Tissue Adhesives

Cyanoacrylate tissue adhesives have been available in Canada and Europe for years, and one product, 2-octylcyanoacrylate, is now available in the United States (Dermabond, Ethicon, Inc.).10 Cyanoacrylate adhesives polymerize rapidly when applied to tissues through an exothermic reaction catalyzed by a small amount of moisture. These adhesives close wounds by forming an adhesive layer on top of intact epithelium, which holds the edges together. Cyanoacrylate adhesives cause an intense inflammatory reaction within subcutaneous tissues and should never be applied within wounds. Adhesives cannot be used near the eye, on mucous membranes or mucosal surfaces, on infected areas, on wounds that are wet or exposed to body fluids, or in areas with dense hair (e.g., scalp). When used on appropriately selected wounds, tissue adhesives can be applied in less than half the time required for sutures and without the need for anesthesia or return for removal.1,1 and 13

Adhesives are most useful when they are used on wounds that close spontaneously, have clean or sharp edges, and are located on clean, nonmobile areas. Wounds where the edges are separated more than 5 mm by the underlying skin tension are unlikely to stay closed with tissue adhesives alone. In this case, subcutaneous sutures can be inserted to relieve this tension and approximate the edges. Also, lacerations longer than 5 cm are prone to shear forces and unlikely to remain closed with tissue adhesives alone.

Two-octylcyanoacrylate is commercially available in a single-use vial with an applicator tip. A violet colorant is added to make it visible during application. Wounds should be cleaned and bleeding controlled before the tissue adhesive is applied, but absolute dryness is not required. The wound should be held together and the edges slightly everted with tissue forceps. Adhesive is applied by lightly wiping the applicator tip over the area (at least 5 mm beyond the skin edges) in the direction of the long axis of the wound (Fig 37-11). Three to four thin layers should be applied successively; droplets or a single thick layer is to be avoided. The wound edges should be held together for about 60 s after the last adhesive application to ensure that the adhesive has time to set fully. Some articles have described the application of tissue adhesives as "spots" along the laceration or as intermittent "stripes" applied perpendicular to the laceration. These techniques might be less useful, since cyanoacrylates are only slightly more viscous than water and subcutaneous penetration is possible from dabs applied to the skin or from unintentional opening of the edges by wiping the applicator tip across the wound. Adhesive applied to unwanted areas can be removed by using petroleum jelly or acetone. Once applied, cyanoacrylates should not be covered with ointment, bandage, or dressing.

FIG. 37-11. Tissue adhesives are applied in several light coats over the wound, carefully avoiding entry of the adhesive into the wound.

Patients should be instructed not to use ointments, apply bandages, or pick at edges of the adhesive. After 24 h, the area can be gently washed with plain water but should not be scrubbed, soaked, or exposed to moisture for any length of time. The adhesive will spontaneously slough off in 5 to 10 days. Should a wound open, the patient should immediately return for closure.

As compared with suturing, wounds closed with tissue adhesives initially have less tensile strength; after 7 days, however this difference disappears. 10 The manufacturer of 2-octylcyanoacrylate notes that the incidence of wound infection with this product is 3.6 percent and the incidence of dehiscence requiring retreatment is 2.2 percent; neither was statistically different by comparison with equivalent wounds closed with sutures. An animal model has found that 2-octylcyanoacrylate can be used to close contaminated wounds with a lower infection rate, although this use has not been validated in humans. 14 The ultimate cosmetic appearance of wounds closed with tissue adhesives is identical to that of closure with sutures. 1315

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