INTRODUCTION

Closure of surgical wounds was initially accomplished with the use of sutures; underlying tissues were also approximated
and stitched in order to promote proper tissue healing. Today, wound closure techniques have evolved from these early
developments in suturing materials to comprise resources that include synthetic sutures, absorbables, staples, tapes, and
adhesive compounds.1 The engineering of sutures composed of synthetic material along with standardization of traditional
materials (e.g., catgut, silk) has made for superior aesthetic results. Similarly, the development of topical skin adhesives as a
substitute for sutures has supplemented the armamentarium of wound closure techniques. Recently, the U.S. Food and
Drug Administration (FDA) has reclassified topical adhesives; as a result, new topical skin adhesives are expected to enter
the market in the near future.2 Optimal wound healing is based on the knowledge and understanding of skin anatomy and
the mechanisms of wound healing as well as clinical considerations regarding appropriate selection and use of topical skin
adhesives. (Note: this continuing education activity will concentrate specifically on the Class II topical skin adhesives, their
advantages and disadvantages, and the associated benefits.)

Adhesives wounds was initially use

of sutures; approximated and stitched
proper tissue healing techniques have
materials to that include absorbables,
staples, compounds
CLINICAL CONSIDERATIONS IN WOUND HEALING
The ability to heal wounds is one of the most powerful defensive properties humans possess.3 Further, wound healing is a
complex, highly organized response by an organism to tissue disruption caused by injury; this process is highly reliable in
the absence of endogenous and exogenous infections, mechanical interferences, or certain other disease processes.
Apposition and maintenance of the edges of a cleanly incised wound almost always results in prompt healing. One of the
goals for the perioperative team is the prevention of surgical site infections as these are causes of morbidity, mortality, and
increased healthcare costs; this is further complicated today by the potential for SSIs due to new strains of antibiotic-
resistant pathogens. 9
In order to understand the role of topical skin adhesives as an effective wound closure technique, the anatomy of the skin,
the types of wound closure, and the wound healing process should be briefly reviewed.
Anatomy of the Skin4
The skin is the largest organ of the body and serves as the first line of defense against infection. The skin provides
protection and sensation, regulates fluid balance and temperature, and produces vitamins (e.g., Vitamin D) and components
of the immune system. Any wound or disruption of the skin can provide a portal for bacteria and possible infection. Key
structures of the skin are (see Figure 1):
Epidermisthe outermost layer of the skin that lines the ear canals and is contiguous with the mucous membranes.
Dermisthe epidermis is supported by the dermis, which is thicker than the epidermis and composed of collagen. The
dermis is the largest portion of the skin and provides strength and structure. Contained within the dermis are blood
vessels, lymph ducts, hair roots, nerves and sebaceous and sweat glands.
Subcutaneous layerthis is the innermost layer of the skin and is composed of adipose tissue that merges with the
deepest layer of the dermis to provide insulation, shape, and support.
Figure 1The Skin

Skin also of infection sensation, balance and

produces D) the 10
Types of Wounds5
The three main causes of wounds are:
1. Traumaticdue to mechanical, thermal, or chemical destruction.
2. Chroniccaused by underlying pathophysiological conditions (e.g., pressure ulcers or venous leg ulcers).
3. Surgicalcaused by an incision or excision. Every day, thousands of patients undergo surgical procedures for one reason
or another, and an inevitable part of the surgery is the creation of an incision and the subsequent healing that must take
place. The amount of tissue loss, the existence of infection or contamination, and the degree of tissue damage are
some of the factors that determine the type of wound closure method selected by the surgeon.

Wounds causes of to thermal, or

destruction caused by pathophysiological
pressure leg ulcers) caused by an
excision Wounds causes of to thermal,
or destruction by pathophysiological
pressure leg ulcers) by an excision
Types of Wound Closure6
The three types of wound closure are primary, secondary, and tertiary intention; each of these is briefly described below.
Primary intentionhealing by primary intention occurs when wounds are created aseptically, with a minimum of tissue
destruction and postoperative tissue reaction. Because these wounds are created under sterile conditions, healing is
optimized and begins almost immediately. Healing by primary intention occurs under the following conditions:
o The edges of an incised wound in a healthy patient are promptly and accurately approximated.
o Contamination is minimized by adherence to strict aseptic technique.11
 o Trauma to the tissue is minimized.
o No tissue loss occurs.
o Upon completion of closure, no dead space remains to become a potential infection site.
o Drainage is minimal.
Secondary intention (granulation)healing occurs by secondary intention when surgical wounds are characterized by
tissue loss and the inability to approximate the wound edges. This type of wound is typically not closed; it is allowed
to heal from the inside toward the outer surface. The area of tissue loss gradually fills with granulation tissue,
comprising fibroblasts and capillaries; scar tissue is extensive because of the size of the tissue gap that must be
closed.
Tertiary intention (delayed primary closure)this healing process occurs when approximation of the wound edges is
intentionally delayed by three or more days after surgery or injury. These types of wounds may require debridement
and usually require a primary and secondary suture line (e.g., retention sutures).
Phases of Wound Healing
Clean, full-thickness wound healing is an intricate biological process that occurs in three distinct, overlapping phases of
healing: inflammation (also called the reactive stage), proliferative, and remodeling, as outlined below and depicted in Figure
2.7
Phase 1Inflammatory Phase. This phase begins within minutes after an injury and is necessary to establish
hemostasis and begin mobilization of the immune system. Inflammation is a prerequisite to wound healing and is a
vascular and cellular response to rid bacteria, foreign material, and dead tissue. Increased blood flow to the area
causes the wound to begin to clot. In this phase, an exudate containing blood, lymph, and fibrin begins to clot and
loosely binds the cut edges together.
Phase 2Proliferative Phase. This phase begins within hours of an injury and allows for new epithelium to cover the
wound. Epithelial cells migrate and proliferate to the wound area, covering the surface of the wound in order to close
the epithelial defect. Epithelialization also provides a protective barrier, which serves as a mechanism to prevent fluid
and electrolyte loss and also prevent the introduction of bacteria into the wound, thereby reducing the incidence of
infection. As reepithelialization occurs, collagen synthesis and wound contraction are also occurring.
Phase 3Remodeling Phase. This phase begins after approximately two to four weeks, depending on the size and
nature of the wound; it may last one year or longer. During this final stage, scar tissue formed during fibroplasia
changes in bulk, form and strength; this allows for the wound to be strengthened. 12
Figure 2The Wound Healing Process

Phases and Timescale healing has

final 20% 80%
Wound strength gradually increases during the healing process.8 After approximately two weeks, a wound has less than 10%
of its final healed strength. By this time, most superficial or percutaneous closure materials are removed, and the resulting
wound has little to rely on for strength unless additional support is available. Wound strength increases to 20% by three
weeks and to 50% by four weeks. By three-to-six months, a wound achieves its maximum strength, which is 70-80% that of
normal skin.13
TOPCIAL SKIN ADHESIVES
Historical Review of Topical Skin Adhesives9
Cyanoacrylates were synthesized in the 1940s and were first used for wound closure in 1959. The early short-chain tissue
adhesives, methyl-2- and ethyl-2-cyanoacrylate, while effective, had limited use because of rapid degradation into
cyanoacetate and formaldehyde, which caused significant tissue toxicity resulting in acute and chronic inflammation.
However, longer-chain cyanoacrylates, n-butyl-cyanoacrylate and 2-octyl-cyanoacrylate, degrade slowly, limiting the
accumulation of toxic by-products in tissues, making them safe for topical skin closure.
Later, in 1998, the U.S. FDA gave approval for use of the first topical skin adhesive. Since that time, several new skin
adhesives have entered the market. Presently, there are two types of topical skin adhesives being used: n-butyl-
cyanoacrylate and 2-octyl-cyanoacrylate. Both of these topical skin adhesives are FDA-approved, and both types have
certain characteristics and clinical benefits that have caused them to gain popularity and approval within the surgical arena
across multiple surgical specialties as well as in emergency care. The unique characteristics of these topical skin adhesives
will be explored in greater detail later in this activity.
FDA Classification of Topical Skin Adhesives10
The FDA has three established categories (classes) of devices, depending on the regulatory controls needed to provide
reasonable assurance of their safety and effectiveness; these categories are class I (general controls), class II (special
controls), and class III (premarket approval). In 2008, the FDA reclassified topical adhesives as class II rather than class III;
class I skin adhesives are available over-the-counter (OTC) in drug stores.
The FDA designates devices as class II if general controls by themselves are insufficient to provide reasonable assurance of
safety and effectiveness, but there is sufficient information to establish special controls to provide reasonable assurance of
the safety and effectiveness of the device for its intended use. After reviewing the relevant information, the FDA determined
that tissue adhesive with adjunct wound closure device intended for topical approximation of skin can be classified into
class II with the establishment of special controls in order to provide reasonable assurance of the safety and effectiveness of
the device.
The FDA has identified the following associated health risks for these types of devices:
Unintentional bonding of device due to misapplication of device, device leaking or running to unintended areas, etc.;
Wound dehiscence;
Adverse tissue reaction and chemical burns;
Infection;
Applicator malfunction; and
Delayed polymerization.14
THE CYANOACRYLATE TOPICAL SKIN ADHESIVES
Overview
Cyanoacrylate topical skin adhesives are the new alternative for closure of surgical incisions. Topical skin adhesives are
made from medical grade cyanoacrylates (i.e., medical grade crazy glue), which polymerize into a thin protective film over
the wound edges when they come into contact with the moisture in the skin. The polymerized cyanoacrylate adheres to the
skin and itself, forming a clean strong adherent bond that holds the edges of skin wounds together so that the wounds can
heal normally underneath the film. When intact, the polymerized film acts as a microbial barrier to protect the wound from
potential contamination. Topical tissue adhesives slough from the skin in five to ten days as the skin heals underneath and it
is no longer required, thus eliminating the need for non-absorbable suture or staple removal.11
The histotoxicity of these adhesives had been found to be proportional to the length of their monomer side chain. These
newer, longer side-chain derivatives undergo a slower process of biodegradation, resulting in fewer toxic by-products
released into the tissues per unit of time. This slower release allows for more efficient tissue clearance of toxic by-products
with less ensuing tissue toxicity.12
Currently, two types of skin adhesives are being used in place of nonabsorbable sutures and staples: n-butyl-cyanoacrylate
and 2-octyl-cyanoacrylate.13

Adhesivesskin of adhesives are grade skin used in

nonabsorbable n-butyl-octyl-Topical Skin Adhesives
Cyanoacrylate topical skin adhesives are the new alternative for
closure of surgical incisions Topical skin adhesives are made from
medical grade cyanoacrylates Currently, two types of skin
adhesives are being used in place of nonabsorbable sutures and
staples: n-butyl-cyanoacrylate and 2-octyl-cyanoacrylate Topical
Skin Adhesives Cyanoacrylate topical skin adhesives are the
new alternative for closure of surgical incisions Topical skin
adhesives are made from medical grade cyanoacrylates Currently,
two types of skin adhesives are being used in place of
nonabsorbable sutures and staples: n-butyl-cyanoacrylate and 2-
octyl-cyanoacrylate Topical Skin Adhesives Cyanoacrylate
topical skin adhesives are the new alternative for closure of surgical
incisions Topical skin adhesives are made from medical grade
cyanoacrylates Currently, two types of skin adhesives are being
used in place of nonabsorbable sutures and staples: n-butyl-
cyanoacrylate and 2-octyl-cyanoacrylate
n-Butyl-cyanoacrylate
n-Butyl-cyanoacrylates have shorter molecular chain lengths, this allows the product to require only one layer and dry
significantly faster while still maintaining its efficacy and strength. These topical skin adhesives dry in 30 seconds, allow for a
one-layer application, and have a low exothermic reaction. Once applied and allowed to dry, 15
n-butyl-cyanoacrylates have a flat, low-sheen finish. Their texture is designed to simulate the natural flaking and healing of a
scab. Ideal for the use in the ED and with pediatric patients due to the fast dry times, less pain, and microbial barrier
protection.
2-Octyl-cyanoacrylate
Approved in 1998, 2-Octyl-cyanoacrylates were the first approved adhesives on the market in the United States. 2-Octyl-
cyanoacrylates have longer molecular chain lengths, this allows the product to have more flexibility and smooth appearance
during healing while still maintaining its efficacy and strength. They do however take a longer time to dry (polymerize) as a
result of the two layer application and longer molecular chain lengths. The two layers provide the same strength as the one-
layer application of the n-Butyl cyanoacrylate. Once applied and allowed to dry, 2-Octyl-cyanoacrylates have a flat, high-
sheen finish. Their texture is designed to be smooth, elastic and long lasting. Ideal for use in the OR in closing low-tension
incisions, while providing a flexible microbial coverage.

cyanoacrylate Skin Adhesives

the longer layer provides layer applied long
Indications and Contraindications14
Topical skin adhesives may be applied topically to intact skin at the wound edges to hold the approximated skin surfaces
(i.e., skin incisions or lacerations) together; they can also be used in conjunction with deep sutures. Generally, topical skin
adhesives can be used in place of nonabsorbable sutures for primary closure of skin incisions and lacerations. For incisions
and lacerations that are under tension, and when closing incisions and lacerations on the extremities and torso, deep
(subcutaneous) sutures are recommended.16
Topical adhesives should not be used on the oral mucosa, hands, feet, or joints, where repetitive movement and regular
exposure to blood and/or fluids may cause the adhesives to slough prematurely. Other types of wounds that are not optimal
for topical skin adhesives are decubitus ulcers, stellate lacerations, animal or human bites, nonsurgical puncture wounds, or
any type of wound with evidence of active infection or gangrene. Topical adhesives also should not be used in patients with
a known hypersensitivity to cyanoacrylate or formaldehyde.
It is important to remember that topical adhesives do not replace the requirement for prudent wound care. Wounds still need
careful examination and exploration with irrigation and debridement when appropriate. In addition, these types of wound
preparations still may require local anesthetic.
ADVANTAGES AND DISADVANTAGES OF TOPICAL SKIN ADHESIVES
Topical cyanoacrylate skin adhesives offer many advantages over traditional wound closure devices. 15 In general, the use of
tissue adhesives can significantly decrease health-care costs and is preferred by patients.16 Adhesives provide a needle-free
method of wound closure, an important consideration in light of the risks presented by blood-borne viruses. In addition,
adhesives do not require local anesthetics.
The cyanoacrylates function as waterproof occlusive dressings, have microbial barrier properties against gram-positive
organisms, and may also reduce infections. The CDC Guidelines recommend that a wound be kept covered for 24-48 hours
post primary closure to reduce the risk of infection. They note that after this time it is unclear whether an incision needs to be
covered as the bodys natural healing mechanisms have commenced and provide protection against microorganisms.
Topical skin adhesives, therefore, provide not only primary closure but an effective microbial barrier throughout this critical
time period.17
The advantages and disadvantages of topical skin adhesives are outlined below.
Advantages:
Increases patient satisfaction: patient can shower immediately, move more freely, and requires no dressing to be
concerned about getting wet;
Eliminates the need for suture/staple removal;
Eliminates the need for a followup visit to the physician;
Reduces the risk of needle sticks to the physician/nurse;
Less stress and discomfort for the pediatric patient;
Ease of use for physician and staff (less prep time and materials needed);
Creates a microbial barrier;
Minimizes the need for a dressing and wound care; and
Lowers cost (less ancillary services and equipment used).17
Disadvantages:
The patient cannot soak in a tub/hot tub/swimming pool;
The adhesive cannot be applied:
o Over a high-tension area (knuckle, knee, elbow);
o In areas of infection;
o To internal tissues, vessels, organs, or nerves;
o To areas with dense hair; and
o To areas that are wet.

APPLICATION OF SKIN ADHESIVES: PATIENT PREPARATION/ INSTRUCTIONS

Skin Adhesives most for

approximated application approximately 30
to set directly protection, a once process,
required, approximately 30-60 to set
Patient Preparation
In applying tissue adhesives, the most important concept is that they are for topical closure only. 18 Give special care to
ensure that the adhesive will not leak between the wound edges. If used properly, the adhesive acts as a strong bridge to
hold the well-opposed wound edges together. If placed in the wound, it acts as a barrier to proper epithelialization and may
slow healing. Once in the wound, the adhesive also has the potential to cause a foreign-body reaction and to increase the
risk of infection.
In preparation for the use of the topical skin adhesive, the wound should be cleaned. Wound edges need to be
approximated and dried prior to adhesive application. Using aseptic technique, bring wound edges together with either the
fingers or forceps, apply a thin layer of skin adhesive, and allow to dry. Do not allow the adhesive to go directly into the
wound. 18
Hold the skin edges for approximately 30 seconds in order for the adhesive to set up.* No dressing is typically used once
the skin adhesive is applied. If the wound needs added protection, a dry gauze dressing can be applied once the adhesive
has fully dried.
Patient Instructions
The patient should be given specific instructions regarding the application of a skin adhesive for wound closure. The skin
adhesive integrity should last somewhere between five to ten days; by this time, the wound should be sufficiently healed.
The patient may notice a gradual loosening of the adhesive edges, and then eventually the adhesive will begin to break
down and slough. It is important that the patient allows the skin adhesive to break down and not assist in lifting it from the
incisional area. This will provide for the optimal degree of protection and healing to the incision site.

cosmesis stick injury staple removal

trauma secondary dressings learning
curve Costs lasting
The patient should also be informed that:
He/she should not rub, scratch, or pick at the wound, as doing so may compromise the integrity of the wound closure.
He/she should not pull on the edges of the adhesive if they begin to lift.
The wound should be kept clean and dry. Light showering is permitted; however, the incisional area should not be
submerged in a hot tub or bathtub.
Although not necessary, a dry dressing to cover the wound may be applied; however, tape should not be placed
directly over the wound.
Barrier creams, petroleum jelly, or mineral oils should not be applied to the wound as this may compromise the integrity
of the wound closure.
The wound should be protected from injury during the healing period.
He/she should avoid prolonged exposure to sunlight or use of a tanning bed.
If the appearance of the wound changes or becomes painful, or if there are any concerns, the patient should contact
the appropriate medical professional.
*2-Octyl-cyanoacrylates have a slower polymerization process, resulting in longer setting time. Two layers are required, resulting in holding the skin edges for approximately 30-
60 seconds between layers in order for the adhesive to set up. 19
CLINICAL BENEFITS OF TOPICAL SKIN ADHESIVES: A REVIEW OF THE LITERATURE
As previously noted, topical cyanoacrylate skin adhesives offer many advantages over traditional wound closure devices for
patients, members of the surgical team, and health-care facilities. The clinical benefits of their use across multiple surgical
specialties, as well as emergency medicine are well-documented in the literature, as outlined below.
Graefe et al. compared cyanoacrylate-based skin adhesives used for skin closure in head and neck surgery with respect to
ease of application, cost-effectiveness and cosmetic results in 25 wounds sealed with a skin adhesive and 25 wounds
sealed with sutures.19 The results demonstrated that bonding of surgical wounds with the adhesive had a high level of
acceptance in all patients. In addition, the tedious, time-consuming and sometimes painful postoperative removal of
numerous sutures in patients is omitted. Patients can shower soon afterward without additional protection as the adhesive
provides a waterproof barrier. Problems of wound healing can immediately be detected through the transparent skin
adhesive. Cosmetic long-term results of skin closure by adhesives are comparable to suture-sealed wounds. The authors
concluded that the adhesives available on the market differ primarily in the form of the applicator, the viscosity on application,
and strength after hardening. Application of the adhesive is easy to implement and significantly faster than conventional
suturing. In addition to the cost savings of materials compared to the use of skin sutures, expensive anesthesia and
operative time also can be saved.
Krishnamoorthy et al., compared the results of skin closure using a topical skin adhesive and subcuticular sutures after
coronary artery bypass grafting (CABG) with respect to its advantages over conventional sutures on cosmetic outcomes,
cost benefits, and operative times.20 The study prospectively enrolled and randomized 106 patients who underwent CABG.
The groups received closure with a topical skin adhesive or subcuticular sutures (53 patients were in each group) after
saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic
appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was
recorded before discharge and at week six. Results demonstrated no significant differences in the total operative time
between the two groups. Closure time was significantly shorter in the topical skin adhesive group; patients in this group also
reported superior cosmetic outcome at weeks one and six and improved satisfaction.
Dowson et al., compared the efficacy of n-butyl-cyanoacrylate tissue adhesive with nonabsorbable monofilament sutures for
laparoscopic port site closure.21 Adult patients having elective laparoscopic procedures were randomly allocated to wound
closure with sutures or tissue adhesive. Study endpoints included skin closure time, wound dressing requirements, wound
complications, and cosmesis, assessed at discharge, then in four to six weeks, and at three months. Seventy-eight patients
randomized to receive sutures and 76 to receive tissue adhesive were eligible for final analysis. Mean closure time was
significantly longer for sutures (220 versus 125 seconds). Fewer dressings were required in the tissue adhesive group
immediately postoperatively (21% versus 97%) and at 20
discharge (24% versus 82%). There were no significant differences in wound complications or in cosmesis at either four to
six weeks or at three months. These investigators concluded that tissue adhesive for laparoscopic port site closure offers
potential savings with respect to time and has comparable wound complication rates and cosmetic outcomes when
compared with nonabsorbable monofilament sutures.
Mourougavan conducted a nonrandomized prospective study of 104 patients with cleft lip and palate in combination with
various degrees of cleft for an age group ranging from 3 months to 5 years to assess the quality of scars following the use of
n-butyl-cyanoacrylate to close the skin during cleft lip repair.22 The author used n-butyl-cyanoacrylate to close the skin after
inserting dermal stitches with delayed absorbable sutures. The results demonstrated that none of the 104 patients required
revision of the vertical scar, which was excellent in nature. Additionally, no patients had complications such as wound
infection, dehiscence, nasal obstruction, or eyelid adhesion. Therefore, the author considered the quality of the scar
following the closure of skin of cleft lip repair using n-butyl-cyanoacrylate to be excellent.
Recently, Murrmann et al., conducted a study to compare postoperative clinical and economic outcomes using topical skin
adhesive (2-octyl cyanoacrylate [OCA]) versus conventional skin closure in women undergoing total abdominal
hysterectomy.23 A multi-hospital administrative database was used to identify women discharged in 2005 who had
undergone total abdominal hysterectomy. The patients, classified by skin closure as suture (21,201patients), staples (23,441
patients), OCA (880 patients), or staples + OCA (489 patients), were compared on length of inpatient stay (LOS), total
inpatient cost, and non-prophylactic antibiotic treatment after the fourth postoperative day. Their results showed the mean
LOS was 3.9, 4.5, 3.7, and 5.2 days for suture, staples, OCA, and staples + OCA, respectively; the percentages of patients
having antibiotic treatment were 12.93%, 17.51%, 11.14%, and 23.72%, respectively. Pairwise comparisons indicated no
difference between sutures and OCA, whereas the outcomes for each of the non-staple groups were more favorable than
those for the staple group. Results were similar in pair wise comparisons between OCA and staples. The authors concluded
that OCA appears to be a safe and cost-effective alternative to topical sutures for patients having total abdominal
hysterectomy; there were less favorable outcomes in groups receiving staples.
Souza et al., evaluated the impact of the use of 2-octyl-cyanoacrylate (2-OCA) as an add-on measure in the closure of
sternotomy incision wounds by comparing postoperative infection rates and length of hospital stays before and after this
procedural change.24 The authors reviewed the records of 680 patients whose cardiovascular surgery was performed
between 2000 and 2004 included the use of 2-OCA; an equal number of patients who did not receive the topical skin
adhesive (surgeries performed between 1995 and 1999) were used as a control group. From 1995 to 1999 (patients without
the topical skin adhesive), the infection rate was 4.9%. This rate was reduced to 2.1% after the systematic use of the topical
skin adhesive. Superficial and deep infection rates decreased from 4.3% and 0.6% to 2.1% and 0%, respectively.
Postoperative hospital stays also were significantly reduced, decreasing from a median of 13 days to 9 days. Based on the
patient records reviewed in this study, the authors concluded that the routine use of 2-OCA as an add-on measure 21
to conventional sutures was associated with a significant reduction in infection rates for cardiovascular surgery patients.
Nipshagen et al., evaluated the use of 2-octyl-cyanoacrylate skin adhesive in plastic surgery.25 They conducted a prospective,
randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared
with those after suture closure in 50 patients undergoing bilateral reduction mammoplasty. The method of closure (sutures
versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were
assessed by the patient and by a blinded panel, at one week, six weeks, and six months after surgery, using various
evaluation and assessment scales. The results demonstrated that both patients and panelists expressed an overall
preference for the adhesive group one week after surgery. Patients visual analogue scale scores for scar comfort and scar
appearance and panelists visual analogue scale scores for aesthetic outcome were significantly better for the adhesive
group after both six weeks and six months, as was the wound evaluation scale score of the panelists after six weeks. The
total patient and observer scar assessment scale score after six months was significantly better for the adhesive group
according to the patients, but not according to the panelists. The authors concluded that 2-octyl-cyanoacrylate is a sound
alternative for wound closure.
SUMMARY
Effective wound closure is a key factor in achieving optimal outcomes for all surgical patients. Today, the use of topical
cyanoacrylate skin adhesives offers many advantages over traditional wound closure devices. As a result of the recent
reclassification of topical skin adhesives by the FDA from class III to class II devices, new topical skin adhesives are
expected to enter the market in the near future. Therefore, the perioperative nurse should be knowledgeable about wound
closure and healing processes and the role of topical skin adhesives as a strong, secure, and effective wound closure
technique in order to achieve optimal patient outcomes.

Instructions rub, scratch, or pick at so may compromise wound

closure pull on the edges of begin to lift kept clean and dry. permitted;
however, should not be tub or bathtub necessary, a dry dressing may be
applied; not be placed wound22
GLOSSARY
Cyanoacrylate The generic name for cyanoacrylate-based fast-acting adhesives such as methyl-2-cyanoacrylate, ethyl 2-
cyanoacrylate, and n-butyl-cyanoacrylate. 2-octyl cyanoacrylate is a medical-grade
glue, which was developed to be non-toxic and less irritating to skin tissue.

Dermis The largest portion of the skin that provides strength and structure; contained within the dermis are blood vessels,
lymph ducts, hair roots, nerves and sebaceous and sweat glands.

Endogenous Growing from, on, or inside the body; caused by factors within the body or arising from internal structural or
functional causes.

Epidermis The outermost layer of the skin that lines the ear canals and is contiguous with the mucous membranes.

Exogenous Growing from or on the outside; caused by factors (as food or a traumatic factor) or an agent (as a disease-
producing organism) from outside the organism or system; introduced from or
produced outside the body.

Infection The invasion and multiplication of microorganisms in body tissues that cause cellular injury and clinical symptoms.

Microbial Barrier Prevents the ingress of microorganisms.

Primary Intention Healing that occurs when wounds are created aseptically, with a minimum of tissue destruction and
postoperative tissue reaction.

Reepithelialization Restoration of epithelium over a denuded area by natural growth.

Secondary Intention (Granulation) Healing that occurs when surgical wounds are characterized by tissue loss with an
inability to approximate wound edges.

Subcutaneous Layer The innermost layer of the skin; it is composed of adipose tissue that merges with the deepest layer
of the dermis to provide insulation, shape, and support. 23
Surgical Site Infection (SSI) An infection at the site of a surgical incision; the infection may be superficial, deep, or it may
extend to organs.

Tertiary Intention Healing that occurs when approximation of (Delayed Primary Closure) wound edges is
intentionally delayed by three or more days after surgery or injury.

REFERENCES/SUGGESTED READINGS

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overview. Accessed February 4, 2011.
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Medicine. 2008;26(4):490-496. Also available at: http://www.ncbi.nlm.nih.gov/pubmed/18410821. Accessed January 21,
2011.
3. McEwen DR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexanders Care of the Patient in Surgery. 14th
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4. McEwen DR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexanders Care of the Patient in Surgery. 14th
ed. St. Louis, MO: Elsevier Mosby; 2011:250-253.
5. McEwen DR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexanders Care of the Patient in Surgery. 14th
ed. St. Louis, MO: Elsevier Mosby; 2011:250-253.
6. McEwen DR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexanders Care of the Patient in Surgery. 14th
ed. St. Louis, MO: Elsevier Mosby; 2011:250-253.
7. McEwen DR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexanders Care of the Patient in Surgery. 14th
ed. St. Louis, MO: Elsevier Mosby; 2011:250-253.
8. Terhune M. Materials for wound closure. Available at: http://emedicine.medscape. com/article/1127693-overview.
Accessed February 4, 2011.
9. Dowson C, Gilliam A, Speake WJ, Lobo D, Beckingham I. A prospective, randomized controlled trial comparing n-butyl
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