June Kim, MD; Harjot Singh Maan, MD; Alicia J. Cool, MD; Allison M. Hanlon, MD PhD; David J. Leffell, MD
Dr. Kim is from Cascade Eye and Skin Center, University Place, Washington.
Dr. Mann is from Department of Dermatology, University of Rochester Medical Center, Rochester, New York;
Dr. Cool is from Advanced Dermatology, PC, Brooklyn, New York.
Dr. Lefell and Dr. Hanlon are from Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.
Disclosure: The authors report no relevant conflicts of interest. Source of funding: Yale University, New Haven, Connecticut
Abstract
Background: Cyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery. Objective: To compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery. Methods: Fourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome. Results: The present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures. Conclusion: Cyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167). (J Clin Aesthet Dermatol. 2015;8(2):24–29.)
Tissue adhesives have been used in surgical procedures for more than 50 years since cyanoacrylate was first discovered in 1949.[1] These adhesives work by self-polymerizing in a spontaneous exothermic reaction. The first widely used variety, N-butyl-2-cyanoacrylate, has been used with good cosmetic outcomes for a number of surgical procedures (blepharoplasty, lacerations, incisions).[2–5] However, this adhesive did not gain widespread use because of its low tensile strength and brittleness.[6] In 1998, the United States Food and Drug Administration (FDA) approved 2-octyl cyanoacrylate for superficial skin lacerations. This cyanoacrylate polymer was designed to be stronger and more flexible and has been used successfully in many studies.[7],[8]
Fast absorbing gut is a plain gut suture that has been heat treated to enable rapid absorption. It is primarily used for epidermal suturing, where sutures are only required for five to seven days.[9] Both cyanoacrylate and fast absorbing gut suture eliminate the need for an office visit for suture removal, which can represent a significant cost savings in patient and staff time as well as related healthcare resources.
Both cyanoacrylate and fast absorbing gut suture are currently routinely used for epidermal closure following Mohs micrographic surgery (MMS). Physician preference currently dictates which epidermal closure method is chosen for a given surgery and depends on weighing advantages and disadvantages of each technique.
Recently, one study reported that for defects on the trunk and extremities, tissue adhesive may not be as effective in achieving optimal cosmesis as fast absorbing gut.[10] The purpose of this study was to compare the cosmetic outcome and patient satisfaction of cyanoacrylate tissue adhesive versus fast absorbing gut suture for the closure of surgical defects on the face following MMS.
METHODS
Approval for this study was obtained from the Yale University School of Medicine Human Investigation Committee. A total of 14 patients undergoing routine MMS for nonmelanoma skin cancer of the face were asked to voluntarily participate in the trial on the day of scheduled surgery and were enrolled after written informed consent was obtained. To be enrolled, the patients had to be 18 years of age or older with a wound length of 3cm or greater, willing to comply with the protocol of standard postoperative care, and be able to attend a postoperative visit three months after surgery. Patients on systemic immunosuppressants and/or organ transplant recipients with a reported or suspected hypersensitivity to cyanoacrylate or fast absorbing gut suture or with a dermatologic disease in the target site that may interfere with examination were excluded from the study.
Two of the authors (JK and DJL) served as primary surgeons during the study, and a primary surgeon performed the closure in each case. All wounds were closed using a linear, bilayered closure method, where the buried intradermal absorbing suture, 5-0 polyglactin 910 (Polysorb, Covidien) was placed along the length of the incision, consistent with standard surgical procedure. Each wound was measured and the length divided in half. Half of the surgical wound was randomly selected (by coin toss) for epidermal reapproximation with n-butyl and 2-octyl cyanoacrylate (GluSeal® Tissue Adhesive, Skinstitch Corporation), whereas the other half was repaired with fast absorbing gut suture (5-0 or 6-0, Fast Absorbing Plain Gut, Ethicon) in standard running fashion. Immediate postoperative photographs were taken. The entire length of the repair was reinforced with Steri-Strips (3M) that were removed after seven days. The patients then returned for follow-up at three months. High-resolution photographs were obtained of the wound at these follow-up visits. These photographs were taken in the same clinic and under the same overhead lighting. Patient preference of closure method was also obtained at these visits.
The high resolution photographs from the three-month visit were presented to six blinded individuals (1 general dermatologist, 1 Mohs surgeon, 2 nurses, and 2 lay persons). A previously validated 10-point visual analog scale (VAS) ranging from 1 (poor) to 10 (excellent) was used to evaluate each half of the scar for overall cosmesis.11 Raters were instructed to take into account such variables as scar width, thickness, dyspigmentation, wound approximation, and contour irregularities. The treatment groups were compared using a paired t-test. Statistical significance was defined as p<0.05. The patient also completed a satisfaction survey.
RESULTS
After MMS, no wound dehiscence, infections, postoperative bleeding, allergic reactions, or any other significant wound closure complications occurred with either technique. Fourteen patients (10 men and 4 women) with nonmelanoma skin cancers of the face were enrolled in the study (Table 1). One patient did not return for a three-month evaluation. The mean age of patients enrolled was 67.5±14.5 years (range 39–89 years). The mean wound length was 4.2±1cm (range 3–6.8cm). Of the 14 repair sites, two were located on the forehead, seven on the cheek, and five on the temple. Examples of patient photos immediately postoperatively and at three months are depicted in Figures 1A & 1B and Figures 2A & 2B.
Overall cosmesis. Using a paired t-test, evaluation of the linear scars at three months for overall cosmesis on the 10-point VAS favored fast absorbing gut suture (M=7.97, SD=1.25) over cyanoacrylate (M=7.47, SD=0.81) by all six blinded individuals. However, this difference was not statistically significant (p=0.23). Stratifying the results to include only healthcare provider (MD and nurse) evaluation, the paired t-test was also not statistically significant (p=0.59), but the difference between the fast absorbing gut suture (M=8.38, SD=1.12) and cyanoacrylate (M=8.25, SD=0.84) was smaller.
Location of wound. The site of the wound had some correlations with the evaluations. For cyanoacrylate, site of the wound had a marginal effect on evaluation, F(2,10)=3.21, though it was not statistically significant (p=0.08). Wounds closed on the forehead using cyanoacrylate were evaluated (M=6.33, SD=0.24) as being significantly worse (p<0.05) than those closed on the cheeks (M=7.69, SD=0.81) or temple (M=7.67, SD=0.61). Such differences in evaluation based on locations of the wounds were not found for fast absorbing gut suture, F(2, 10)=0.07, p=0.94.
Wound length. An analysis of variance (ANOVA) analysis looking at continuous study variables (e.g., age, repair length, evaluation of wounds closed with cyanoacrylate, and fast absorbing gut suture) was performed. Two associations were found, but neither was statistically significant. First, there was a correlation between repair length and the absolute difference in evaluation between cyanoacrylate and fast absorbing gut suture (r=0.51, p=0.07). Second, there was a correlation between repair length and the cyanoacrylate evaluation (r=-0.49, p=0.09). These marginal p-values suggest that longer repair lengths may be correlated with greater discrepancies between cyanoacrylate and fast absorbing gut suture evaluations and that longer repair lengths may be correlated with worse evaluations of the cyanoacrylate technique.
Patient preference. Most patients did not have a preference for wound closure technique (64%, n=9), but those who did significantly favored cyanoacrylate (29%, n=4) over fast absorbing gut sure (7%, n=1) (Figure 3 ). Fisher’s exact test revealed an association between patient preference and the location of the skin cancer, (p=0.035). The patterns can be seen in Table 2. An ANOVA analysis revealed that patient preferences did seem to be linked to repair length, such that those with preferences tended to have longer repair lengths than those without preferences, F(2, 11)=4.10, p=0.003.
CONCLUSION
Cyanoacrylate is a rapidly polymerizing topical adhesive commonly used as an alternative to traditional sutures for epidermal closures following MMS. Cyanoacrylate has been reported to decrease trauma to the epidermal edges, minimize suture track marks in surgical scars, reduce the risk of wound infections, and decrease the risk of inflammatory reaction to suture material.[7],[12] Its ease of use and rapidity of application are also advantages.[12],[13] Several studies have found favorable aesthetic outcomes with epidermal closure by cyanoacrylate. High-viscosity 2-octyl cyanoacrylate has been reported to be cosmetically equivalent to 5-0 polypropylene for closure of linear facial wounds.[14]
Cyanoacrylate, however, does not allow for wound eversion. Wound eversion minimizes the risk of a depressed scar from tissue contraction during healing. As with all sutures, fast absorbing gut suture allows for wound eversion, which is believed to facilitate optimal epidermal approximation. Fast absorbing gut suture also may be preferable for achieving hemostasis in the wound that is at risk for postoperative bleeding. Further, fast absorbing gut suture degrades by proteolysis, which can result in an inflammatory reaction and affect the final cosmetic outcome (i.e., postinflammatory hyperpigmentation).
Many recent studies have shown similar cosmetic outcomes between cyanoacrylate and sutures for a variety of surgical procedures.[7],[12],[15–17] The authors report a comparative study of cyanoacrylate tissue adhesive with fast absorbing gut suture in the closure of facial defects following MMS. The present study found no significant difference in cosmetic outcomes between the two techniques at three months after closure of linear facial wounds resulting from MMS. It has been reported that a patient’s cosmetic appearance at three months is predictive of long-term cosmetic appearance.[18] Evaluation of overall cosmesis slightly favored fast absorbing gut suture over cyanoacrylate, but this difference was not statistically significant. A higher powered study could potentially show a significant difference between the two techniques.
The location of the skin cancer had some relationships with the overall aesthetic outcome. Forehead wounds closed using cyanoacrylate were evaluated as being significantly worse than those closed on the cheeks or temple. However, this difference was not seen for fast absorbing gut suture. Forehead wounds tend to be under greater tension as compared to the cheeks or temple. This difference was not seen for fast absorbing gut suture, suggesting that cyanoacrylate may not be as effective for closure of wounds in high tension areas such as the forehead.[19] The authors’ finding echoes that of a study showing that fast absorbing gut suture was superior to cyanoacrylate at achieving optimal cosmesis for wounds on high tension areas of the trunk and extremities.10 Since cyanoacrylate has a tensile strength similar to that of a 5-0 suture, it follows that any wounds for which a 4-0 suture or stronger might be used would not be appropriate for tissue adhesive.[14]
Also, a trend toward significance was found between repair length and overall aesthetic outcome. Longer wound lengths correlated with a greater discrepancy between the two techniques and that longer repair length may correlate with a worse evaluation of the tissue adhesive. Also patient preference appeared to be linked to repair length, such that those with preferences tended to have longer repair lengths than those without preferences. However, a causal relation cannot be inferred because the effect may be confounded by other factors that coincide with longer repair lengths. Also, it is difficult to determine whether repair length is associated with a particular patient preference because there is only one patient who preferred the fast absorbing gut suture.
The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate tissue glue was significantly favored over sutures. Overall, patient preferences should be considered in the decision to choose between the two epidermal closure techniques.
There are several limitations to this study. A higher powered study with more patients could show more significant associations and better elucidate the trends noted above. The authors also did not achieve 100-percent follow-up. While wounds were all closed in a linear fashion, there was variability in wound closure length. Still, the mean lengths of wounds were similar to those of wounds in previous studies.7,12 Also, the fast absorbing gut suture used was either 5-0 or 6-0 based on physician preference at the time of the surgery. Limitations include a relatively small number of patients.
In conclusion, it is clear that cyanoacrylate tissue adhesives are a safe and effective alternative to fast absorbing gut suture and in general achieve similar cosmetic results. However, it appears that cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the face that are generally under greater tension, such as the forehead or of longer repair lengths. It is noteworthy that patients preferred cyanoacrylate. Cyanoacrylate and fast absorbing gut suture are both excellent options for epidermal closure of linear wound after MMS on the face. These closure options are appealing to both patient and surgeon as they remove the need for suture removal, preserving time and healthcare dollars. Surgeons may take into account factors, such as wound tension, need for eversion, and hemostasis, when deciding which technique is preferable for each surgical patient.
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