Suture Substitutes: Using Skin Adhesives

Aaron Rubin, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 4 - APRIL 98

Cyanoacrylate adhesives offer an attractive alternative to the use of sutures for closing lacerations, especially in sports medicine. Skin adhesives take less time to apply and cause less pain than suturing, and they require no dressing and no needle use—advantages that have obvious value in athletic settings. Further, studies (1,2) indicate that the cost of using tissue adhesives may be only 20% of that of suturing.

"Super glues," as cyanoacrylate adhesives are commonly known, polymerize on contact with a fluid or basic substance to form a strong bond. Various forms of these adhesives have been commercially available for years and are used by some physicians, though they are not approved by the US Food and Drug Administration (FDA) for medical use in the United States. A new-generation adhesive, octylcyanoacrylate, reportedly forms a stronger, more flexible bond than older cyanoacrylate glues (3). This substance has been approved for use by Health Canada for topical skin closure and appears likely to win FDA approval soon.

In one randomized trial (1), octylcyanoacrylate proved to be as effective as suturing in closing lacerations and was also faster and less painful. When evaluated at various follow-up intervals, the wounds were similar in appearance regardless of whether they had been treated with adhesive or with sutures. Dehiscence occurred in 3 of the 50 patients in the glue group vs 1 of 48 in the suture group.

Indications for Use

Wounds that are suitable for closure with tissue adhesives include lacerations on the face, torso, and extremities that do not have any of several contraindications. Contraindications include location on the hands or feet, location over a joint or at a mucocutaneous junction, and heavy contamination.

In addition, skin adhesives should not be used in pregnant women or patients with a history of peripheral vascular disease, diabetes mellitus, or prolonged corticosteroid use, or on patients who have puncture wounds or bite or scratch wounds (animal or human in origin).

Application

Preparation for using a skin adhesive includes standard wound management steps: control of bleeding, assessment, irrigation, cleansing, and removal of any devitalized tissue. Depending on the depth of the wound, deep suturing may be necessary to eliminate "dead space" that could become infected.

To close the wound (figure 1: not shown), manually approximate the skin edges and paint the wound line with adhesive. These steps must be executed carefully to avoid introducing any adhesive into the wound or gluing yourself to the patient. Continue to hold the wound edges together for at least 30 seconds after applying the adhesive. As mentioned above, no dressing is required. However, in some athletic settings, you may wish to add wound closure tapes or a butterfly bandage to reinforce the wound and a dressing to cover it.

Follow-up

The wound area should be inspected daily by the patient for signs of infection such as redness, swelling, warmth, tenderness, and drainage. The adhesive usually peels off within a few days after it is applied, depending on the site and the nature of the patient's activities. In most of these cases no follow-up will be required, but in some patients the nature of the wound and the patient's activities may suggest a need for a second look to make sure of proper healing. Clinical judgement can be your guide to follow-up.

References

1. Osmond MH, Klassen TP, Quinn JV: Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr 1995;126(6):892-895
2. Bruns TB, Simon HK, McLario DJ, et al: Laceration repair using a tissue adhesive in a children's emergency department. Pediatr 1996;98(4 pt 1):673-675
3. Quinn J, Wells G, Sutcliffe T, et al: A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997;277(19):1527-1530

Dr Rubin is director of the Kaiser Permanente Sports Medicine Fellowship in Fontana, California. He is a member of the editorial board of The Physician and Sportsmedicine and a fellow of the American Academy of Family Physicians and the American College of Sports Medicine.

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