Closure of skin wounds with adhesives or staples
(UpToDate)
Goals of wound management :
1. Assist in hemostasis
2. Avoid wound infection,
3. Provide an esthetically pleasing scar
The healing process of skin occurs in several stages
1. Coagulation begins immediately following the injury. Vasospasm as well as platelet
aggregation and fibrous clot formation occur. During the inflammatory phase,
proteolytic enzymes released by neutrophils and macrophages break down
damaged tissue.
2. Epithelialization occurs in the epidermis, which is the only layer capable of
regeneration. Complete bridging of the wound occurs within 48 hours after
suturing.
3. New blood vessel growth peaks four days after the injury.
4. Collagen formation is necessary to restore tensile strength to the wound. The process
begins within 48 hours of the injury and peaks in the first week. Collagen
production and remodeling continue for up to 12 months.
5. Wound contraction occurs three to four days following the injury, and the process is
poorly understood. The full wound thickness moves toward the center of the
wound, which may affect the final appearance of the wound.
WOUND ASSESSMENT
1. Determination of the mechanism of the injury
2. Age of the injury
3. Identification of possible contamination or foreign body
a. Consider plain xray with glass injury (sens 90%)
4. Assessment of extent of the wound
a. Fracture or tendon/nerve laceration
5. Assessment for neurovascular compromise or tendon injury in the surrounding area
6. Need for tetanus prophylaxis
7. Identification of risk factors that might affect healing.
a. DM, steroids, CRF, tendency to form keloids, presenting beyond 18 hours
WOUND PREPARATION
1. Wound irrigation
a. Saline or tap water, splash guard
b. Can use dilute betadine (1:10 Betadine/saline) for contaminated wounds.
2. Foreign body removal
a. Remove splinters, glass, metal
3. Necrotic tissue debridement
Indications for secondary closure (ie, by granulation) include:
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Deep stab or puncture wounds that cannot be adequately irrigated
Contaminated wounds
Small noncosmetic animal bites
Abscess cavities
Presentation after a significant delay (>18h, or>24h head and neck)
Types of closure
1. Sutures
a. Simple interrupted commonly used
2. Tissue adhesives
a. cyanoacrylate polymers Dermabond (Ethicon).
3. Staples
A. Tissue adhesives
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Physiology — Cyanoacrylate tissue adhesives are liquid monomers that undergo an
exothermic reaction on exposure to moisture (eg, on the skin surface), changing to
polymers that form a strong tissue bond. When applied to a laceration, the polymer
binds the wound edges together to allow normal healing of the underlying tissue.
Maximum bonding strength is achieved within 2.5 minutes of application
DERMABOND is 2 Octyl cyanoacrylate – low toxicity, has addition of plasticizers which
provide increased flexibility. Replacement for 5-0 or smaller sutures
Advantages — over sutures and staples:
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Less painful application, and sometimes no need for local anesthetic injection
More rapid application and repair time
Cosmetically similar results at 12 months post-repair
Waterproof barrier, no need to keep areas dry; bandages usually not required
Antimicrobial properties
Better acceptance by patients
No need for suture or staple removal or follow-up
Efficacy — Several randomized clinical trials in both children and adults have found
that there is no significant difference in outcomes when either lacerations or surgical
incisions are repaired with tissue adhesive versus standard wound closure (eg, sutures,
adhesive strips)
INDICATIONS- good wound approximation with no wound tension. The ideal
laceration is clean and linear.
CONTRAINDICATIONS1. Complex stellate lesions or crush injuries should not be closed with tissue
adhesives since good wound approximation is difficult to achieve.
2. Hands, feet, or joints, unless immobilized
3. Oral mucosa or other mucosal surfaces
4. Areas of high moisture such as the axillae and perineum.
5. hairline or vermilion border of the lip require more precision
6. Puncture wounds and most bites- increased risk of infection
7. Patients with diabetes mellitus, chronic vascular disease, peripheral vascular
disease, decubitus ulcers, prolonged steroid use, history of keloids, bleeding
diathesis, allergy to adhesives
TECHNIQUE OF APPLICATION
http://www.dermabond.com/bgdisplay.jhtml?itemname=how-it-works
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Wound prep
Cleanse wound, placement of subcutaneous sutures if necessary
Evert or appose edges using the fingers or tissue forceps.
Achieve hemostasis because blood interferes with adherence of the adhesive to
the skin.
Remove any tissue or hair that extrudes through or overlies the wound edges
Crack vial, squeeze to saturate the foam tip, wipe gently over the wound edges
in a single motion, spreading a thin film
Don’t press into the wound, (may cause a foreign body reaction that prevents
normal wound healing) .If this occurs, wipe off, using petroleum jelly or
antibiotic ointment to loosen the polymer.
allow to dry for 30 to 40 seconds while continuing to hold the wound edges
together to allow complete polymerization
repeat three to four times in an oval pattern around the wound
Wound closure strength is enhanced by extending the application 5 to 10 mm
beyond the margin of the incision
Don’t touch the wound for about 5 minutes.
AFTERCARE
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No bandage needed
No ointment
May shower ;avoid long soaks
No scrubbing or picking for 7-10 days
Peels in 5-10 days or can use petroleum jelly to remove
No follow up needed
COMPLICATIONS
Leakage, sticks to gloves/instruments
If gets in the eye or eyelids generous amounts of ophthalmic antibiotic ointment should
be placed on the eyelid to break down the adhesive and an ophthalmologist should be
consulted
COST- $24/vial ($5 for suture pack), but similar in terms of time, f/u appt, suture
removal kit
B. Staples
Pros (over sutures)
Cons
1. More rapid
2. Avoid needle stick risk
3. Good wound eversion
1. More painful removal
2. Higher risk of scarring
3. Less precise- avoid in
face/neck/hands/feet
4. CT- artifact; MRI -avulsion
Ideal wound- linear with straight, sharp edges
PROCEDURE
1. Wound assessment
2. Anesthesia- regional or local
3. Evert wound with forceps or by pinching the skin with the thumb and index
finger.
4. Place stapler firmly on the surface but without indenting the skin; squeeze the
handle gently to eject the staple into the tissue. Release by pulling the wrist back.
5. Apply antibiotic ointment (eg bacitracin), dressing for 24-48hours
Removal of staples (same as sutures)
1. Neck - 3 to 4 days
2. Face and scalp - 5 days
3. Eyelids - 3 days
4. Trunk and upper extremities - 7 days
5. Lower extremities - 8 to 10 days
Wound management and tetanus prophylaxis
Previous doses of
adsorbed tetanus
toxoid*
Clean and minor wound
All other wounds
Tetanus toxoid
TIG
Tetanus toxoid
TIG
<3 or unknown
Yes§
No
Yes§
Yes
Only if last dose
given 10 years
ago
No
Only if last dose
given 5 years ago
No
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