, in general terms, involves harvesting the grafts, removal of skin and subcutaneous tissue from the donor strip or unit, and then the preparation of the recipient sites for graft implantation.

While no medical procedure is completely without risk, hair transplantation has a lower risk of associated postoperative infection and a minimal incidence of complications. Due to the robust blood supply of the scalp, there is often quick healing and an extremely low rate of postoperative infection, though complications may include bleeding, folliculitis, allergic reactions, telogen effluvium, also known as “shock loss,” ingrown hairs, infection, etc.⁵

Aside from mild discomfort, there is a risk of infection, graft dislodgement, and tissue loss, among other complications. In the author’s 10-year data collection involving 2,896 patients, no patients experienced major complications, and only minor complications were observed in 0.1% of patients. These minor complications mostly consisted of sterile folliculitis in around 200 patients.

The remainder of the complications included 26 unhappy patients and minor infections in 5 patients, 2 of whom were diabetic. Although this data pertains to 1 practice, it is generally true that most complications during hair transplantation are avoidable with a detailed medical history, careful examination and treatment of the donor and recipient areas, and proper postcare.¹

The study focuses on a medical practice that orders 1400 pairs of sterile gloves of various sizes every other week.

The cost analysis is based on the following data:

• Biweekly order of sterile gloves: 1400 pairs (sizes ranging from size 6 to size 9)

1. Cost of biweekly order of sterile gloves: $2380
2. Orders per year: 26

Current Yearly Cost of Sterile Gloves

• Annual Cost = Cost per order x number of orders per year
• Annual Cost = $2,380 x 26 = $61,880

Projected Expenditure on Nonsterile Gloves

• Cost per biweekly order of nonsterile gloves: $181.72
• Annual cost of nonsterile glove:$181.72 x 26 = $4,724.72

Cost Savings

The potential cost savings from switching to nonsterile gloves are calculated as follows:

• Annual savings = Annual cost of sterile gloves - Annual cost of nonsterile gloves
• $57,155.28 = $61,880 - $4,724.72

The cost of a pair of sterile gloves is $1.70, while a pair of nonsterile gloves costs $0.07. (Figure 1)

A cost analysis indicates that replacing sterile gloves with nonsterile gloves for non-critical applications can yield substantial annual cost savings for the practice, amounting to $57,155.28. (Figure 3) Currently, the practice spends $2,380 every 2 weeks on sterile gloves and $181.72 on nonsterile gloves. (Figure 2) This represents a reduction of approximately 92.4% in glove-related expenses.

These findings highlight the significant impact this intervention would have. For context, this amount is nearly twice the salary of a receptionist in a typical private practice. This stark contrast emphasizes the potential cost savings achieved by replacing even a few sterile gloves per week. The literature review suggests that shifting to a “clean” procedure would unlikely affect the infection rate, particularly given the anatomical characteristics and robust blood supply of the surgical site in hair restoration.

The results of this study show significant potential for cost savings. While a review of the existing literature indicates that postoperative infection rates are not different between glove types for patients undergoing Mohs micrographic surgery, the cost analysis undertaken in the current study raises the question of whether this intervention should be further studied in the surgical hair restoration patient population. Careful consideration of each patient, including a detailed medical history, is essential to making this decision safely. Practices that have switched to a nonsterile but “clean” approach still commonly use sterile gloves in situations where immunocompromised patients are undergoing surgery.

Beyond the described cost savings, there may be a meaningful environmental impact to consider. On average, 200 sterile gloves are used daily in the practice, and each pair is packaged in both paper and plastic, whereas nonsterile gloves are tightly packaged in a cardboard box. While the focus of this article is not on ascertaining the environmental impact of the switch, it is relevant to highlight this difference. The dual benefits of cost savings and sustainability appear meaningful within the practice described.

Given the parallels between the blood supply of the skin and scalp, it seems prudent to conduct formal studies to assess whether a similar safety profile is present and can be validated in surgical hair restoration.

While the data analyzed in this cost study reflects a significant difference in cost between both alternatives, it is important to note that some latitude can and should be undertaken to make individually-based clinical decision-making for certain immunocompromised patients who may carry an inherently higher risk of postoperative infections and may in fact benefit from the use of sterile gloves, as has also been documented within the Mohs micrographic surgical literature already.

The findings of this cost analysis study suggest that strategically substituting sterile gloves with nonsterile alternatives can lead to significant cost efficiencies. Future research should explore the clinical implications and patient safety considerations associated with this shift in order to ensure that quality of care and excellent surgical outcomes are never compromised.

It is important to note that this practice has chosen to remain anonymous, as they are not, and will not be, applying the results of this study, as they feel their participation could call into question their sterile practices. However, all data were obtained directly from the practice’s inventory, yielding the aforementioned information.

References

1. Garg AK, Garg S. Complications of Hair Transplant Procedures-Causes and Management. Indian J Plast Surg. 2021;54(4):477-482. Published 2021 Dec 31. doi:10.1055/s-0041-1739255
2. Humphreys TR. Commentary: Comparison of the prevalence of surgical site infection with use of sterile and nonsterile gloves for resection and reconstruction during Mohs surgery. Dermatol Surg. 2014;40(3):240. doi:10.1111/dsu.12434
3. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362-370. doi:10.1016/j.annemergmed.2003.09.008
4. Rhinehart MB, Murphy MM, Farley MF, Albertini JG. Sterile versus nonsterile gloves during Mohs micrographic surgery: infection rate is not affected. Dermatol Surg. 2006;32(2):170-176. doi:10.1111/j.1524-4725.2006.32031.x
5. Goldin J, Zito PM, Raggio BS. Hair Transplantation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 2, 2025.

Acknowledgment

The author thanks Lucas Numa for assistance with data calculation and figure preparation.