Lacerations: Does closure technique matter?

First10EM Laceration evidence technique
Cite this article as:
Morgenstern, J. Lacerations: Does closure technique matter?, First10EM, November 28, 2022. Available at:
https://doi.org/10.51684/FIRS.128664

There are a lot of strong opinions about how lacerations should be repaired. There may be even more laceration repair techniques. This seems like a good spot for a ‘more than one way to skin a cat’ joke, but what we really want is evidence. Which laceration repair technique is the best, according to science? Because I am going to try to tackle all the usual techniques you will see, this will be a relatively long post, but if you want the short summary, it probably doesn’t matter at all. The many techniques all seem to result in similar results. The human body does most of the hard work in repairing lacerations, and we mostly just need to get out of the way and let it do its job. 

General comments

Before diving into the science, there are some general sources of bias that will come up repeatedly, which are worth considering.

First, it is impossible to blind the individual performing the repair. The physician needs to know whether they are using sutures or skin glue. It is also very difficult to blind patients. (It could be done, but I don’t think it is in any of these studies.) Most studies use a blinded, independent assessor for their outcomes. However, that assessor could easily be influenced if the patient knows their outcomes. (Imagine the difference between a patient showing up and complaining of the awful scar they got after ‘just being glued’, as compared to the happy patient with the exact same scar after sutures.)

The effect of skill on outcomes is a more complex and fascinating scientific topic. It is possible that skill really matters when assessing suturing. If that is the case, a study that compares dermabond to sutures done by students may provide an unfair depiction of the value of suturing. If you believe that you are the world’s best suture artist, you might not believe that any of these results apply to you. (And despite the fact that, by definition, half of the people reading this will be below average in their skills, I can guarantee you that almost 100% of you rate your skills as above average.)

Personally, I doubt that skill has a huge impact on outcomes. In large part, that is because of my faith in human physiology. In almost all scenarios, the human body repairs itself at least as well as we do as physicians. Skin was healing for millennia before the invention of sutures, so there is a reasonable expectation that if the wound edges are approximated, the wound will heal itself. Furthermore, despite a slight potential for circular reasoning, I think the evidence mostly suggests that skill is irrelevant. After all, what is skill when it comes to wound repair? Many experts would have argued that eversion is an important marker of skill, but as was covered in part four of this series, there is absolutely no evidence that eversion matters at all. So my personal bias is that skill is probably mostly irrelevant, at least within the context of these studies, where the minimum skill level is still a highly trained resident physician.

There are a plethora of other factors that might impact the outcomes in laceration repair. What are the best aftercare instructions? What is the best method for clearing wounds? How should we manage complications such as dehiscence and infection? Are prophylactic antibiotics ever warranted? Do individual patient factors influence the ideal repair technique? Because these factors are almost never controlled for in these studies, the results are difficult to interpret. You could imagine a small benefit from suturing being completely obscured because both groups were given poor aftercare instructions, resulting in worse outcomes in both groups.

Finally, the primary outcome of these trials is usually cosmesis, which is a highly subjective outcome, and prone to bias. Some of these studies add some objective measures, like the specific size of the scar. Functional outcomes are rarely (if ever) discussed. Therefore, the risk of bias will remain high across the board.

Skin glues

The most ‘up to date’ Cochrane review on skin adhesives dates back to before I was even in medical school, but as of 2002 there were 13 RCTs. (Farion 2002) 2 compared different adhesives to each other, with no significant differences. The other 11 compared adhesives to standard care (mostly sutures), and found no differences in cosmesis at any point measured. There is a clear benefit from adhesives in terms of both pain scores (mean weighted difference -13.4mm) and procedure time (-4.7 minutes). However, skin adhesives did have a slightly higher rate of dehiscence (2.5%) and more erythema (10%). The Cochrane review specifically excluded studies where wounds were infected, contaminated, crossing joints, in hair-bearing areas, in patients who develop keloids, and in those with chronic disease.

As always, I think a meta-analysis is a good place to start, but you should never stop at the meta-analysis. Too often, the statistical averaging of studies hides essential details. I always suggest reviewing at least a few of the bigger or most impactful studies included in the meta-analysis to decide whether you believe the results.

An example of a paper worth a closer look is the RCT by Saxena and Willital. (1999) It is an RCT that included 64 children between the ages of 2 and 16 who had lacerations of the extremities that were under high tension (over joints). They compared octyl cyanoacrylate to sutures (5-0 nonabsorbable), and like all the studies found no difference in cosmetic outcome. There was 1 infection in the suture group and 2 dehiscences (with no consequence) in the adhesive group. The important caveat in this paper is that all skin adhesive was reinforced with steri-strips and splints were used to immobilize the joint for 7-10 days. Obviously, we don’t know if the splint was required, but that is a major downside that needs to be considered. (I use a lot of glue over joints without splinting, and I haven’t seen obvious complications.) I think it is also nice to know this is an option you can discuss with parents for wounds with high risk of dehiscence.  

Two publications describe the same RCT, but with different follow-up periods (Bruns 1996 looked at 2 month follow-up and Simon 1997 looked at 1 year follow-up). This is an RCT of 64 children between 1 month and 18 years old with lacerations less than 5 cm long, excluding any lacerations over areas of high tension. All lacerations greater than 5mm in depth received a deep absorbable suture, and then they compared Histoacryl Blue to 5 or 6-0 non-absorbable sutures. All the suturing was done by the 6 investigators (4 physicians and 2 extenders). Cosmesis was judged by 2 blinded plastic surgeons based on photographs at 2 months and a year. The brief summary is that there were no differences between the groups, but looking at the details reveals a couple of the major limitations of this data. First of all, the 2 surgeons didn’t agree with each other at all, reminding us that this subjective scoring of cosmesis is prone to bias. (At 2 months, surgeon A thought the 2 groups were essentially identical, with scores of 55 vs 59 out of 100, whereas surgeon B thought skin adhesive was significantly better 43 vs 68, p=0.05. The results were basically the same at 1 year, but the difference wasn’t statistically significant because so many patients were lost to followup.) The other big problem these numbers highlight is that although equal in both groups, cosmesis was actually pretty horrible, with an average of only 50/100 on a subjective scale. Perhaps that is just the cosmesis to be expected after emergency wound repair, but it is also possible that skin adhesive is being compared to poor suturing technique. This is always a problem when RCTs look at interventions that require clinician skill – the clinicians in the study may not have the same level of skill as you do. Unfortunately, it is generally impossible to know if they are more or less skilled than you are, which makes assessing generalizability of research of skill based interventions very difficult.

In an RCT out of the Children’s Hospital of Eastern Ontario, 81 children with clean facial lacerations not more than 4cm long and 0.5 cm wide were randomized to either histoacryl blue or non-absorbable 5-0 or 6-0 sutures. Exclusions were animal bites, lacerations on hair-bearing surfaces or crossing muco-cutaneous junctions, or heavily soiled wounds. They specify that dehiscence was closed by delayed primary closure, which is another wrinkle to add to this data. Long term outcomes might be heavily influenced by the management of complications, or other factors such as aftercare instructions, that were not done identically between the two groups. Using photographs reviewed by blinded plastic surgeons, there was no difference in cosmesis, but again the outcomes were not great (60 out of a 100 point scale, where 100 is the worst outcome). Pain was less with glue (4/10 vs 2/10, p<0.01) and glue took less time (8 vs 16 minutes, p<0.001). There was 1 infection in both groups, and 3 dehiscences with glue as compared to 2 with sutures. 

Another relatively large RCT was published after the Cochrane review. (Holger 2004) They included 145 patients over the age of 5 with facial lacerations, and compared 3 groups: absorbable sutures (rapid absorbing gut), non-absorbable sutures (nylon), and skin glue (Dermabond). The sutures were both 6-0 in size, and had topical antibiotics applied for 2 days afterwards. All laceration repair in this study was performed by physician assistants, but they present previous data that PAs perform at least as well (if not better) than attending physicians. (Singer 1996) Two physicians and the patient all rated the cosmetic outcomes at a 9-12 month follow up visits, and there were absolutely no differences. There were no differences in complications. Of course, the outcomes are rather subjective and the study was only partially blinded. They also only had about 60% follow-up at the 9 month visit. So this is only weak evidence, but it is consistent evidence, suggesting that the technique used to close has no impact on long term cosmetic outcomes. 

Another unblinded RCT without a clear primary outcome concluded that Dermabond resulted in better outcomes than sutures. (Wong 2011) They compared Dermabond to nylon stitches in 201 patients with uncomplicated sutures less than 8 cm in length. The objective wound score they used actually wasn’t different between the groups, but on patient self assessment, Dermabond was statistically better. However, I imagine this difference isn’t clinically significant, so it is probably inappropriate to conclude results were better (92/100 vs 85/100 on self assessment, p<-.0005). Infection was 1% in both groups. 

Although study exclusions limit direct extrapolation of results, they do not mean that an intervention is contraindicated. For example, I have heard numerous times that skin adhesive is contra-indicated on the scalp (I think based on the Cochrane exclusions, and the fact that many of these early RCTs excluded lacerations in hair-bearing areas), but there is evidence dating back decades that skin adhesives work just fine on the scalp. For example, Morton 1988 is an observational study of 50 patients (aged 4-75) with scalp lacerations. All were repaired with skin adhesive, and 5 days later 49 were fully healed. The one that wasn’t completely healed just had a 3mm area of wound dehiscence. There were no infections or complications. 

It probably doesn’t even need to be said, but adhesive has less strength than sutures. (Bresnahan 1995) However, it isn’t easy to translate the numbers reported in the studies I have come across into clinical practice. Sutures may have double the tensile strength of glue (420 grams versus 188 grams), but what we really want to know is how often wounds that are repaired with glue and placed under normal physiologic tension come apart. Combining steristrips with glue appears to double the tensile strength as compared to using either alone. (Brown 2021) Ultimately, dehiscence does seem slightly more common with skin adhesive, but it doesn’t seem to have any impact on long term cosmesis, so it isn’t clear that the dehiscence being reported is anything other than a minor inconvenience. 

A cost analysis out of Ottawa, Canada in 1995 found that non-dissolving sutures were more expensive than dissolving sutures, which were more expensive than skin glue (based largely on the need for a follow-up visit in the non-dissolving sutures). (Osmond 1995) In 1995 Canadian dollars, the costs were: $58.20 for closure with non-dissolving sutures, $20.30 for use of dissolving sutures, and $8.60 for tissue adhesive closure. In the same study, they performed a survey of parents, and 90% favoured glue (with the remaining 10% wanting dissolving sutures, and no one wanting what I still think is the most commonly used option of non-dissolving sutures). The study by Wong (2011) also looked at costs, and thought that skin adhesive was more expensive than sutures, but they only looked at direct costs and the difference was less than $5.

Based on a 2020 study using the National Hospital Ambulatory Medical Care Survey database, which included 26 millions patients with lacerations, it appears that about 78% were repaired with sutures alone and 16% with tissue adhesives alone. (Otterness 2020) Total emergency department length of stay was significantly shorter (by about half an hour) for patients receiving skin glue, even after adjusting for potential confounding variables, which makes sense. 

There is also some surgical literature we can consider. A meta-analysis including 4 trials and 404 patients comparing sutures and skin adhesive in the closure of laparoscopic port-site wounds found no difference in dehiscence, wound infection, or patient satisfaction, but tissue adhesives were quicker. (Sajid 2009)

Skin adhesive for specific lacerations

Most of the RCTs focus on simple dermal lacerations, but skin adhesive has been used in a large variety of injuries.

Nail bed lacerations: In one small (40 patient) RCT, dermabond was compared with 6’0 sutures in the closure of nail bed lacerations. (Strauss 2008) Not surprisingly, dermabond was much quicker (10 minutes versus 28 minutes for the full procedure). There were no differences in cosmesis as rated by either clinicians or patients, nor were there differences in pain or function. (Of course, I think the evidence says we don’t need to repair these nail bed injuries at all, but that is a question for another day.)

Tongue lacerations: This one surprised me, but Dermabond has even been used on the tongue. (Kazzi 2013) This is only a single case report, and so doesn’t really provide us with any evidence at all, but they did use Dermabond to repair a child’s tongue laceration. (They have a picture, and I might have argued that the laceration didn’t need any intervention at all.) I include the paper because, although the product information sheet will state that dermabond is not indicated for use on mucosal surfaces, the Material Safety and Data Sheet (MSDS) states there are no anticipated adverse events from ingestion, and this author also talked to poison control, who affirmed that Dermabond is almost certainly safe to use in the mouth.

Skin adhesive summary

The available research is far from perfect. It uses subjective outcomes. The trials are imperfectly blinded. There is often significant loss to follow-up.The cosmetic outcomes might be heavily influenced by the skill of a small number of clinicians doing the suturing.  We are therefore left with significant uncertainty.

That being said, there is no indication that suturing is better than skin adhesives. There is also no physiologic reason to think suturing would be better than adhesives (especially once we eliminate the myth that wound edges need to be everted).

There are some clear benefits with using skin glue, namely speed and comfort. I think most parents and most patients are thrilled to get glue instead of sutures. 

Conversely, there are some potential downsides to be considered. Wound dehiscence is almost certainly more common, although this doesn’t seem to have any impact on long term outcomes. Clinical judgment is probably required when deciding which wounds are under too much tension for adhesives alone. Furthermore, many patients at higher risk for infection and poor wound healing were excluded from these trials. However, there is no indication that skin adhesives increase infection or cause poor wound healing, so it is unclear whether these exclusions are clinically relevant. (I have even seen it stated in many locations that cyanoacrylate glues are bacteriostatic, and perhaps bacteriocidal, although I could never find an original citation to confirm that fact.) Again, clinical judgment and patient preference will have to be considered for higher risk wounds, if only because you might be blamed for bad outcomes, even if that blame is scientifically inappropriate. 

Personally, I use skin adhesive for that vast majority of lacerations in the emergency department (probably well over 90%). This is based on years of talking to my patients, and discovering the almost universal preference for glue over sutures. Considering the lack of long term difference, it seems pretty clear that we should go with whatever our patients prefer (while using our judgment to pick the more complex wounds that may require sutures).

Hair apposition technique

I thought I was an early adopter of the hair apposition technique, hearing about it while I was still in residency. It turns out that it was described well before I was even in medical school. In case anyone is unaware, the hair apposition technique involves taking strands of hair from each side of the wound, twisting them together, and securing them with a single drop of tissue adhesive. (Personally, I use a hybrid method with more liberal application of adhesive along the entire length of the wound.)

The HAT study is a RCT comparing the hair apposition technique to sutures in 189 emergency department patients with scalp lacerations between 3 and 10 cm in length. (Hock 2002) Patients were excluded if they had significant wound contamination, arterial bleeding that didn’t stop with 5 minutes of pressure, or if they required resuscitation. Local anesthetic was used for suturing but not hair apposition. Hair washing was allowed after 3 days with hair apposition and 7 days with sutures. Total procedure time was faster with hair apposition (5 vs 15 minutes). There was more pain in the suture group (2 vs 4 out of 10). At 7 days, 100% of the hair apposition group had adequate wound healing, as compared to 96% of the suture group. By 4 weeks, all wounds were healed, but scars were bigger in the suture group. When asked if they would want the same procedure in the future, 84% of the hair apposition group said yes, as compared to only 10% of the suture group.

There is a HAT 2 study, but it doesn’t actually look at the efficacy of the hair apposition technique. (Ong 2008) In this study, all patients received the hair apposition technique, and the comparison was having the procedure done by a doctor or a nurse. Doctors were a little faster, but the outcomes were all identical, so it is perfectly reasonable to train nurses to perform this laceration repair technique.

Bottom line

There is only a single RCT, but it is enough for me to incorporate this technique into my practice. As long as there is not arterial bleeding, my laceration repair technique for the scalp is generally guided by the length of the patient’s hair. If they have medium to long hair, I use the hair apposition technique. If they have short to no hair, I just apply the skin glue directly to the scalp. Either way, skin adhesives will repair almost every scalp laceration.

Steri-strips

Historically, I have not used a lot of steri-strips, as it felt uncomfortable to tell patients that after driving to the hospital, paying for parking, and waiting to see me, all they really needed was a product available at their pharmacy. However, the evidence suggests I am probably under using the product.

There is a single center RCT comparing Dermabond and steri-strips in pediatric facial lacerations. (Zempsky 2004) They included wounds less than 2.5 cm in length and less than 12 hours old, excluding grossly contaminated wounds, wounds requiring deep sutures, or those in areas of high tension or mobility. Prior to application of the steri-strips, wound edges were painted with compound benzoin tincture, which does seem to increase stickiness, but is almost impossible to find in the EDs I work in. The study used a convenience sample of 100 patients, and the treating clinicians were not blinded, although the final outcome was based on photos and the assessing cosmetic surgeons were blinded. Complications were not statistically different, although dehiscence occurred in 1 patient (2%) with steri-strips and 6 patients (12%) with glue. Cosmesis at 2 months was not statistically different, but was numerically a bit worse in the dermabond group. 

In another single center pediatric RCT, Dermabond was compared with 3M brand steristrips in traumatic lacerations less than 5 cm in length, with no signs of infection, not caused by a bite, and not involving the mucous membranes, scalp, or areas of high tension. (Mattick 2002) There was no difference in cosmesis at 3 months based on photographs judged by blinded plastic surgeons. Ease of application and the parent’s opinion of the treatment was also identical in both groups. 

In another small multi-center RCT, sutures were compared to steri-strips in 90 emergency department patients less than 5 cm long, less than 5 mm deep, not involving muscle, and not requiring debridement. They were very particular about both suture technique (every 5 mm) and steri-strip technique (swabbing the skin with benzoin tincture first, and then reinforcing the steri-strips with a second layer running parallel to the wound.) At 2 months, the scar width was the same in both two groups (2.9 mm with sutures and 2.5 mm with tape, p=0.07). In the subgroup with wounds less than 20 mm, the tape group was statistically better (1.7 vs 2.5 mm, p=0.01).

There is a systematic review and meta-analysis looking at tissue adhesives and adhesive tape in pediatrics patients, including both traumatic lacerations and surgical wounds. (Tandon 2021) There are 31 studies in the systematic review, 16 homogeneous enough to be in the meta-analysis. Some studies directly compared tissue adhesives to adhesive tape, while others compared to sutures. I think the biggest take home is that the quality of the data is poor, with small study sizes, somewhat mixed results, and a lot of heterogeneity. Of the many analyses they did, there was one which was statistically significant: steri-strips seem to outperform glue on cosmesis. However, this was based only on 3 small RCTs, and the results were driven primarily by 1 study. In all other comparisons, including infections and dehiscence, they found no differences between tissue adhesives, adhesives tapes, and sutures. 

In small laparoscopic trocar wounds in children, an RCT of 49 children was probably too small to demonstrate real differences between tissue adhesive and steri-strips, but the 90 day outcomes as judged by the surgeons were thought to be better in the steri-strip group. (Romero 2011) In a similar study in adults looking at wound closure post ankle arthroscopy, there were no differences between a single steri-strip when compared to a single 3-0 nylon suture. (Stavrou 2012) In another very small (10 patients) study of wound closure after surgical skin excision in a dermatology clinic, wounds were divided in half, and steri-strips were compared to 4-0 polypropylene running sutures. (Yang 2015) Closure was about 2.5 minutes faster with steri-strips than sutures (p=0.0002). For a study with only 10 patients, there are a lot of results. The most important finding was that by 26 weeks, there was no difference between the two repair techniques. Steri-strips might actually have been somewhat better during early follow-up (which makes sense as there is no intra-dermal inflammatory material), but that seems rather irrelevant if long term outcomes are identical. 

In another RCT published just as I was finishing this review, skin glue alone was compared to skin glue with underlying steri-strips in children with simple facial lacerations. (Munns 2022) Their primary outcome was cosmesis, and was unchanged. Other important outcomes, such as ease, dehiscence, and infections were also identical, but adding the steri-strips did add extra time to the procedure. That being said, they focused on simple lacerations, which doesn’t make a lot of sense to me, as they always come together well with glue. I use the combined approach with complex lacerations, where I need the steri-strips to help with alignment prior to applying glue.

Steri-strip summary

Like everything today, there are numerous possible sources of bias, and so we shouldn’t be too certain of any conclusions. However, the consistency of the data is comforting to me. It basically seems to suggest that long term cosmetic outcomes will be identical whatever technique we choose. Therefore, factors like comfort, cost, and patient preference should play a large role in making this decision. 

I have always been a big fan of skin glue, but this data suggests my patients may do just as well if I used steri-strips instead. (Honestly, I frequently use a combination: steri-strips to get the alignment I want, and glue for what I thought was added strength.)

Staples

I will admit my bias up front: I have never been a fan of staples. I have seen too many really bad scars with ‘railroading’ from staples, and had too many patients complain about pain with removal. Even the simple fact that they have to be removed is a major detriment when I have multiple options (glue and absorbable sutures) that don’t require the patient to waste time and money on a follow-up appointment. That being said, my opinions don’t seem to be all that evidence based. 

In a small RCT of 42 pediatric patients with scalp wounds, staples were compared with sutures, and there were no differences in cosmetic outcomes at 6 months. (Khan 2002) The staples were faster (5 versus 15 minutes), but it has never taken me 15 minutes to suture a scalp wound, and I think this number is artificially inflated by the technique used (mandating sutures every 5mm, rather than just placing sutures as required to obtain adequate closure).

Another small RCT of 87 lacerations in the emergency department found that staples were faster than absorbable sutures, with no difference in satisfaction. (Brickman 1989) Another small RCT of 48 ED patients again found that staples were faster than sutures, with no difference in discomfort, infection rates, cosmetic result, or ease of removal. (Shuster 1989) The times in this study seem more reasonable, at 97 seconds in the staple group and 281 seconds in the suture group. 

There is a BMA BEST BETs short cut review on staples versus sutures for scalp lacerations from 2002. (Hogg 2002) They found 4 relevant papers. There are no large prospective studies. Based on the small studies they found, staples appear to be faster and less expensive than sutures. They were not able to assess clinical outcomes.

Although I never use staples personally, I see a lot of patients with staples in place, with the vast majority occurring after orthopedic surgery. Interestingly, this seems to be the group with the lowest quality evidence. There is a 2010 systematic review and meta-analysis that includes 6 studies (3 randomized and 3 observational) of patients after orthopedic surgery, and concludes that there is a significantly higher rate of wound infection in patients closed with staples as compared with sutures (relative risk 3.83, 95% confidence interval 1.38 to 10.68; P=0.01). (Smith 2010)

Another more recent meta-analysis of surgical patients found 42 RCTs with a total of 11,067 patients, all of which were judged to be low or very low quality. (Cochetti 2020) The main conclusion is that the lack of high quality evidence precludes any conclusions. In this meta-analysis, infection rates were not statistically different, although the point estimate was still higher with staples. All adverse events were higher with staples as compared to sutures (7.3% vs 3.5%, RR 2.0, 95% CI 1.44 – 2.79). These adverse events aren’t specifically defined, so I don’t know how clinically relevant they are.

I think a major flaw to these studies is the assumption that suturing is the baseline standard of care. Scalp lacerations are the primary indication for which staples get used, and I would argue that the hair apposition technique could be considered the standard, at least from a patient preference perspective. What we really need is an RCT comparing staples to hair apposition technique (and my guess is that there will be no important differences, but that hair apposition will cause much less pain, and will be greatly preferred by patients.)

Staples summary

Staples seem to have much weaker evidence than our other alternatives to sutures. The higher rate of infection or adverse events in surgical patients is somewhat concerning, but this finding has very low certainty. My guess, based on a mix of clinical experience and this literature, is that staples are quicker than sutures, and probably have very similar long term outcomes to our other options. 

However, in my experience, patients generally hate staples. Evidence based medicine is about more than RCTs and p-values. We need to be able to incorporate our patients’ opinions with the best available literature.

Based just on the literature, staples seem like a fine option. However, I still can’t see myself using them all that often. The big argument against, in my mind, is the need for removal. That seems like a pretty big downside. I have never met a patient who chose non-absorbable sutures over absorbable. Unless the patient wants to remove the staples themselves, this strategy is condemning them to another visit, which even in a healthcare system like Canada’s will result in costs (parking) and wasted time. Personally, I will stick with glue for 90% of lacerations, and absorbable sutures for most of the rest, but clearly patients should be involved in these decisions, as the clinical science is not enough to define a clear best option. 

No closure

We often assume that lacerations need something, but benign neglect is one of the best interventions in medicine, and wounds had been healing for eons before the invention of the suture.

In one RCT, they looked at 95 patients with hand lacerations that were no longer than 2 cm, but which the treating physician thought needed suturing, and they randomized them to either sutures or conservative management (dressing and antibiotics ointment only). (Quinn 2002) At 3 months, there was no difference in cosmesis as judged by both blinded doctors and the patients. Obviously, this is a very select group of lacerations, and the trial is far too small to say anything about complications, but it fits with the overall hypothesis that our interventions have very little impact on long term outcomes in lacerations. 

Overall summary

For long term outcomes, it really doesn’t seem to matter what technique we use to close wounds in the emergency department. As long as we get the edges somewhat close, the body will repair itself. Without a clear winner based on the literature, the decision should rely heavily on patient preference.

Personally, my preference has always been for dermabond, based on years of discussion with patients. As long as the outcomes are going to be identical to sutures, patients (and especially parents of patients) are incredibly happy to hear that they can ‘get away with’ being glued rather than stitched.

The evidence reviewed seems to suggest that for small lacerations, just using steri-strips is probably at least as good as (if not better than) tissue adhesives. My only concern is that patients don’t see the same value in steri-strips. Patients seem to be generally unhappy to wait hours in the ED only to receive a treatment they could have applied themselves. I am not sure that is a good enough reason to favour skin glue, but it does seem to make patients happier. 

Although I favour tissue adhesives, there are obviously still many scenarios in which sutures may be needed or preferred. None of the evidence seems to provide a very strong scientific justification for choosing one method over another. Tissue adhesives have a slightly higher rate of dehiscence, so sutures may be better in areas of high tension or with lots of expected movement (although I still use glue over joints all the time). I am also somewhat cautious about glue in patients who cannot resist picking it off (mostly toddlers, but I suppose adults might be similar). That isn’t always a reason to avoid glue, but I often add dressings or steri-strips which are technically unnecessary just to protect the glue for a few days. 

Infection is a more difficult topic, and I am not sure that these studies help. In the available studies, infection does not seem to correlate with repair technique, but highly contaminated wounds and high risk patients are generally excluded. Honestly, I don’t think there is a good physiologic basis for choosing one technique over another. The idea of leaving wounds open ‘to let infection escape’ doesn’t make a lot of sense to me, and skin adhesives may actually have antibiotic properties. Right now, infection risk impacts my wound preparation, and my discharge instructions, but doesn’t affect my choice of closure technique.

At the end of the day, you are well justified whatever your chosen technique. The only thing that seems unjustifiable is not accounting for patient preference. 

Others FOAMed

Three things you didn’t know about gluing skin on lacerationrepair.com

References

Bresnahan KA, Howell JM, Wizorek J. Comparison of tensile strength of cyanoacrylate tissue adhesive closure of lacerations versus suture closure. Ann Emerg Med. 1995 Nov;26(5):575-8. doi: 10.1016/s0196-0644(95)70007-2. PMID: 7486365

Brickman KR, Lambert RW. Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med. 1989 Oct;18(10):1122-5. doi: 10.1016/s0196-0644(89)80945-x. PMID: 2679247

Brown JL, Jehle D, Mayrose J, Schwartz L, Pugh J, O’Brien C. Skin tapes and tissue adhesive vs. either method alone for laceration repair in a porcine model. Am J Emerg Med. 2021 Jul;45:317-323. doi: 10.1016/j.ajem.2020.08.081. Epub 2020 Sep 4. PMID: 33059984

Bruns TB, Simon HK, McLario DJ, Sullivan KM, Wood RJ, Anand KJ. Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics. 1996 Oct;98(4 Pt 1):673-5. PMID: 8885944

Cochetti G, Abraha I, Randolph J, Montedori A, Boni A, Arezzo A, Mazza E, Rossi De Vermandois JA, Cirocchi R, Mearini E. Surgical wound closure by staples or sutures?: Systematic review. Medicine (Baltimore). 2020 Jun 19;99(25):e20573. doi: 10.1097/MD.0000000000020573. PMID: 32569183

Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds’ Scar. Adv Biomed Res. 2018 Mar 27;7:49. doi: 10.4103/abr.abr_148_16. PMID: 29657934

Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002;2002(3):CD003326. doi: 10.1002/14651858.CD003326. PMID: 12137689; PMCID: PMC9006881.

Foster GE, Hardy EG, Hardcastle JD. Subcuticular suturing after appendicectomy. Lancet. 1977 May 28;1(8022):1128-9. doi: 10.1016/s0140-6736(77)92385-6. PMID: 68225

Hock MO, Ooi SB, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med. 2002 Jul;40(1):19-26. doi: 10.1067/mem.2002.125928. PMID: 12085068

Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004 Jul;22(4):254-7. doi: 10.1016/j.ajem.2004.02.009. PMID: 15258862

Kazzi MG, Silverberg M. Pediatric tongue laceration repair using 2-octyl cyanoacrylate (dermabond(®)). J Emerg Med. 2013 Dec;45(6):846-8. doi: 10.1016/j.jemermed.2013.05.004. Epub 2013 Jul 1. PMID: 23827167

Khan AN, Dayan PS, Miller S, Rosen M, Rubin DH. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002 Jun;18(3):171-3. doi: 10.1097/00006565-200206000-00005. PMID: 12066001

Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002 Sep;19(5):405-7. doi: 10.1136/emj.19.5.405. PMID: 12204985

Morton RJ, Gibson MF, Sloan JP. The use of histoacryl tissue adhesive for the primary closure of scalp wounds. Arch Emerg Med. 1988 Jun;5(2):110-2. doi: 10.1136/emj.5.2.110. PMID: 3408528

Munns E, Kienstra AJ, Combs PD, Gabriele G, Wilkinson M. Cosmetic Outcomes of Simple Pediatric Facial Lacerations Repaired With Skin Adhesive Compared With Skin Adhesive With Underlying Adhesive Strips: A Randomized Controlled Trial. Pediatr Emerg Care. 2022 Oct 1;38(10):477-480. doi: 10.1097/PEC.0000000000002837. Epub 2022 Aug 26. PMID: 36018733

Ong ME, Chan YH, Teo J, Saroja S, Yap S, Ang PH, Lim SH. Hair apposition technique for scalp laceration repair: a randomized controlled trial comparing physicians and nurses (HAT 2 study). Am J Emerg Med. 2008 May;26(4):433-8. doi: 10.1016/j.ajem.2007.07.008. PMID: 18410811

Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995 Jun;126(6):892-5. doi: 10.1016/s0022-3476(95)70203-2. PMID: 7776090

Otterness K, Thode HC Jr, Singer AJ. Methods of laceration closure in the ED: A national perspective. Am J Emerg Med. 2020 Jun;38(6):1058-1061. doi: 10.1016/j.ajem.2019.158365. Epub 2019 Jul 25. PMID: 31466912

Quinn JV, Drzewiecki A, Li MM, Stiell IG, Sutcliffe T, Elmslie TJ, Wood WE. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med. 1993 Jul;22(7):1130-5. doi: 10.1016/s0196-0644(05)80977-1. PMID: 8517562

Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. BMJ. 2002 Aug 10;325(7359):299. doi: 10.1136/bmj.325.7359.299. PMID: 12169503

Quinn J, Wells G, Sutcliffe T, Jarmuske M, Maw J, Stiell I, Johns P. 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 Dec;32(6):645-9. doi: 10.1016/s0196-0644(98)70061-7. PMID: 9832658 

Romero P, Frongia G, Wingerter S, Holland-Cunz S. Prospective, randomized, controlled trial comparing a tissue adhesive (Dermabond™) with adhesive strips (Steri-Strips™) for the closure of laparoscopic trocar wounds in children. Eur J Pediatr Surg. 2011 May;21(3):159-62. doi: 10.1055/s-0030-1270458. Epub 2011 Jan 31. PMID: 21283958

Sajid MS, Siddiqui MR, Khan MA, Baig MK. Meta-analysis of skin adhesives versus sutures in closure of laparoscopic port-site wounds. Surg Endosc. 2009 Jun;23(6):1191-7. doi: 10.1007/s00464-009-0373-y. Epub 2009 Mar 5. PMID: 19263132

Saxena AK, Willital GH. Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity lacerations. Am Surg. 1999 May;65(5):470-2. PMID: 10231221

Shuster M. Comparing skin staples to sutures. Can Fam Physician. 1989 Mar;35:505-9. PMID: 21248986

Simon HK, McLario DJ, Bruns TB, Zempsky WT, Wood RJ, Sullivan KM. Long-term appearance of lacerations repaired using a tissue adhesive. Pediatrics. 1997 Feb;99(2):193-5. doi: 10.1542/peds.99.2.193. PMID: 9024445

Singer AJ, Hollander JE, Valentine SM, Thode HC Jr, Henry MC. Association of training level and short-term cosmetic appearance of repaired lacerations. Acad Emerg Med. 1996 Apr;3(4):378-83. doi: 10.1111/j.1553-2712.1996.tb03454.x. PMID: 8881549

Singer AJ, Gulla J, Hein M, Marchini S, Chale S, Arora BP. Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial. Plast Reconstr Surg. 2005 Aug;116(2):363-8; discussion 369-70. doi: 10.1097/01.prs.0000172758.00088.81. PMID: 16079656

Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ. 2010 Mar 16;340:c1199. doi: 10.1136/bmj.c1199. PMID: 20234041

Stavrou P, Symeonidis PD, Iselin LD, Dracopoulos G. Sutures versus sterile strips for closure of ankle arthroscopy portals: prospective crossover trial. Foot Ankle Int. 2012 Mar;33(3):190-5. doi: 10.3113/FAI.2012.0190. PMID: 22734279

Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008 Feb;33(2):250-3. doi: 10.1016/j.jhsa.2007.10.008. PMID: 18294549

Tandon S, Smale M, Pacilli M, Nataraja RM. Tissue adhesive and adhesive tape for pediatric wound closure: A systematic review and meta-analysis. J Pediatr Surg. 2021 May;56(5):1020-1029. doi: 10.1016/j.jpedsurg.2020.07.037. Epub 2020 Aug 5. PMID: 32888718

Wong EM, Rainer TH, Ng YC, Chan MS, Lopez V. Cost-effectiveness of Dermabond versus sutures for lacerated wound closure: a randomised controlled trial. Hong Kong Med J. 2011 Dec;17 Suppl 6:4-8. PMID: 22147351

Yang S, Ozog D. Comparison of Traditional Superficial Cutaneous Sutures Versus Adhesive Strips in Layered Dermatologic Closures on the Back-A Prospective, Randomized, Split-Scar Study. Dermatol Surg. 2015 Nov;41(11):1257-63. doi: 10.1097/DSS.0000000000000507. PMID: 26448315

Zempsky WT, Parrotti D, Grem C, Nichols J. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care. 2004 Aug;20(8):519-24. doi: 10.1097/01.pec.0000136068.45198.ae. PMID: 15295247

Leave a Reply

%d bloggers like this: