A Super Alternative for Wound Closure: A New Generation of Cyanoacrylate
ABSTRACT & COMMENTARY
A new cyanoacrylate compound is now under investigation at several sites in the United States prior to FDA approval. Quinn and colleagues from the University of Ottawa report their results with the use of octylcyanoacrylate on uncomplicated wounds in adults.
In this study, adult patients were randomized to standard treatment with suturing or wound closure with octylcyanoacrylate tissue adhesive (OCTA). Wounds that were included were those on the face, torso, or extremities, regardless of length or the need for deep sutures. Exclusion criteria were extensive: soiled or contaminated wounds needing debridement, animal or human bites, puncture wounds, wounds crossing mucocutaneous junctions, scalp lacerations, patients with a history of keloid formation, ear lacerations, wounds of the hands or feet, any wounds crossing joints, and extremity lacerations in patients with a history of peripheral vascular disease, diabetes mellitus, or prolonged corticosteroid use.
As a result, a very narrow range of laceration types was included in this study, with an average laceration length of 1 inch. Quinn et al state that they tried to include all eligible patients, but they did not state that the enrolled patients were consecutive. The groups were compared regarding time of closure, patient-rated pain, and cosmetic result. A cosmesis score was assigned by an independent plastic surgeon who rated photographs of wounds at three months using a visual analog scale. Photographs were shown to the plastic surgeon on more than one occasion to ensure intra-rater reliability.
Results: The time of wound repair was significantly shorter in the OCTA group, 3.6 vs. 12.4 min. Treatment with OCTA was significantly less painful as rated by patients on a visual analog scale. There were no differences between the groups in the blinded cosmetic outcome at three months. Patients also received early follow-up from research nurses who were aware of the type of closurerendering their evaluation, for research purposes, meaningless; however, it did provide an added safety measure since there were four wound dehiscences (3 in the OCTA group and 1 in the suture group). (Quinn J, et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997;277:1527-1530.)
COMMENT BY JEFFREY W. RUNGE, MD, FACEP
We have all heard of super glue closure of lacerations, and we have been awaiting the Food and Drug Administration’s (FDA) approval of what should be a relatively painless way to close wounds. The previous generation of cyanoacrylate tissue adhesive (CTA) was made from butylcyanoacrylate, a polymer that has had very limited application because its breaking strength on day 1 is only about 10-15% of a wound closed with 5-0 sutures. The compound used in this study, octylcyanoacrylate, is a new generation polymer that forms a stronger bond and is also reported to be more flexible and less apt to break than its predecessor.
This study was not perfect, but few wound closure studies are. There was certainly an opportunity for bias to occur in this study in that the patients were not necessarily consecutive; there were some very subjective exclusion criteria; and, in spite of the inclusion of wounds of any length, the wounds in the study were nearly all about 1 inch long. Quinn et al are to be commended for trying to eliminate evaluation bias in taking photographs of the wounds and having a plastic surgeon rate the scars on two occasions to eliminate intra-rater reliability issues.
In summary, this study looks very promising, and although it studied only 130 patients with very uncomplicated wounds, it still holds promise for those of us who would love to have a quicker and more painless way to close wounds with a good cosmetic result.
Other issues to be addressed with respect to CTAs were not mentioned in the paper. Does this type of wound closure require fewer supplies to stock and sterilize? Will the cost of the CTA be prohibitive when compared to the very small cost of nylon skin sutures? Will the avoidance of needle sticks alone and their inherent cost make the use of CTA worthwhile? Can correct technique in application of this substance eliminate the foreign body reactions reported in other studies when the CTA is introduced into (not on top of) the wound? Can this technique be safely performed by lay people? All of these will be areas of further study, and these questions are very likely on the mind of the FDA officials reviewing the compound. I am sure other studies will be forthcoming, but I don’t look for suturing to become a lost art any time soon.