International Journal of Oral & Maxillofacial Surgery
Volume 35, Issue 4 , Pages 318-323, April 2006

A prospective comparison of octyl-2-cyanoacrylate and suture in standardized facial wounds

  • J.G.K. Handschel

      Affiliations

    • Department of Cranio- and Maxillofacial Surgery, Heinrich-Heine-University, Moorenstr. 5, D-40225 Düsseldorf, Germany
    • Corresponding Author InformationAddress: Jörg G.K. Handschel, Department of Cranio- and Maxillofacial Surgery, Heinrich-Heine-University, Moorenstr. 5, D-40225 Düsseldorf, Germany. Tel: +49 211 8118181; Fax: +49 211 8118877.
    • ,
  • R.A. Depprich

      Affiliations

    • Department of Cranio- and Maxillofacial Surgery, Heinrich-Heine-University, Moorenstr. 5, D-40225 Düsseldorf, Germany
    • ,
  • D. Dirksen

      Affiliations

    • Laboratory of Biophysics, University of Münster, Robert-Koch-Str. 45, D-48129 Münster, Germany
    • Department of Prosthetic Dentistry, University of Münster, Waldeyerstr. 30, D-48129 Münster, Germany
    • ,
  • C. Runte

      Affiliations

    • Department of Prosthetic Dentistry, University of Münster, Waldeyerstr. 30, D-48129 Münster, Germany
    • ,
  • A. Zimmermann

      Affiliations

    • Department of Cranio- and Maxillofacial Surgery, Heinrich-Heine-University, Moorenstr. 5, D-40225 Düsseldorf, Germany
    • ,
  • N.R. Kübler

      Affiliations

    • Department of Cranio- and Maxillofacial Surgery, Heinrich-Heine-University, Moorenstr. 5, D-40225 Düsseldorf, Germany

Accepted 19 October 2005.

Article Outline

Abstract 

Regarding the cosmetic results of wound closure using tissue adhesives as opposed to sutured wounds, most published studies are performed on children and with non-standardized lacerations, which makes it difficult to transfer the results to facial incisional wounds in adults. There are also conflicting conclusions about the cosmetic results. The purpose of this randomized prospective study was to compare the cosmetic outcomes of wound closure with sutures and octyl-2-cyanoacrylate in standardized facial wounds in adults. To compare very similar facial wounds, the infraorbital cut (lower eyelid incision) was used in 45 patients. The assessment was performed by patients and surgeons blind to the data. Phase-shifting profilometry was used to measure the profile of the scars. No early complications were observed in any group. The wound depth in the tissue adhesive group was significantly greater than in the suture group. There were no differences in the overall cosmetic results among all patients in the two groups. Interestingly, in the younger patients the result of the sutured wounds was superior to that of the adhesive-treated patients. The Dermabond® skin adhesive provides a means of closure of facial surgical wounds without early complications, but adjustment of the edges of the wound and the cosmetic result in younger patients are less successful than with thin sutures.

Keywords: aesthetic outcome, wound closure, skin adhesive, suture

 

The cosmetic result is one key measure in the assessment of operations in the head and neck region. The appearance of facial skin wounds is relevant to the rating by patients and surgeons. If sutures are tied too tightly or left on too long, they may leave permanent suture marks which affect the cosmetic result17. Suture removal sometimes causes discomfort because this procedure is often associated with increased patient anxiety as the face is very sensitive.

Cyanoacrylate adhesives were discovered in 1949 and, 10 years later, Coover et al.3 reported their use in surgical procedures. These adhesives polymerize via an exothermic reaction when coming into contact with a fluid or basic medium, thereby forming a strong bond when applied to skin. For a number of years N-butyl-2-cyanoacrylate has been used for wound closure23, but it is less strong and flexible than conventional monofilament sutures10, 24. For this reason, octyl-2-cyanoacrylates were developed for cutaneous application. This derivative has a longer side chain and forms a stronger and more flexible bond, with a three-dimensional breaking strength four times that of butyl-2-cyanoacrylate6, 12. Several investigations into the cosmetic results of wound closure have been published in the last few years, but most were performed in children4, 8, 18, with the results difficult to transfer to facial wounds in adults, and in many studies the wounds were not standardized for length, localization and shape11, 22. The results also conflict with regard to the cosmetic results of wound closure with adhesives as opposed to sutures; whereas some authors reported superior results for wound closure with sutures1, 21, other studies demonstrated better or equal cosmetic results with cyanoacrylates8, 22.

A randomized prospective trial was conducted to compare the cosmetic results of wound closure with sutures and octyl-2-cyanoacrylate in standardized facial wounds in adults. A new objective method was used to measure the profile of the scars.

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Material and methods 

To compare very similar facial wounds of nearly equal length, localization and shape, the infraorbital cut (lower eyelid) was used. Forty-five Caucasian patients with an orbital floor fracture were included in this investigation. Patients were eligible for inclusion in the study if they were of generally good health without significant systemic abnormalities, had the medical indication for a surgical orbital floor reconstruction and provided informed consent. The study report meets the criteria of the local ethics committee. Patients meeting all eligibility requirements were randomized for treatment with either a local application of octyl-2-cyanoacrylate (Dermabond®, Ethicon, Norderstedt, Germany) or standard wound closure (6-0 Ethilon®, Ethicon, Norderstedt, Germany). Wound length was between 2.5 and 3.0cm. In all cases periost sutures (4-0 Vicryl®, Ethicon, Norderstedt, Germany) were applied to aid in apposing the edges of the wounds. Randomization occurred before surgery either in the test group (octyl-2-cyanoacrylate) or the control group (suture). Dermabond® was applied in two layers with each layer followed by 15-s periods of waiting for polymerization to take place according to the manufacturer's instructions. The adhesive was allowed to peel off on its own after the operation.

Patients were evaluated 10 days after the operation for the presence of complications such as dehiscence or wound infection. Three months after surgery, photographs were taken at standard settings, and patients were asked to rate the cosmetic result as well as the suture or adhesive removal procedure on a visual analogue scale (VAS). The VAS was a 10-cm line, with 0 representing the worst outcome and 10 representing the best possible result. The VAS had already been validated as a useful tool for assessing the cosmetic results in a previously published study14. In addition, three cranio- and maxillofacial surgeons blind to the data rated the colour and overall cosmetic outcome on a VAS. The surgeons were asked to analyse the photographs using uniform parameters for analysis (scar width, scar colour).

For assessment of the wound profile, phase-shifting profilometry was used as previously described2, 7. Briefly, 3 months after surgery impressions were taken using a light body (Abformmaterial) (Xantopren®, Fa. Bayer, Leverkusen, Germany). A plaster cast of the wound surface was made using the impression. To acquire three-dimensional object coordinates of the wound surface, parallel lines were projected onto the cast surface, using a halogen light-projecting system and a transparent, metal-coated glass substrate with the required pattern. During the recording period, four line patterns were projected in sequence. All data are stored by an image-processing system and, for further measurement, data are displayed in the form of grid surfaces (Fig. 1). Five measurement points are defined on each wound surface. The middle of the linear scar is the first point. The other four measurement points are located at distances of 10mm and 20mm to the right and left of the centre. The distance to a tangential line from the surrounding skin surface is measured at these points (Fig. 2). The mean of the five measured values is calculated for statistical analysis.

Statistical analysis was performed using SPSS 12.0 for Windows. The inter-rater reliability was determined by Cronbach's alpha, and the Mann–Whitney U-test was used to compare the VAS values and the measured values of the wound surface analysis for the different groups. Variables were reported as mean values±SD or medians with interquartile ranges. The correlation between the age of the patient and the cosmetic result was calculated using the Spearman test. If there is a significant correlation between age and cosmetic result, the above-mentioned analysis should be performed separately for younger and elderly patients. Finally, the age of 25 years was chosen as the divide between older and younger patients because with higher thresholds (e.g. 30 years) no significant effect could be ascertained. Statistically significant differences were defined as P<0.05.

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Results 

A total of 45 patients met the previously defined inclusion criteria and were examined about 3 months after surgery. In 19 patients, wound closure was performed with a skin adhesive (Dermabond®) and in 26 patients with a monofilament suture (Ethilon®). The two treatment groups were similar regarding age, duration of surgery and follow-up time. The mean age of the patients in the adhesive group was 47 years against 42 years in the suture group. The total surgical procedure took 63min (skin adhesive) or 60min (suture), and the follow-up interval was about 3 months in each group (106±20 days after surgery in the adhesive group and 103±13 days in the suture group). No patients showed wound dehiscence or infection during the first 2 weeks after surgery, and there was no evidence of prolonged healing time that could indicate that the adhesive had entered the wound.

Three months later, the patient VAS score for the overall cosmetic result of the wound closure was slightly higher in the skin adhesive group than in the suture group (Fig. 3). This was in accordance with the subjective rating of the removal procedure (Fig. 3). Interestingly, the assessment by the three cranio- and maxillofacial surgeons blind to the data shows the opposite result: the assessment of both colour and total cosmetic result is better in the sutured patients than in the adhesive group (Fig. 3). None of these differences are, however, statistically significant. There is strong inter-rater reliability regarding the assessments by the three surgeons (α=0.71).

  • View full-size image.
  • Fig. 3. 

    Assessment of wounds by patients and surgeons blind to the data. The white bars represent the skin adhesive group and the black bars the sutured patients. PR OA=patients’ rating of overall cosmetic outcome; PR RE=patients’ rating of removal procedure; SU COL=surgeons’ rating of colour discrepancies between scar and surrounding skin; SU OA=surgeons’ rating of overall cosmetic result. Note that there are no statistically significant differences.

In contrast to the VAS scores, a statistically significant difference was detected in the depth of the scars. The profile of the wounds treated with skin adhesive shows a deeper scar (0.47mm±0.51) than that of the sutured wounds (0.21mm±0.10). The distribution of the measured values is shown in Fig. 4.

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  • Fig. 4. 

    Assessment of the scar profile when measuring the depth of the wound. Medians and quartiles are displayed in the box plot. Note that there is a statistically significant difference between the two treatment groups (P<0.05).

In order to detect a possible interdependence between the age of the patients and the cosmetic result, the correlation between age and the overall assessment by the surgeons was calculated. Fig. 5 shows that an increase in age is associated with a higher VAS score, this correlation being statistically significant. Owing to this result, the above-mentioned VAS score was calculated separately for patients younger and older than 25. Interestingly, in the younger patients this revealed a statistically significant difference between the adhesive group and the suture group, showing a better cosmetic result in the sutured patients (8.4±0.83) than in the other group (7.1±0.41) (Fig. 6). Two representative photographs of an adhesive-treated and a sutured young patient are presented in Fig. 7, Fig. 8.

  • View full-size image.
  • Fig. 5. 

    Correlation between age and total cosmetic result independent of wound closure technique. The correlation is statistically significant (Spearman coefficient, P<0.05).

  • View full-size image.
  • Fig. 6. 

    Assessment of the wounds of young patients by patients and surgeons blind to the data. The white bars represent the skin adhesive group and the black bars the sutured patients. PR OA=patients’ rating of overall cosmetic result; PR RE=patients’ rating of removal procedure; SU COL=surgeons’ rating of colour discrepancies between scar and surrounding skin; SU OA=surgeons’ rating of overall cosmetic outcome. Asterisk (*) marks a statistically significant difference (P<0.05).

  • View full-size image.
  • Fig. 7. 

    Young patient with an adhesive-treated infraorbital incision 3 months after surgery. The crescent-shaped scar appears reddish and bulging compared to the surrounding tissue.

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Discussion 

Tissue adhesives are an area of tremendous interest and research. The use of skin adhesives has become very popular, particularly for paediatric patients. Cyanoacrylates used as skin adhesives are liquid monomers that polymerize into a solid material forming a thin film that causes the opposite edges of a wound to adhere. While the short-chain cyanoacrylates (methyl and ethyl forms) have been associated with tissue toxicity as a result of rapid degradation, the higher chain derivatives (such as 2-octylcyanoacrylate) have been shown to have minimal, if any, cytotoxicity5. Numerous studies have shown the utility of tissue adhesives in uncomplicated laceration repair not only in children but also in adult patients8, 18, 20. In the case of facial wounds, besides avoiding infection, patients are more concerned with the ultimate cosmetic appearance of their wounds13. Unfortunately, many investigations evaluating cosmetic results were performed with varied wounds not standardized for length, localization and shape11, 22. Therefore, an experiment was needed to compare the cosmetic results of wound closure with sutures and octyl-2-cyanoacrylate in standardized facial wounds in adults.

In this study, the skin adhesive performs as well as the standard wound closure technique in terms of early complications such as infection and wound dehiscence. This is in agreement with previously reported studies9, 19. Whereas patients preferred the tissue adhesive for its overall cosmetic result, the surgeons’ rating for the sutured wounds was higher; however, there is no statistically significant difference between the two ratings. This is comparable to the results of Switzer et al.21, who found a similar cosmetic result in the closure of standardized inguinal incisions. The difference between patients and surgeons might be explained in part by the patients’ perception of skin adhesives as more advanced and up to date. Another reason might be that the surgeons assessed the outcome only by looking at photos, although this method is also used by other investigators16. Statistically, the wound depth in the tissue adhesive group is significantly greater than in the sutured patients. Although most measured wounds in both groups are quite flat (between 0.2 and 1.3mm), the suture seems to make the edges of the wound adjust better. This small difference is hardly seen in photographs. That could be a reason for the surgeons’ rating being different from the profile analysis.

In determining the role of age and the various age-dependent dermal conditions, a statistically significant correlation between the age of the patients and the overall cosmetic results assessed by the surgeons was found. The older the patient is, the better the result. Obviously, in aged and often wrinkled skin a scar is not as conspicuous as in younger, smooth skin. Surprisingly, in patients under 25 a significant difference between the tissue adhesive and the sutured groups could be detected. This means that the above-mentioned correlation is more pronounced in adhesive-treated than in sutured wounds. A similar effect can be found in published studies on lacerations; whereas Bernard et al.1 reported a worse result for tissue adhesive in children, Toriumi et al.22 described a better result in adults.

A criticism could be made that the wounds were not monitored for long enough. It has, however, been reported previously that there is strong agreement between wound scores (VAS) at 3 months and 1 year15. The results of the present study are, thus, representative of cosmetic outcome.

In conclusion, the Dermabond® skin adhesive is a safe method of closing wounds in facial surgery as far as early complications are concerned; however, the adjustment of the edges of the wounds as measured by the depth of the scar is significantly worse than in thin sutures. The sutured wounds give better cosmetic results in younger patients in particular.

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References 

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PII: S0901-5027(05)00356-5

doi:10.1016/j.ijom.2005.10.003

International Journal of Oral & Maxillofacial Surgery
Volume 35, Issue 4 , Pages 318-323, April 2006

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