Key Practice Points
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Alternatives to sutures for wound closure include wound adhesives, tapes, and staples. For the most part, all wound closure materials ultimately have the same cosmetic outcome.
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Of the available wound adhesives, octyl cyanoacrylate (Dermabond) has the best wound closure characteristics.
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The proper technique for applying adhesives restricts their use to the skin surface. Adhesives are toxic to subcutaneous tissue.
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Adhesives are in liquid form as they exit the applicator; therefore care is taken to prevent “runoff” of the adhesive into the eyes and the mouth.
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Wound tapes are appropriate for narrow, straight lacerations (commonly on the face), for flaps, and for the fragile skin of the elderly.
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Staples are less reactive than sutures, and staples potentially cause less scarring and infection.
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During the stapling of wounds, it is important to apply the stapler gently to the skin before activating the trigger to prevent driving the staple too deeply.
Through the years, sutures and their alternatives — wound adhesives, tapes, and staples — have become established and are routinely used in wound care. Emergency physicians value staples, because they are easy to apply, they save time, and the outcome of their use is good. Staples are particularly useful for scalp and truncal lacerations. After they were introduced in the 1980s, wound tapes commonly were used for straight lacerations that were under little tension, for surgical incisions, and for supporting lacerations with recently removed sutures. With the advent of adhesives, a new alternative has become available.
Tissue Adhesives
Tissue adhesives are relatively new to wound and laceration closure in the United States; they were approved by the Food and Drug Administration in 1998. Since the 1980s, tissue adhesives have been successfully used in Europe, Canada, the Middle East, and Asia. These compounds derive from the cyanoacrylate adhesives used in common household super glues. Formulated for medical purposes, they are well tolerated, effective, and nontoxic.
Until 1998, n-butyl cyanoacrylate (Histo-Acryl Blue, Indermil) was the most commonly used tissue adhesive worldwide. In 1998, a new compound, octyl cyanoacrylate (Dermabond), was released for general use. Dermabond has many advantages over Histo-Acryl Blue. Dermabond contains a plasticizer that makes it flexible and useful for irregular or moving surfaces. Dermabond has a bacterial protection effect and a higher breaking strength. Finally, in contrast to Histo-Acryl Blue, Dermabond is packaged sterilely and can be stored at room temperature. In the United States, Dermabond is currently the tissue adhesive with the most desirable characteristics for wound care.
Dermabond can be used in many wounds and lacerations ordinarily closed with sutures, tapes, or staples. It is particularly effective for lacerations on the face. There are no limits to laceration length, and it can be used over joints if properly splinted. Dermabond is an improvement over sutures for the closure of wounds of thin, aged, or corticosteroid-affected skin. If easy approximation can be achieved, Dermabond closes wounds with flaps and corners. Tissue adhesives are not used on mucous membranes or hair-bearing or weight-bearing areas. The following criteria can guide the decision to use tissue adhesives:
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Fresh lacerations that are within the “golden period”
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Laceration under low tension that are easy to approximate
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Lacerations with clean and even edges that can be closed with no gaps
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Lacerations with little or no blood oozing
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Situations in which adhesive runoff can be controlled or avoided
The cosmetic result of wounds closed with adhesives is indistinguishable from that of sutured wounds. Investigators have followed wounds for 3 months and have used “blinded” observers who could not tell the difference between adhesive-closed wounds and sutured pediatric lacerations. For reasons of convenience and patient comfort, parents prefer closure of their children’s lacerations with wound adhesives when asked to compare with previous experiences of standard suturing techniques. It has been reported, however, that children occasionally pick off the glue with their fingers, and in these cases, wounds have been closed successfully with sutures as delayed primary closures. Finally, although not statistically significant, the infection rate for adhesive-closed wounds tends to be lower than that for sutured wounds, and under experimental conditions, adhesive-closed wounds resist contamination more than sutured wounds do.
The most attractive features of wound adhesives are short wound closure time and no requirement for anesthesia. Wound closure time is approximately 20% to 50% of the time necessary for standard suturing. Adhesives polymerize within seconds after application, and the wound needs manual support for only 30 to 60 seconds after application of the adhesive. Wounds closed with adhesives are at greater risk for breaking open immediately after closure than sutured wounds. After 7 days, there is no difference, however, in tensile or bursting strength between adhesive-closed and sutured lacerations. Breaking strength of adhesives is equivalent to a 4-0 nylon suture. Less technical expertise is required for adhesive closures, and patients do not have to return for suture removal. For increased strength in long lacerations, a combination of wound tapes and wound adhesive can be considered.
In emergency wound care, wound adhesives are restricted to skin surfaces, and care must be used to prevent penetration into the wound. Cyanoacrylates applied within tissue can cause acute inflammatory responses, giant cell reactions, inclusion body formation, and seromas. Subcutaneously or within organs, they can remain in tissues for extended periods (1 year). Cyanoacrylates have accumulated an excellent and safe record for use in wound care. In large amounts, cyanoacrylates generate exothermic heat that can cause pain. In wound care, small amounts of adhesive are applied externally, and the adhesives peel off after the wound heals.
Adhesive Wound Closure Technique
Dermabond comes in a sterile, plastic-covered glass vial with an applicator tip ( Fig. 14-1 ). Until recently, there was only one choice of adhesive viscosity and applicator tip. Because of concerns about runoff of adhesive from wounds, a new, higher viscosity formulation has been introduced. When compared with the low-viscosity formulation, the higher viscosity adhesive had significantly less runoff from the wound area. Otherwise, the outcomes were comparable. The standard applicator tip is rounded and has a tendency to depress or invert the wound edges if excessive pressure is applied during application. A new, chisel tip is more versatile and allows for even application of adhesive without undue pressure on the wound edges to cause inversion. The procedure for application of adhesive is as follows ( Fig. 14-2 ):
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After wound cleansing and any necessary débridement, any significant bleeding should be controlled. The wound does not have to be strictly dry, however, because polymerization occurs in the presence of a liquid, either water or blood.
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The patient is placed in a position so that the wound is facing directly up, and adhesive runoff is prevented. It is advisable to have nearby or to hold a gauze sponge to mop excessive adhesive quickly. A rim of petrolatum ointment placed around the wound helps block runoff.
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The eye is especially vulnerable to “runoff” and inadvertent gluing of the eyelids together. Therefore, if the laceration is above the eye, place the patient in a slight Trendelenburg position. For lacerations below the eye, the patient is placed in the reverse Trendelenburg position.
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When the patient is properly prepared and placed, the plastic Dermabond applicator is crushed and squeezed until adhesive covers the applicator tip.
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The wound is approximated gently with fingers or forceps. In some wounds, a second person can assist with wound edge approximation and excess adhesive removal.
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Adhesive is layered over the wound with a margin of 5 to 10 mm. Finger or forceps approximation is maintained for 30 to 60 seconds to allow for polymerization. After 15 to 20 seconds, more adhesive can be applied. Three separate layers are recommended to complete the closure. It takes 2.5 minutes for adhesive to reach its full tensile strength.
Histo-Acryl Blue is a combination of adhesive and blue dye. It is not as versatile as Dermabond and is recommended for short, straight lacerations. It comes in a container with an applicator tip but is applied more easily by cutting off the tip and replacing it with a 25-G needle. Because of its consistency, Histo-Acryl Blue requires a different technique for application than does Dermabond. After the wound edges are approximated, small drops, “spot welds,” are placed along the wound until it is closed. The wound has to be supported for 30 to 60 seconds to ensure proper polymerization. Histo-Acryl Blue is more brittle than Dermabond and can break more readily.
Adhesive Closure Aftercare
The patient is instructed to keep the wound clean and dry for 24 hours. After this period, gentle cleansing can be done with great care and caution so as not to disrupt the closure. If a wound dehisces, the patient is instructed to return so that delayed primary closure with wound tapes or sutures can be performed. No follow-up is necessary for glue removal because it peels off on its own or comes off with the natural sloughing of keratinized epidermis.
Inadvertent Adhesive Runoff and Removal
Because adhesives are liquid, they can run off the wound area by accident or drip onto unwounded surfaces. Vulnerable areas include the eyes, nose, mouth, ears, and fingers. If possible, the runoff should be wiped up before drying. If polymerization occurs, petroleum ointment can be applied to accelerate breakdown and peeling. Antibiotic ointments can be used for this task. The most effective removal substance is acetone. Because acetone is toxic to delicate tissues, great care must be taken around the eyes. Forceps also can be used when the adhesive is completely dry to flake it away gently.
Wound Taping
There are several advantages to wound taping compared with suturing. Advantages include a reduced need for anesthesia, ease and speed of application, even distribution of tension across the wound, no residual suture marks, application by nonphysician personnel, and the elimination of the need for suture removal. Tapes also have advantages in closing flap lacerations and have a greater resistance to wound infection than sutures. Tapes do not work well on surfaces that are oily or hair bearing, on joint surfaces, on lax skin, on gaping wounds under tension, or on very young or uncooperative children. The cosmetic outcome is equivalent to adhesive closure.
A bewildering variety of wound tapes are currently on the market. Steri-Strips are the best known; other brands include Shur-Strip, Cover-Strips, Suture-Strip, Clearon, Nichi-Strip, and Curi-Strip. The various brands have differing porosity, adhesion, flexibility, breaking strength, and elongation capability. An early study that compared Clearon and Steri-Strips showed a better overall performance by Steri-Strips. In another comparison study of six tapes (Curi-Strip, Steri-Strips, Nichi-Strip, Cicagraf, Suture-Strip, and Suture-Strip Plus), an overall scoring method was devised to rank their performance under laboratory conditions. The three highest ranking tapes were Nichi-Strip, Curi-Strip, and Steri-Strips. Under experimental conditions, tape closures resisted wound infection better than nylon sutures. Tapes also are well suited for supporting grafts and flaps.
Indications for Taping
Wound taping can be considered under the following conditions:
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Superficial, straight lacerations under little tension. Areas suitable for taping include the forehead, chin, malar eminence, thorax, and nonjoint areas of the extremities.
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Flaps in which sutures might compromise vascular perfusion at the wound edges.
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Lacerations with a greater-than-usual potential for infection.
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Lacerations in an elderly or steroid-dependent patient who has thin, fragile skin.
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Support for lacerations after suture removal.
Tapes do not work well on irregular wounds, wounds that cannot be made free of blood or secretions, intertriginous areas, scalp, and joint surfaces.
Taping Technique
Most taping of emergency wounds can be done with 1⁄4-inch-wide tape of varying lengths. For wounds that are greater than 4 to 5 cm in length, ½-inch width is preferable. The following steps are performed:
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The wound is cleansed, irrigated, and débrided if necessary. Hemostasis has to be complete and the skin surface completely dried.
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Benzoin is applied to the surrounding skin to increase adhesion. Care is taken not to spill this agent into the wound. Benzoin is left to dry until it becomes tacky.
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Tapes are cut to the length desired while they are still on the backing sheet. Usually 2 to 3 cm of overlap is allowed for each side of the wound.
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One of the perforated end tabs is gently removed to prevent deforming of the tape ends ( Fig. 14-3 ).
