Vol. 16 Issue 3
Laceration Repair with Tissue Adhesives
A Solution for Simple Wounds
Many office-based health care providers send patients to emergency departments for wound closure. Reasons that factor into these decisions include the type of wound, the potential for infection, and the potential for adverse cosmetic outcomes.
But such referrals may harm relationships with patients. In addition, routinely referring wounds for closure in EDs equals a loss of potential income for the practice. Many lacerations can be repaired in the office setting with good outcomes. By closing these wounds in the office, NPs can eliminate the need for referral and generate income from initial wound closure and from the postprocedure wound check 2 or 3 days later.
NPs can become more comfortable with wound closure by concentrating on one technique at a time. It is unrealistic to believe that any provider will walk into the office and begin building wound repair experience by closing multiple-layer facial lacerations. A stepwise approach is more appropriate. For example, learn and become comfortable with wound closure techniques and devices that require little manual dexterity. Offer only these services until your comfort level improves. It is perfectly acceptable to see a walk-in patient, evaluate the wound, and determine that he or she should go to the ED for closure. As your comfort level increases, you can incorporate more complicated wound closure techniques.
Tissue adhesives are a feasible and simple tool for building your wound closure repertoire. Patients generally prefer this type of wound closure because it is noninvasive and produces good outcomes. In one study, patients who were treated with an adhesive described themselves as "satisfied" or "very satisfied" with cosmetic outcomes in all cases.1
Tissue adhesives are often marketed under the brand names Dermabond and Indermil. Some people refer to these as "medical super glue."2
Adhesives vs. Sutures
Tissue adhesive has tensile strength equal to 4.0 subcuticular sutures. This level of strength is ideal for the face and areas of the body where there is little chance that the skin will stretch after wound closure. Tissue adhesives should not be used on parts of the body that frequently articulate, such as joint surfaces or some areas of the torso, because frequent movement after closure may result in premature sloughing of the adhesive and dehiscence of the wound.3
Application is painless. Since adhesive is not placed directly into the wound and no needles are required, there is no need to infiltrate the wound with anesthetic. Patients also prefer the ease of care after adhesive application (compared with sutures) and that there is no need for suture removal later.4
Cosmetic outcomes are often a consideration when choosing a wound closure technique. Tissue adhesives have demonstrated cosmetic outcomes that are identical to standard closure using 5.0 sutures.5 This may be related to the lack of "railroad tracks" left behind when sutures are pulled through the skin to close a wound. In addition, sutures are perceived by the immune system as a foreign body, and thus they initiate an inflammatory response. Because tissue adhesives remain on the exterior of the wound, the inflammatory response is contained to the natural response to the initial trauma and the wound itself.
History and Physical Examination
When deciding whether to close a wound, first gather the history of the event. Could a foreign body be present? Do other injuries require evaluation at the emergency department? Are there comorbid conditions that might hinder the healing process, such as diabetes, history of keloids or an immunocompromised state? Any of these conditions could lead to infection or poor cosmetic outcomes and suggest the need for referral to someone with more experience closing wounds.
If the wound was caused by an animal or human bite, it should not be closed with tissue adhesive. Wound closure of bite wounds is controversial and not within the scope of this article. In most cases, animal bites should not be closed, relying instead on closure by secondary intention.6
Once you have taken the history, examine the wound. Tissue adhesive is an appropriate tool only for lacerations that occur in a moderately straight line. A crooked or uneven laceration line can certainly be closed with tissue adhesives but it requires a bit more skill and should not be attempted by a novice.
To evaluate the potential effectiveness of tissue adhesive, simply use a gloved hand to push each side of the wound together. If the wound approximates easily when you push the two sides together, the wound can be closed with tissue adhesive.
If the wound is a candidate for tissue adhesive, the next step is to cleanse it thoroughly. Squirting saline directly into the wound is a good start, but the edges of the wound should be cleaned as well.
Perhaps the most influential determinant of cosmetic outcome is infection risk. Wound preparation prior to closure is a critical step for infection prevention. Irrigation of the wound is an effective means of removing bacterial and other contaminants from the wound. This is easily accomplished by using a normal saline-filled syringe to copiously flush the wound and surrounding tissue.7
After proper wound preparation, use your nondominant gloved hand to approximate the wound edges. Apply the adhesive over the top of the wound using the dominant hand, as if painting the area with the adhesive. Cover the surrounding tissue as well. Applying the adhesive outside the wound margins allows the substance to act as an anchor, stabilizing the wound.
Allow the adhesive to dry for 30 seconds. Then apply a second layer in the same manner. Allow it to dry, then apply a third layer in the same way. This three-layer approach ensures a strong bond that will hold the wound in place while healing.
After you apply the third layer, continue stabilizing the wound with the nondominant hand until the adhesive is completely dry. This usually takes about 60 seconds (Table 1).2
Aftercare instructions include education about wound infection and day-to-day care of the wound. Patients should return to the clinic for evaluation immediately if they experience any signs of infection. The adhesive should remain in place for 5 to 10 days, then slough off.
Inform patients that they should not apply ointments or creams to the wound, since these cause premature sloughing of the adhesive. Exposure to prolonged moisture, including excessive perspiration or swimming, may also cause premature sloughing. Brief exposure to moisture, as in routine showering, is permissible as long as the wound is not submerged in water and is dried thoroughly afterward.7
Wound Evaluation After Closure
Ask the patient to return in 2 or 3 days for a wound check. This time frame will allow you to intervene early in cases of wound infection. Evaluate the wound for erythema, tactile temperature changes or purulence. Interventions for infected wounds are similar to those for other skin infections. Decisions about removing tissue adhesive from infected wound sites should be made on a case-by-case basis. Although wound infection is rare after proper wound preparation, it can occur. Therefore, a wound check should be considered standard practice.
Tips and Pitfalls
Although the application of a tissue adhesive is simple and effective, a few tips are helpful. Application near the eyes should be done with great care. If the adhesive drips or runs into an eye, the eye could be glued closed. To avoid this, simply tilt the head so that the wound is below the eye. In the worst case scenario, you can dissolve adhesive in an eye that is glued closed by applying ophthalmic ointments that contain erythromycin or bacitracin.
Be aware that adhesive can drip or run onto your gloved hand while you are stabilizing the wound. This will result in the embarrassing situation of being "glued" to the patient. You can easily resolve this by applying ophthalmic ointment or, if the wound is not located near the mouth or eyes, acetone solvent (Table 2).
Putting It Into Practice
Tissue adhesives are valuable tools for NPs who are interested in expanding their skill set and capturing revenue. You can bill for the initial visit and wound closure procedure, as well as the follow-up wound check. In addition to capturing this revenue, providing wound closure allows NPs to reinforce their positions as complete primary care providers.
1. Hancock NJ, Samuel AW. Use of Dermabond tissue adhesive in hand surgery. J Wound Care. 2007;16(10):441-443.
2. Bruns TB, Worthington M. Using tissue adhesive for wound repair: a practical guide to Dermabond. Am Fam Physician. 2000;61(5):1383-1388.
3. Shapiro AJ, et al. Tensile strength of would closure with cyanoacrylate glue. Am Surg. 2001;67(11):1113-1115.
4. Sniezek PJ, et al. A randomized, controlled trial of high viscosity 2-octyl cyanoacrylate tissue adheshive versus sutures in repairing facial wounds following Mohs micrographic surgery. Dermatol Surg. 2007;33(8):966-971.
5. Quinn J, et al. Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3 month, and 1 year cosmetic outcome. Ann Emerg Med. 1998;32(6):645-649.
6. Taplitz RA. Managing bite wounds. Current recommended antibiotics for treatment and prophylaxis. Postgrad Med. 2004;116(2):49.
7. Singer AJ, Hollander JE. Lacerations and Acute Wounds: An Evidence Based Guide. Philadelphia: F.A. Davis Company; 2003: 17-19.
Jim Jolly is a family nurse practitioner in the emergency department at Kaweah Delta Health Care District in Visalia, Calif.
Table 1: Wound Closure With Tissue Adhesive
Step by Step
1) Determine whether the wound is a candidate for closure with tissue adhesive (edges can be easily approximated with your hands).
2) Thoroughly cleanse and irrigate the wound.
3) Approximate the wound edges with your nondominant gloved hand.
4) Apply adhesive to the wound and surrounding area.
5) Allow the first layer to dry for 30 seconds.
6) Repeat the application for two additional layers.
7) Allow the adhesive to fully dry before touching the wound area.
Table 2: Helpful Hints
Place the wound in a position that allows excess adhesive to drain away from the eyes.
Use ophthalmic preparations or acetone to dissolve accidental adhesive exposures.
Contact sales representatives for samples and practice aids.