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Minor wound repair with tissue adhesives (cyanoacrylates)

Minor wound repair with tissue adhesives (cyanoacrylates)
Literature review current through: May 2024.
This topic last updated: Aug 11, 2023.

INTRODUCTION — Laceration repair with tissue adhesives is discussed here. Information concerning repair of surgical incisions with tissue adhesives, wound preparation and irrigation, topical and infiltrative anesthesia, and wound closure with sutures or staples is found separately as follows:

(See "Overview of topical hemostatic agents and tissue adhesives".)

(See "Minor wound evaluation and preparation for closure".)

(See "Clinical use of topical anesthetics in children".)

(See "Subcutaneous infiltration of local anesthetics".)

(See "Skin laceration repair with sutures".)

(See "Closure of minor skin wounds with staples".)

PROPERTIES OF TISSUE ADHESIVES — Tissue adhesives were approved for minor wound repair in the United States in 1998, although they have been widely used in Europe and Canada for much longer [1-3]. Although tissue adhesives other than the cyanoacrylates are available, this discussion will primarily be limited to cyanoacrylate polymers, since they are most commonly used for minor laceration repair. Commercially available tissue adhesives primarily contain n-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) or 2-octyl cyanoacrylate (eg, Dermabond, SurgiSeal).

Cyanoacrylate tissue adhesives are liquid monomers that undergo an exothermic reaction on exposure to moisture (eg, on the skin surface), changing to polymers that form a strong tissue bond [4]. When applied to a laceration, the polymer binds the wound edges together to permit normal healing of the underlying tissue.

The chemical composition, especially the length of the side chain, largely determines key properties of the tissue adhesive. Shorter side chains (eg, methyl-2, ethyl-2, or n-butyl-2 cyanoacrylate) form tighter and stronger polymer bonds rapidly (within 15 seconds) [4]. However, these bonds are more brittle, resulting in a higher likelihood of wound dehiscence than long-chain adhesives.

Tissue adhesives with longer side chains (eg, 2-octyl cyanoacrylate) form weaker bonds more slowly (approximately 30 seconds) but are less brittle and have a lower risk of wound dehiscence than short-chain adhesives [4]. Furthermore, the addition of plasticizers also permits the longer chain compounds to form a flexible, more adherent bond [5].

Once applied, maximum bonding strength is achieved within 2.5 minutes of application. The tissue adhesives form a barrier to moisture and microbes over the wound, with adhesives with longer side chains taking longer to set [4,5]. The bonded adhesives spontaneously slough off within 5 to 10 days.

Compared with wounds closed with either absorbable or nonabsorbable sutures, the tensile strength of wounds closed by tissue adhesives is less at the time of initial application but equalizes by one week after repair [1-3,5,6].

Cyanoacrylates degrade into the toxic byproducts cyanoacetate and formaldehyde; these byproducts theoretically can cause an inflammatory response in the surrounding tissues that may compromise wound healing [4]. However, the rate of degradation in currently used cyanoacrylates (eg, n-butyl-2 cyanoacrylate or 2-octyl cyanoacrylate) is slow enough that the compound has sloughed off before any significant accumulation of toxic byproducts can occur.

Results of an in vitro study suggest that tissue adhesives may have inherent bactericidal activity against gram-positive organisms [7].

INDICATIONS — The table describes key aspects of wounds that affect the selection of a wound closure method (table 1).

We suggest that patients with short (<5 cm) traumatic skin lacerations that are clean, have good wound approximation, and are under low wound tension undergo repair with tissue adhesives rather than sutures (figure 1 and figure 2). Wounds that meet all of these criteria are typically located on the face, especially the forehead. If n-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) is used, then the length of the laceration should be <4 cm to avoid wound dehiscence. The application of tissue adhesives is described below. (See 'Techniques' below.)

Based upon clinical experience and evidence from case series or reports, tissue adhesives may also provide closure for other types of wounds, including:

Skin tears and flaps in patients with fragile skin that cannot be easily sutured (eg, older adult patients), either as the primary means of closure [2,4,8] or applied adjacent to the wound to reinforce atrophic skin edges prior to suture placement [9]

Traumatic lacerations in athletes to permit a more rapid return to competition [10,11]

Wounds under tension after placement of subcutaneous sutures (see 'Preparation' below)

Scalp wounds, as long as the hair around the wound needs to be trimmed prior to closure

Wound closure in patients susceptible to keloids to promote less reaction than sutures [12]

Tissue adhesives have the following advantages for repair of short, clean, straight, traumatic lacerations with low wound tension when compared with sutures [2,4,8,13-15]:

Less painful procedure

More rapid repair time

Creation of a waterproof and antimicrobial barrier

Better acceptance by patients

No need for suture removal or follow-up

Cosmetically similar results post-repair

Safer for the provider than sutures because needlesticks are avoided

Based upon a meta-analysis of 13 small trials of children and adults with traumatic lacerations that were linear and under low tension, tissue adhesives were significantly less painful, quicker to apply (on average, five minutes faster), and produced similar cosmetic outcomes at 12 months compared with wounds repaired with sutures [13]. Tissue adhesives were associated with a small but significantly increased risk of wound dehiscence (risk difference 2 percent, number needed to harm: 40), although the clinical importance of this finding is unclear and the total number of wound dehiscences was low. Most traumatic lacerations undergoing repair in these studies were <5 cm in length and were located on the face (eg, forehead).

CONTRAINDICATIONS AND PRECAUTIONS — Tissue adhesives should not be used for the following wounds [2,4,8]:

Wounds under tension, unless subcutaneous sutures can be placed to lessen tension and permit good wound approximation.

Complex stellate lesions, crush wounds, or other lacerations with poor wound approximation.

Wounds on the hands and feet or over joints, unless the affected areas are immobilized, because repetitive movements could cause the adhesive bond to break before sufficient wound healing has occurred.

Wounds on the oral mucosa or other mucosal surfaces (eg, vagina) or areas of high moisture, such as the axillae and perineum. Although successful tissue adhesive closure of a tongue laceration has been described, use of tissue adhesives on mucosal surfaces is not recommended by the manufacturer because of more rapid loss of adherence [16].

Wounds in hairy areas, unless the hair is trimmed.

Wounds requiring a high level of precision (eg, hairline or vermilion border).

Bite wounds and other wounds at increased risk of infection (eg, puncture wounds, wounds with devitalized or contaminated tissue). (See "Human bites: Evaluation and management", section on 'Wound closure' and "Animal bites (dogs, cats, and other mammals): Evaluation and management".)

Allergy to adhesives (or formaldehyde), including patients who have had a prior allergic reaction to acrylates used in application of false nails or eyelashes, since potential cross-reactivity has been reported [17,18].

Caution should be used when applying tissue adhesives to wounds in patients with diabetes mellitus, chronic vascular disease, peripheral vascular disease, decubitus ulcers, prolonged steroid use, bleeding diathesis, or any other condition that may delay wound healing [2,3,19]. However, tissue adhesives may be better than other options for wound closure in patients with poor wound healing, at least for small lacerations, because no foreign material is placed into the wound [12].

PREPARATION

Pain control — Given the low pain of the procedure, we suggest that children undergoing minor wound repair with tissue adhesives receive a topical anesthetic (eg, lidocaine-epinephrine-tetracaine [LET]) on an as-needed basis rather than injection of a local anesthetic. Many children do well without any analgesia, although topical anesthesia further decreases pain. For example, in a blinded trial of over 200 children undergoing wound closure with tissue adhesives, patients who received LET for anesthesia reported significantly less pain and were more likely to report a pain-free procedure than children who received placebo (52 versus 28 percent, respectively) [20]. However, the level of pain reported in both groups was low. Thus, if timing is an important factor, topical anesthesia may be omitted, especially in older patients.

Sedation — Laceration closure with tissue adhesives can typically be performed without sedation in most children. For uncooperative and anxious young children undergoing repair of lacerations with skin adhesive and for whom nonpharmacologic methods are inadequate, mild sedation (eg, intranasal or oral midazolam) may be warranted to achieve satisfactory wound irrigation and repair.

Wound preparation — Wounds closed with tissue adhesives warrant thorough irrigation and cleansing [4,8]. Because adhesives create an impermeable barrier over the wound, inadequate cleansing is associated with local infection and abscess formation. (See 'Wound infection' below and "Minor wound evaluation and preparation for closure".)

A wall of antibiotic ointment or damp gauze may be placed around the laceration to prevent excess glue leakage around the wound. (See 'Excess leakage' below and 'Ocular exposure' below.)

For deep lacerations, particularly to the torso and extremities, subcutaneous sutures should be placed prior to application of tissue adhesive [4,8]. Failure to strengthen such wounds with subcutaneous sutures may increase the risk of wound dehiscence and adversely affect the cosmetic result, since the adhesive typically peels off within 5 to 10 days [21]. (See "Skin laceration repair with sutures", section on 'Dermal closure'.)

Patient positioning — Position the patient so that the wound is horizontal or tilted away from adjacent structures (eg, the eyes) to minimize leakage of the adhesive. (See 'Complications' below.)

In uncooperative and/or anxious patients, it is strongly encouraged to have an assistant help to stabilize the area of the wound when placing skin adhesive.

Materials — Assemble the following materials:

Sterile gloves for the provider

Sterile 4 x 4 inch gauze

Sterile drapes

Irrigation solution (eg, sterile normal saline or clean tap water) (see "Minor wound evaluation and preparation for closure", section on 'Irrigation solution')

30 to 60 mL syringe with 18- to 19-gauge intravenous catheter or irrigation device with splash shield (eg, Zerowet, Igloo wound irrigation system)

Tissue adhesive (2-octyl or n-butyl-2 cyanoacrylate)

Toothed tissue forceps for wound approximation during the procedure (optional)

TECHNIQUES

Choice of adhesive — The choice of adhesive does not have an important impact on wound outcomes as long as the clinician is aware of the differences between adhesives and uses appropriate technique. Both commonly used tissue adhesives (n-butyl-2 cyanoacrylate and 2-octyl cyanoacrylate) have similar efficacy for the closure of low-tension, traumatic lacerations <4 cm in length [22]. Repair with 2-octyl cyanoacrylate (eg, Dermabond, SurgiSeal) is associated with an increased sensation of warmth, especially if the high-viscosity formulation is used [23]. N-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) complexes more quickly than 2-octyl cyanoacrylate but forms more brittle bonds, which increases the likelihood of wound dehiscence, although the risk of dehiscence is low for both agents. (See 'Indications' above.)

2-octyl cyanoacrylate (eg, Dermabond, SurgiSeal) — Application is performed as follows [4,8]:

Ensure complete hemostasis so that blood oozing from the wound does not interfere with adherence of the tissue adhesive to the skin. Topical application of lidocaine-epinephrine-tetracaine (LET) prior to wound repair may also assist in achieving hemostasis.

Remove any adjacent tissue that extrudes through the wound or any hair that overlies the wound.

Ensure that the skin adjacent to the wound is completely dry.

For wounds that do not approximate well, place subcutaneous sutures prior to application of the adhesive.

For long, superficial lacerations, apply adhesive surgical tape (eg, Steri-Strips, Leukostrips) to assist with wound approximation [24].

Appose or attempt to evert the wound edges using gloved fingers or tissue forceps. (See 'Preparation' above.)

Warn patients that they may feel a sensation of warmth [2,3,5].

2-octyl cyanoacrylate tissue adhesives (eg, Dermabond, SurgiSeal) are packaged in a plastic, single-use vial with a foam or tapered tip applicator at one end. Crush the vial to begin the polymerization process, then squeeze the vial to force the adhesive to permeate the foam-tip applicator. Pay attention to the following points:

Use the vial within the first few minutes, or polymerization within the vial tip will prevent use.

Squeeze the vial gently to avoid dripping of the adhesive; stop squeezing as soon as a drop begins to form at the tip.

Once the tip is saturated, swipe it gently over the wound edges in a single motion, spreading a thin film over them (figure 3). Never press the applicator tip into the wound because this may lead to glue within the wound margin, which can cause a foreign body reaction that prevents normal wound healing [21]. If this occurs, wipe off the adhesive using petroleum jelly or antibiotic ointment to loosen the polymer. Then, reclean and reclose the wound [2,3,25].

Briefly remove the operator's hand (or forceps, if used) from the skin before the glue polymerizes to ensure that it does not adhere to the wound.

Allow the adhesive to dry for 30 to 40 seconds to permit complete polymerization while continuing to hold the wound edges together. This first layer reaches full tensile strength in approximately two minutes. If wound edges are not well aligned after the first application, wipe away the adhesive with gauze within about 10 seconds [2]. Application of antibiotic ointment or petroleum jelly for 30 minutes will allow removal of the polymer if the glue has already hardened.

Repeat the application process three to four times in an oval pattern around the wound to encompass a greater surface area on the skin. Enhance wound-closure strength by extending the application 5 to 10 mm beyond the margin of the incision [5]. These subsequent layers typically take longer to dry than the first layer because less moisture is available for polymerization. Do not touch the repaired wound until complete drying has occurred, which may take as long as five minutes.

N-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) — Butyl cyanoacrylates polymerize much more quickly than octyl cyanoacrylates (approximately 10 to 15 seconds) [8]. They also are more prone to wound dehiscence and are primarily indicated for straight lacerations that are less than 4 cm in length. (See 'Properties of tissue adhesives' above.)

They are packaged in ampules, and application is as follows [8,26]:

Ensure complete hemostasis so that blood oozing from the wound does not interfere with adherence of the tissue adhesive to the skin.

Remove any adjacent tissue that extrudes through the wound or any hair that overlies the wound.

Ensure that the skin adjacent to the wound is dry.

For wounds that do not approximate well, place subcutaneous sutures prior to application of the adhesive.

Appose or slightly evert the wound edges using the fingers or tissue forceps. (See 'Preparation' above.)

Remove the cap from the vial and hold it with the tip upwards. Flick the vial so that any adhesive trapped in the tip is removed. Cut off the tip of the vial.

Appose the wound edges using a gloved hand or tissue forceps. Apply the butyl cyanoacrylate glue directly from the tip or through a 25-gauge needle attached to the tip. The pattern should be in discrete drops along the wound margin, and only a single application is required (figure 4).

Briefly remove the operator's hand (or forceps, if used) from the skin before the glue polymerizes.

Avoid touching the wound margin with the applicator while applying the glue.

AFTERCARE — Wounds repaired by tissue adhesives do not require external bandages; the adhesive itself acts as a water-resistant bandage. Antibiotic ointment should not be used because it can break down the adhesive prematurely. The patient should receive tetanus prophylaxis as needed (table 2).

Patients may shower while the adhesive is on the skin but should not soak or scrub the area for 7 to 10 days. Wet skin should be gently patted dry. Children should not take baths if bathing would result in submersion of the affected area.

The adhesive will peel off when the epithelial layer sloughs off, usually by 5 to 10 days [1-3,5,27]. Antibiotic ointment or petroleum jelly can be applied to the wound if the adhesive does not come off on its own.

No follow-up visit is required unless there are signs of infection or nonhealing.

COMPLICATIONS — Most complications of tissue adhesives relate to leakage onto unwanted areas, although improper wound preparation or use of adhesives on wounds at risk for infection can lead to cellulitis or abscess.

Excess leakage — Squeezing the vial too forcefully can result in adhesive draining away from the wound. This should be wiped off before it hardens. If the glue has set, it can be removed from adjacent skin by application of petroleum jelly or antibiotic ointment. Some authors recommend applying a protective periphery or "wall" of antibiotic ointment around the wound to prevent runoff and adhesion to adjacent structures. Gauze can also be used in the vicinity of the tissue adhesive to prevent adhesive runoff, but it should be moistened to decrease the probability of adherence to the skin [25]. Moistened gauze should be squeezed well, however, because it should not wet the skin where the adhesive is applied.

Gluing of gloves or instruments — Care should be taken to prevent leakage of the adhesive onto the glove or the forceps because they can become glued to the patient [8,25]. Alternating the hands or briefly removing the forceps from the skin before the adhesive hardens helps to prevent this problem. (See 'Techniques' above.)

If the wound is held together with fingers during repair, use of vinyl gloves helps reduce this complication because adhesion to vinyl gloves is substantially weaker than to rubber latex gloves [25]. If adhesion occurs, mild tension is usually enough to separate the bond. If that fails, the glove can be removed and cut so that only a small piece of the glove remains attached to the patient.

Tissue adhesives also stick less well to metal than to plastic forceps. If the instrument becomes attached to the patient, application of antibiotic ointment or petroleum jelly and gentle traction typically suffices for removal.

Ocular exposure — The eyes should be well protected during repair of adjacent lacerations. If adhesive gets into the eye or under the eyelid, or glues the eyelashes together, generous amounts of ophthalmic antibiotic ointment should be placed within the eye and on the eyelid to break down the adhesive [25,28,29]. Gentle manual traction typically permits reopening of eyelids that have been glued shut. If manual traction is unsuccessful, an ophthalmologist should be consulted. Once the eyelids are reopened, the patient should be assessed for corneal abrasion. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)

Wound infection — Wound infections may result from inadequate cleansing of the wound or application of tissue adhesives to wounds with a high risk of infection (eg, puncture wounds, animal bites, or wounds in patients with comorbid conditions [eg, diabetes mellitus]) [30]. Periorbital cellulitis and necrotizing fasciitis have been described. Clinicians should provide the same degree of meticulous wound cleansing and preparation for wounds undergoing closure with tissue adhesives as they would for wounds being repaired with sutures. (See "Minor wound evaluation and preparation for closure" and 'Contraindications and precautions' above.)

Contact dermatitis — Localized allergic reactions to octyl cyanoacrylates have been reported, especially in patients who have had prior similar reactions to acrylates used in application of false nails and false eyelashes [17,18,31]. Topical skin adhesives should not be used on patients with a known history of allergic reactions to acrylates.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Skin glue for minor cuts (The Basics)")

SUMMARY AND RECOMMENDATIONS

Available tissue adhesives – The currently used tissue adhesives include n-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) and 2-octyl cyanoacrylate (eg, Dermabond, SurgiSeal). Butyl cyanoacrylates set more quickly than octyl cyanoacrylates. (See 'Properties of tissue adhesives' above.)

Indications – In a patient with a short (<5 cm) traumatic skin laceration that is clean, has good wound approximation, and is under low wound tension, we suggest repairing with tissue adhesives rather than sutures (Grade 2A). Wounds that meet all of these criteria are typically located on the face, especially the forehead (table 1). If n-butyl-2 cyanoacrylate (eg, Histoacryl Blue, PeriAcryl) is used, then the length of the laceration should be <4 cm to avoid wound dehiscence. (See 'Indications' above.)

Although evidence is limited, tissue adhesives may also provide closure for other types of wounds including:

Skin tears and flaps in patients with fragile skin that cannot be easily sutured (eg, older adult patients), either as the primary means of closure or applied adjacent to the wound to reinforce atrophic skin edges prior to suture placement

Traumatic lacerations in athletes to permit a more rapid return to competition

Wound closure in patients susceptible to keloids to promote less reaction than sutures  

Contraindications – Tissue adhesives are not recommended for the following wounds (see 'Contraindications and precautions' above):

Wounds under tension, unless deep sutures are placed to permit wound approximation

Lacerations of the hands, feet, or joints, unless immobilized

Complex stellate lesions, crush wounds, or other lacerations with poor wound approximation

Wounds on the oral mucosa or other mucosal surfaces (eg, vagina) or areas of high moisture such as the axillae and perineum

Wounds in hairy areas, unless the hair is trimmed

Wounds requiring a high level of precision (eg, hairline or vermilion border)

Bite wounds and other wounds at increased risk of infection (eg, puncture wounds, wounds with devitalized or contaminated tissue) (see "Human bites: Evaluation and management", section on 'Wound closure' and "Animal bites (dogs, cats, and other mammals): Evaluation and management")

Wounds in patients with allergy to adhesives (or formaldehyde), bleeding disorders, or comorbid conditions that delay or prevent proper healing

Pediatric pain control – In a child undergoing minor wound repair with tissue adhesives, we suggest a topical anesthetic (eg, lidocaine-epinephrine-tetracaine [LET]) on an as-needed basis rather than injection of a local anesthetic (Grade 2C). Many children do well without any local anesthetic, although topical anesthesia further decreases pain. (See 'Pain control' above.)

Wound preparation – Wounds closed with tissue adhesives warrant thorough wound irrigation and cleansing. Because adhesives create an impermeable barrier over the wound, inadequate cleansing is associated with local infection and abscess formation. A wall of antibiotic ointment or damp gauze may be placed around the laceration to prevent excess glue leakage around the wound. (See 'Wound preparation' above.)

Patient positioning – The patient should be positioned so that the wound is horizontal or tilted away from adjacent structures (eg, the eyes) to minimize leakage of the adhesive. (See 'Patient positioning' above.)

Application technique – The techniques for applying tissue adhesives (2-octyl cyanoacrylate or n-butyl-2 cyanoacrylate) to superficial skin lacerations are described (figure 3 and figure 4). (See 'Techniques' above.)

Aftercare – No external bandages are necessary over a wound closed by tissue adhesives. The adhesive itself acts as a water-resistant bandage. Antibiotic ointment should not be used as it can break down the adhesive prematurely. The adhesive will peel off when the epithelial layer sloughs off, usually by 5 to 10 days. Antibiotic ointment or petroleum jelly can be applied to the wound if the adhesive does not come off on its own. No follow-up visit is required unless there are signs of infection or nonhealing. (See 'Aftercare' above.)

Complications – Most complications of tissue adhesives relate to leakage onto unwanted areas. Tissue adhesive can be wiped away from these areas within 10 seconds. Alternatively, application of antibiotic ointment or petroleum jelly can break down the adhesive to allow removal. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Rana Kronfol, MD, who contributed to an earlier version of this topic review.

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References

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