Jason and his little brother, Freddie, were chasing each other and running around the house when little Fred slipped and went flying into the coffee table. There were screams, there were tears and there was blood. As you peel away the Paw Patrol plaster from his forehead you see a 2cm vertical laceration. An anxious parent hovers nearby, almost afraid to look. “Will he need stitches, doctor?”
Tissue adhesive has saved my bacon more times than I can count. I’ve always got some at home for when the inevitable happens and either my, or one of the neighbours, children get injured.
The discovery of tissue adhesive
More than just the evil plan of Lord Business, superglue was, like a lot of inventions, developed in part due to the war effort. Kodak Eastman was looking for a means to make clear plastic gunsights. Harry Coover started looking at the cyanoacrylates and Eastman 910 – better known as superglue – came into being. Coover recognized the potential of this wonder material and by the time of the Vietnam War, it was in use to patch up casualties.
It is worth bearing in mind that the modern day tissue adhesives that we use are not superglue, as some unlucky children have found out.
The two main types of tissue glue
The cyanoacrylates are liquid monomers that polymerize via an exothermic reaction when they contact the skin. In doing so they form a thin but flexible means of wound opposition. There are two main types in use – the butyl-cyanoacrylates (e.g.Histoacryl©) and the 8 carbon octyl-cyanoacrylates (OCA or Dermabond©). The butyl-cyanoacrylates are less pliable and more brittle.
Tissue adhesive is not the same as the superglue you might have at home. An ‘interesting’ animal study compared the ears of rabbits that had Krazy Glue placed in one floppy ear and histoacryl in the other. There was a marked inflammatory reaction, coupled with tissue necrosis, in the ear that had the superglue in it compared to the alternative glue.
How they work
Cyanoacrylate plus formaldehyde plus a base form the liquid monomer that we see in the dispenser. When they mix, it polymerizes and binds to the epithelium forming a polymer bridge. This reaction takes seconds (around twenty or so) and is exothermic, generating heat that can surprise the unprepared.
So glue or sutures?
There are a number of factors that need to be considered prior to applying the glue.
OCA has a tensile strength equivalent to 5/0 sutures. It shouldn’t be used in areas that require anything stronger. If you want to use it in such an area then it might be wise to relieve some of the tension with some deep sutures first.
Wet or dry?
Because it does tend to slough off when wet it can’t be used effectively on mucous membranes. You should also be careful in the axillae or groins as those areas tend to be moist too.
Clean or dirty?
It shouldn’t be used in dirty or contaminated tissue to the slightly increased risk of infection and wound dehiscence. If it gets between the opposing edges of skin it may act as a nidus for infection though some studies have found that cyanoacrylate might have mild bacteriostatic properties and thus lower potential Staphylococcal spp. counts.
Dollars or cents?
We often forget about the cost of what we use, either to the patient or the healthcare system. Simple sutures come in at around 5$ a pack. Dermabond currently sells at around $33AUD a pop.
A 2014 Cochrane review found no real difference in the cosmetic outcome, or patient or user satisfaction.
How to apply them
Dermabond (Ethilon) comes in a little glass vial encase in plastic. By crushing the vial between your fingers you can then squeeze the liquid to the roller surface. Once the clean and dry wound edges have been opposed you should gently draw the tip of the applicator over the wound creating a thin layer of glue. This will polymerize in 30-45 seconds (and blowing on it will not speed up this process). You should then repeat the action a couple more times. Three gentle, thin passes are more effective than one big blob of glue.
Tips and tricks
The newer glues have a low viscosity and so they seem to go absolutely everywhere if you are not careful. As we are fixing a forehead laceration, in this case, I would have the patient lying down (perhaps with is head on his mum’s lap). I normally place a pad of moist gauze over the eye. This both reduces eye and forehead movements and provides a means to quickly wipe away any dripping glue. Another alternative, in older children, is to place a piece of Tegaderm just under the wound in case of runoff.
What happens if you get it in the eye
The cyanoacrylates have been used for the treatment of corneal perforations so clearly they are safe if they get into the eye. Most of the time we are more worried about them sticking lashes together. If this should happen then a generous layer of chloramphenicol ointment can loosen the lashes and allow the eye to open.
Singer et al. (2004) performed a review of performance data and found that the overall infection rate after OCA was 1.1% compared to 0.7% with other measures. There is also a slightly increased risk of wound dehiscence (0.9% vs 0.3%) with tissue adhesive. But these are rarely what parents worry about. They are much more likely to worry about long term cosmetic effects. Adult data found no difference between suture and skin adhesive at 3 months and 1 year follow up (Quinn et al. 1997). The result holds true in the paediatric population too with Toriumi et al (REF) comparing tissue adhesive with vertical mattress sutures performed by a plastic surgeon. At 3 months they scored similarly on a visual analog scale but by the one year mark, the adhesive had achieved a better cosmetic outcome.
The blue/purple ‘scab’ that is formed by the adhesive tends to fall off in about 5 to 10 days (unless it gets picked off sooner) and so does not require a repeat visit for suture removal.
My bottom line
“Mrs. Krueger, we are going to use a special medical glue to fix this cut. It is faster and less painful than stitches. It will do two things – it will help bind the edges together and also form an artificial scab that will help keep out any infection. Most experts wouldn’t be able to tell the difference between sutures and glue in a couple of month’s time.”
Bernard L, Doyle J, Friedlander SF, Eichenfield LF, Gibbs NF, Cunningham BB. A prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents. Archives of dermatology. 2001 Sep 1;137(9):1177-80.
Bruns TB, Worthington JM. Using tissue adhesive for wound repair: a practical guide to dermabond. American family physician. 2000 Mar;61(5):1383-8.
Cascarini L, Kumar A. Case of the month: Honey I glued the kids: tissue adhesives are not the same as “superglue”. Emergency Medicine Journal. 2007 Mar 1;24(3):228-9.
Coover HN, Joyner FB, Sheere NH, et al. Chemistry and performance of cyanoacrylate tissue adhesive. Surgery. 1968; 63:481-9.
Eiferman RA, Snyder JW. Antibacterial effect of cyanoacrylate glue. Archives of Ophthalmology. 1983 Jun 1;101(6):958-60.
Howell JM, Bresnahan KA, Stair TO, Dhindsa HS, Edwards BA. Comparison of effects of suture and cyanoacrylate tissue adhesive on bacterial counts in contaminated lacerations. Antimicrobial agents and chemotherapy. 1995 Feb 1;39(2):559-60.
Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emergency medicine journal. 2002 Sep 1;19(5):405-7.
Singer AJ, Hollander JE, Valentine SM, Turque TW, McCuskey CF, Quinn JV, Stony Brook Octylcyanoacrylate Study Group. Prospective, randomized, controlled trial of tissue adhesive (2‐octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Academic Emergency Medicine. 1998 Feb;5(2):94-9.
Singer AJ, Thode Jr HC. A review of the literature on octylcyanoacrylate tissue adhesive. The American journal of surgery. 2004 Feb 1;187(2):238-48.
Toriumi DM, Raslan WF, Friedman M, Tardy ME. Histotoxicity of cyanoacrylate tissue adhesives: a comparative study. Archives of Otolaryngology–Head & Neck Surgery. 1990 May 1;116(5):546-50.
Thanks Andy! To prevent runoff, I often use a tegaderm with a wound shaped hole cut in the middle placed over the wound. If you leave the paper tag bits on there, it’s easy to get off once the glue hardens