Lacerations: To Glue or Not to Glue?
Author: Donald W. Alves, MD, FACEP, Assistant Professor, Division of Emergency Medicine, Department of Surgery and EMS Fellowship Director, University of Maryland School of Medicine, Baltimore
Peer Reviewer: Andrew D. Perron, MD, FACEP, FACSM, Associate Professor & Residency Program Director, Maine Medical Center, Portland
Introduction
As the pace of medical practice accelerates, health care providers seek tools that expedite patient care in a safe high-quality manner. The clinical utilization of cyanoacrylate tissue adhesives (or glues) is an example of a popular clinical topic that has the potential to enhance patient care. As many of the articles selected for this review will support, there is a clear time benefit to gluing. Questions do remain regarding cosmetic outcome, wound closure stability, infection risk, and the benefit of other potential, even less-sophisticated, wound closure techniques. Articles were selected based on their ability to maximize coverage of issues in the medical literature concerning tissue adhesive utilization, while selecting representative papers from within specific topic areas that are particularly relevant to clinical practice. The majority of literature reviewed is from the last two years, but articles were selected based on clinical relevance and applicability. The overall objective of this article is to arm the reader with a broad array of information regarding the clinical utilization of tissue adhesives, and allow him/her to answer the burning clinical question: to glue or not to glue?
Skill Level Needed?
Source: Lin M, et al. Tissue adhesive skills study: The physician learning curve. Pediatr Emerg Care 2004; 20:219-223.
This study sought to identify acceptable methods for introducing tissue adhesive use to medical students and house staff. Researchers prospectively identified two groups. The participants in one group were oriented by attending a 30-minute lecture that reviewed the medical literature, utilization of glue, exclusion criteria, and tissue application technique. Another group was trained on an individual basis. Practitioners were queried following each appropriate wound closure regarding:
- their perception of time required for closure versus suturing;
- difficulty of closure with tissue adhesive versus the expected complexity if it had been sutured;
- their personal satisfaction with immediate post-repair appearance of the wound; and
- the number of prior experiences utilizing tissue glue for wound closure.
During the nine-month study period, 81 such encounters were evaluated. Respondents in both groups uniformly reported significant time saved, expectation of substantially greater complexity of closure had the wound been sutured, and very good overall cosmesis-with measures >/= to 4.0 on a 1-5 scale; 37 of the 81 respondents were first-time tissue adhesive users. The authors concluded that wound closure utilizing tissue glue is an easily acquired skill and that the type of initial training did not significantly alter the parameters evaluated.
Commentary
Initial training, need for in-service education, and the manner to be selected for such training are important considerations for program or department level decision makers regarding the implementation of tissue adhesive in the ED. Current "gluers" may have difficulty recalling exactly how or when they were introduced to the technique, but particularly in settings that receive frequent new, junior, or rotating providers, consideration must be given to the adequacy of initial instruction to minimize the risk of adverse outcomes for patients. While the number of participants was small, the data presented strongly support that wound closure utilizing tissue adhesives is an easily acquired skill. Advocates for tissue adhesive utilization may reasonably use this data to support the ease of acquirement of this skill. An additional layer of complexity that would have further supported the cosmetic outcome similarity would have been a query of the patient or a supervising clinician for their assessment of immediate post-procedure cosmesis.
Application Technique
Source: Santibanez-Gallerani A, et al. Improved esthetic results with fine-tip Dermabond application technique. J Craniofac Surg 2004;15:890-892.
Dr. Santibanez-Gallerani and colleagues sought a means to enhance the accuracy of application of tissue adhesive to better limit contact to the dermal layer of the wound, which they report is the source of the strength of the closure. To achieve this accuracy, at time of wound closure, deep dermal sutures were placed initially; after crushing the adhesive's inner container, a 25-gauge needle on a 1-mL syringe is introduced into the cotton-top applicator and the contents aspirated. The wound to be closed is dried and approximated. The needle is then allowed to "fall" into the break in dermal continuity without skin penetration by the needle. The tissue glue is then applied along the wound's defect without overflow onto surrounding intact skin. The wound is held approximated for 45 seconds to allow adequate time for polymerization and then released. The authors queried the patients immediately post-procedure; more than 90% reported a "good to excellent" esthetic result and patient satisfaction score. They concluded that this application technique could result in lower complication rates and superior esthetics than is currently reported in the literature.
Commentary
The authors pointed out that contact of the normal surrounding skin with tissue adhesive may result in a "chemical wrinkle-like effect" that can persist for several weeks, as well as a glue-based "scab" that persists around the wound for 9-25 days. These esthetic concerns combined with the potential for the standard packaging applicator swab to contact foreign objects (e.g., gloves or instruments) were motivators in the creation of this study. The potential to minimize or eliminate these occurrences made this an excellent area for study. The study included 20 patients, and the authors reported surveying participants immediately post-procedure and at 1-week and 4-week follow-ups. Patient complaints were documented and monitored. No information is provided on the 1- or 4-week survey results, and no information is provided as to the nature of complaints, if any. No mention of presentation to an Institutional Review Board is included in the article. Despite these issues, the potential for further improvement of our clinical tissue adhesive application skills led me to include this paper. The authors concluded with the proviso that "basic [wound closure] principles must be followed." Further study would be required to determine suitability of using this technique in an outpatient (clinic or emergency department) setting where deep dermal sutures are not routinely placed for wound tension relief and closure support.
Steri-Strip Closure vs Tissue Adhesive
Source: Zempsky WT, et al. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri-Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care 2004;20:519-524.
The primary purpose of this study was to compare the cosmetic outcome of tissue adhesive (Dermabond®) versus tape closure strips (Steri-Strips™) on simple facial lacerations in children. Only patients with low-tension wounds less than 2.5 cm in length, less than 12 hours old, and who presented during the clinical shifts of one of the authors were eligible. Topical anesthesia with lidocaine-epinephrine-tetracaine (LET) was allowed to facilitate wound cleansing and care if required. Steri-Strips were applied following benzoin application and supplemented by a second layer of strips perpendicular to the first. The tissue adhesive closure group was approximated manually or using forceps and applied with usual technique. Both groups were instructed to keep the sites dry for five days. Follow-up phone calls to caregivers were made after one week to assess for wound dehiscence or infection.
At two months post closure, the wounds were photographed using a standardized technique and then evaluated by two cosmetic surgeons who were blinded to the closure technique used. The cosmetic outcome determination showed moderate agreement, and the 95% confidence intervals around each mean overlapped. Six (12%) of the glued wounds dehisced by report, although all were reported as "small" or after new trauma.
Commentary
The authors in Hartford, CT, elaborated upon a similar previous study by Mattick and colleagues from Edinburgh, UK (Emerg Med J 2002;19: 405-407), that had larger numbers: 100 total versus 60 and follow-up on 89 versus 44. The current study's conclusions are compatible with the prior study and lend support to the option to not formally close (with sutures, staples, or glue) appropriate simple facial lacerations in children, and still achieve "similar cosmetic outcomes," acceptable to plastic surgeons and parents alike.
The authors did comment on the need for hemostasis prior to tissue adhesive application and that a burning sensation may be reported. They noted that both of these may be mitigated by topical anesthetic application—LET or similar—however, they also identified an important limitation to this study: the utilization of such agents should be assessed for any independent effect on the study wound. An additional potential limitation was the provision of "research support" from 3M, Inc.
Potential 'Sticky' Situations
Source: Lo S, et al. A review of tissue glue use in facial lacerations: Potential problems with wound selection in accident and emergency. Eur J Emerg Med 2004;11:277-279.
Lo and associate conducted what they report as the first study to review the appropriateness of facial lacerations selected for tissue adhesive closure based upon current evidence. They retrospectively examined charts from a six-month period and identified 200 facial lacerations. Their search criteria excluded bite-related wounds and wounds to the neck or scalp; 45 of the 200 wounds were closed with tissue adhesive. Three of these 45 (7%) were nonlinear, and as such were assessed as not proper candidates for glue use.
Commentary
The authors did great work reviewing and identifying limitations of other tissue adhesive studies including restriction to lacerations less than 4 cm, and the absence of trials addressing traumatic flaps or stellate wounds. They commented on the risk of dehiscence and provided a 4% risk for a number needed to harm of 25, but they did not specify if this was borne out in their review or is only referencing published data. The authors subdivided the face into 15 areas to allow localization of the lacerations, and did identify 25/45 on the forehead, 12/45 in the periorbital area, and the final eight on the remainder of the face. The frequency of glue use in the periorbital area is an interesting finding as this typically is discouraged due to risk of eye injury.
An older study (Simon, et al. Lacerations against Langer's lines: To glue or suture? J Emerg Med 1998;16:185-189) assessed 48 children with facial wounds oriented either with or against Langer's lines and evaluated them for cosmetic appearance at a two-month follow-up visit. Two plastic surgeons evaluated the photographs and reported appearance as significantly worse for wounds counter to Langer's lines. In a larger study population, the addition of laceration detail— such as with this prior study—may provide further information to clinicians to help determine the appropriateness of a given facial laceration for tissue adhesive closure versus an alternate method.
Subcuticular Closure vs Tissue Adhesive
Source: Switzer EF, et al. Subcuticular closure versus Dermabond: A prospective randomized trial. Am Surg 2003;69:434-436.
This paper evaluated a new application of tissue adhesive to deeper wounds — specifically inguinal herniorrhaphy incisions —compared to subcuticular closure. Informed consent was obtained from 45 consecutive volunteers preoperatively. All patients had three interrupted 3.0 Vicryl® deep dermal sutures placed and, then, were randomized to either tissue adhesive or running subcuticular skin closure. Time for closure was significantly shorter in the adhesive group. Patients were followed up at two and four weeks by four staff surgeons who were blinded to the repair technique. The evaluators scored cosmetic and functional issues of step-off, contour irregularities, dehiscence, edge inversion, distortion, and overall appearance. The mean cosmetic scores reported were 3.88 for glue versus 4.20 for suture (on a 1-5 scale) and were not statistically significantly different.
Commentary
By randomization, the tissue adhesive group had a nonsignificant younger mean age (42.8 versus 50.2, p=0.23), which, if anything, might have led to an expectation of fewer wound healing complications, making the five found more attention grabbing. The authors explained the placement of the deep dermal sutures was a responsible precaution against frank adhesive closure failure and was standardized to both groups to minimize confounding. They attributed the failures to the increased fluid seepage from deeper wounds during the first 24 hours, which may have lifted the adhesive and led to the wound separations.
An editor's letter and author's reply (Am Surg 2004;70:369; author reply: 370-1) elaborated that while this was intended as a pilot study, with plans to repeat the methodology absent the deep dermal sutures, this intent and the pilot study itself were terminated early due to investigator concerns regarding the unacceptably high rate of "problems" encountered (5 of 24). The authors' response concluded with the recommendation that dermal sutures be placed to protect against wound separation should tissue adhesives be considered for use in deeper wounds. This study may further guide practitioners in their determination of the appropriateness of tissue adhesive use to minimize the overall complication rate.
Use in Traumatic Laceration Repair
Source: Farion K, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev 2002;(3):CD003326.
Fairon and colleagues examined the literature for the use of tissue adhesives in adult and pediatric traumatic lacerations for the Cochrane Database. They cited the major factors—increasing popularity of glue use, ease of use, decreased pain, decreased time to apply, and no required follow-up visit—as advantages contributing to the popularity of this technique. None of the substantial number of studies published to date had adequate power or consistency in study parameters to allow assertion of definitive answers regarding the efficacy of tissue adhesives. The authors vigorously searched for randomized controlled trials and included them for comparison if they addressed acute, linear, low-tension traumatic (nonsurgical) lacerations. Eight studies were compared; no significant difference for cosmetic result was found. Favorable reductions in both procedural pain and time to complete were reported. A "small but statistically significant risk" of wound dehiscence was identified with tissue adhesives—number needed to harm (NNH) 25, with 95% CI 14-100, as well as local erythema—NNH 8, 95% CI 4-100. Their conclusions reflected these findings and reported tissue adhesives to be an "acceptable alternative to standard wound closure for simple traumatic lacerations."
Commentary
Since my initial introduction to it in residency training, the Cochrane Collaboration has been praised for its rigorous efforts and methodologies to present meta-analyses with the best information available for clinical application. I found no reason for change in my esteem of their reputation based upon my review of their methodology of literature search, scoring, inclusion, and review techniques used for this topic. Their conclusions pre-dated many of the other papers summarized here, and are further supported by the findings of the subsequent authors. Of note to readers: A one-page summary of Fairon and colleagues' contribution is presented in Evid Based Nurs 2003; 6:46.
Antimicrobial Barrier Properties
Source: Bhende S, et al. In vitro assessment of microbial barrier properties of Dermabond® topical skin adhesive. Surg Infect(Larchmt) 2002;3:251-257.
This study was performed to gather additional information for the clinician (based upon an in vitro study) regarding the antimicrobial/ barrier effect of tissue adhesives in general, and octylcyanoacrylates (Dermabond®) in particular. Sterile agar containing bromocresol purple (as a color-change indicator of biological activity) was prepared and then layered with one or three "films" of adhesive with liquid from individual applicators, to create uniformly thick films, each approximately 20 mm in diameter. Positive control plates were created by punctures with a sterile needle. Negative controls included plain agar and uninoculated glue film agar plates. Twenty films per organism were subjected to a broad spectrum of organisms, including S. epidermidis, methicillin resistant S. epidermidis (MRSE), S. aureus, MRSA, E. faecalis, vancomycin-resistant Enterococci (VRE), E. coli, Klebsiella pneumoniae, Proteus species, S. marcescens, Acinetobacter baumanii, and Candida albicans. The plates were then incubated right side up for three days at 37°C. The 300 single-layer films had one plate lost due to compromise of the integrity of its glue layer, resulting in "95% confidence of 98.5% efficacy for 72 hours" as an in vitro barrier to microbial penetration. The 300 triple-layer films had one plate demonstrate growth around the layer as a contamination rather than an accepted true-positive result (=failure) by growth through the layer. This yielded similar efficacy estimates.
Commentary
The introduction does comment on potential mechanisms for reduction in the risk of infection with the use of tissue adhesives:
- elimination of punctures (for anesthesia and suture) that may introduce skin flora into the wound;
- the absence of suture material that may provide a migration path through the skin for bacteria; and
- the flexible seal over the wound to reduce secondary contamination.
The project was conducted with resources from Jansen® and Ethicon®, which could pose the only potential "cloud" over this otherwise elegant basic science investigation; however, as reported it is unlikely that there would be any interference with the project as reported.
The paper is well written and contains background information on tissue adhesives that likely only a manufacturer would be able to detail. The authors mentioned a guinea pig wound closure study that found lower infection rates than with traditional monofilament suture closures and built from this point to reflect that in this in vitro study model; absent the protection of an immune system's inherent protections, penetration of the film(s) by even one microorganism could have caused an agar color change and resulted in a positive (=failed) barrier determination.
Hair Apposition Technique
Source: Hock MO, et al. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med 2002;40:19-26.
This article compared a hair twist secured by tissue adhesive against standard suturing. Researchers required the lacerations to be linear, not actively bleeding or severely contaminated, less than 10 cm total length, in an area with hair at least 3 cm long, and hemodynamic stability of the patient to be randomized.
Participating practitioners were in-serviced on the technique prior to the study. Ninety-six patients had hair apposition technique (HAT) used, and 93 were sutured. The patients were instructed to not wash the wound for two days. Wound inspection was performed after one week, and infection, bleeding, allergy, scarring, and wound breakdown were noted as either present or absent based upon definitions elaborated upon in the article. The examiner at follow-up was also to determine if "satisfactory wound healing had occurred." If this was not the case, the patient was brought back weekly until healing was deemed complete.
Demographic and wound characteristics were similar between groups. The investigators reported a significant reduction in procedural time with hair apposition and glue (p < 0.001) and an increased incidence of scarring and infection in the suture group (p = 0.004 and 0.005, respectively). They reported limitations of patients with very short or no hair, profusely bleeding wounds, or grossly contaminated wounds. They reported HAT to be simple, effective, and able to be "learned quickly by anyone."
Commentary
The authors mentioned prior studies with use of hair, but clarified that those physically knotted the strands to oppose the wound edges and, thus, had to eventually be cut off. The related editorial (Ann Emerg Med 2002;40:27-29) elaborated on prior reports in the literature of hair-assisted wound closure techniques, plus pointed out that only the outermost layers of skin are opposed, which could potentially result in a deeper tissue dead space, and wound edge eversion with HAT would be very difficult to obtain. The editorialist pointed out that function and cosmesis are not critical in most scalp wounds, and that early wound appearance does not correlate to later outcome. The authors, editorialist, and I agree in the end that knowledge of this technique could only serve to benefit the occasional, appropriately wounded patient in the future. Lastly, brief synopses of Hock's work have been presented in two articles (Weick R, et al. Hair apposition technique is better than suturing scalp lacerations J Fam Prac 2002;51:818; and Brosnaham J. Treatment of scalp lacerations with a hair apposition technique reduced scarring, pain, and procedure duration compared with suturing. Evid Based Nurs 2003;6:17.)
Needle-stick Injuries and Glue Use
Source: Gordon CA. Reducing needle-stick injuries with the use of 2-octyl cyanoacrylates for laceration repair. J Am Acad Nurse Pract 2001;13:10-12.
This small descriptive study sought to confirm an expectation of reduced needle-stick exposure risk through the utilization of tissue adhesives for laceration repair. Thirty-eight patients had data collected when their treating practitioner (physician or nurse practitioner) selected glue as the closure method for a laceration; 58% of these cases were pediatric. "At the end of treatment," 92.1% of wounds were completely approximated, and there was no erythema, wound drainage, or warmth reported by any patient. They reported that 7.9% required reapplication of the adhesive due to wound dehiscence. Among the providers, no needle-stick injuries were reported as a result of these wound closures, and 82.3% preferred tissue adhesive as a closure technique.
Commentary
This study is reviewed here to remind us of the obvious: stuff happens. No matter the level of precaution, if someone/something moves wrong at the wrong time during a suture closure of a laceration, there is a potential for percutaneous blood exposure. Because it is widely acknowledged that more than 25% of persons with HIV do not know they have it, it is not just a "nondisclosure" circumstance. The opportunity to avoid contact with needles or other sharps in a procedure, when feasible, does make the risk of a sharps-related injury that much less likely.
Conclusion/Recommendations
I will preface this summary with mention that given an appropriately cleansed, nonbleeding wound and a willing patient, I use tissue adhesives in a broad variety of laceration presentations, generally with excellent results. If an acceptable closure cannot be achieved in this manner, the glue is then removed and the wound prepped and closed in an alternate fashion. Lin demonstrated the relative simplicity of providing initial instruction on procedural aspects of this technique to a varied skill-level audience.
The syringe-and-needle technique as an alternate applicator may eventually migrate into the outpatient arena where "glue-clot" and self-adhesion issues can complicate wound closure, however this will require further investigation. Two separate, alternate techniques for laceration approximation were presented (hair apposition and adhesive strip application) with potentially even less discomfort than tissue adhesive application, and comparable cosmetic outcomes to broaden the practitioner's procedural armamentarium in appropriate lacerations. The Bhende paper elaborated on the potential added benefit to the use of tissue adhesives of an antimicrobial barrier, an excellent investigation utilizing an in vitro model.
Several of the abstracts either directly or indirectly drew attention to the importance of selecting appropriate wounds for tissue adhesive application to optimize the likelihood of satisfactory outcomes for our patients. Excessive depth, significant incongruity with Langer's lines, or lacerations located in more mobile or tensile areas of skin are factors that should be considered to yield an educated decision to utilize an alternate closure technique. The clinician should be able to articulate the rationale for selection of closure technique to the patient or other practitioners, if asked.
Alternately, if the clinical decision is made to utilize cyanoacrylate glue on a laceration that would reasonably pose an increased risk of dehiscence, the old-fashioned practice of adding support and additional protection to a wound once closed via overriding adhesive strips, bulky dressings, or even splinting if necessary, will improve the odds in favor of the wound healing in an acceptable fashion.
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