Review Article

Absorbable Versus Nonabsorbable Sutures

in the Management of Traumatic Lacerations
and Surgical Wounds
A Meta-Analysis
Tawfik Al-Abdullah, MD,* Amy C. Plint, MD,y and Dean Fergusson, PhDzx

Objectives: To complete a systematic review of randomized

controlled trials (RCTs) that compare the cosmetic outcomes and
L acerations are a common reason for patients to present
to the emergency department (ED) with an estimated
2 million traumatic wounds treated by emergency physicians
complications of traumatic lacerations and surgical incisions closed
annually in North America.1 At our pediatric ED, there are
with absorbable sutures versus nonabsorbable sutures.
more than 2500 annual visits for lacerations, accounting for
Design/Methods: We searched MEDLINE, EMBASE, and
nearly 5% of total patient visits.2 Many of these wounds are
Cochrane Central to identify all RCTs comparing absorbable versus
closed using tissue adhesives. Tissue adhesives have several
nonabsorbable sutures that assessed cosmetic outcomes or compli-
advantages over sutures including less distress for patients3
cations. Reference lists of all identified trials were also searched.
and the convenience of not requiring a follow-up visit for
Two independent reviewers screened abstracts for eligibility,
suture removal. Nevertheless, there are some lacerations that
extracted study data, and assessed trial quality. Disagreements
require sutures because of the size or location of the wound.
were resolved by consensus or a third party.
Although standard texts and teaching often recommend the
Results: Three hundred thirty-eight citations were retrieved, of
use of nonabsorbable sutures in the repair of traumatic
which 7 met inclusion criteria. Studies were heterogeneous with
lacerations in children,4 this view has been challenged. Some
respect to specific interventions and outcome measures; sample
physicians suggest that all lacerations should be closed with
sizes ranged from 44 to 166. There was no statistically significant
absorbable suture material with the exception of lacerations
difference between absorbable and nonabsorbable sutures in short-
over areas of tension.5 – 11 If nonabsorbable sutures are not
or long-term cosmetic score, scar hypertrophy, infection rate,
associated with worse cosmetic outcome or an increase in
wound dehiscence, and wound redness/swelling.
wound complications, their use would be preferred as health
Conclusions: Our meta-analysis suggests a lack of large, method-
care dollars would be saved by eliminating additional visits
ologically sound RCTs evaluating the effectiveness of absorbable
for suture removal and by removing the anxiety (particularly
versus nonabsorbable sutures. Although our analysis demonstrates
among children) associated with suture removal. However,
that nonabsorbable sutures seem to be no better than absorbable
the recommendations to use absorbable sutures have, on the
sutures in the management of wound repair, a large methodolog-
whole, been made on the basis of case series, retrospective
ically sound RCT is needed to adequately answer this question.
studies, and small prospective studies rather than large
Key Words: sutures, lacerations, meta-analysis randomized controlled trials (RCTs).7 – 11 As a result, we
chose to review the best available evidence for the effect of
absorbable sutures in the management of wounds and
*Emergency Department, King Faisal Specialist Hospital and Research lacerations. Specifically, we evaluated RCTs that compared
Centre, Riyadh, Saudi Arabia; yDepartments of Pediatrics and the cosmetic outcomes and complications of traumatic
Emergency Medicine, University of Ottawa; zClinical Epidemiology lacerations and surgical incisions closed with absorbable
Program, Ottawa Health Research Institute and xDepartments of
Medicine and Epidemiology and Community Medicine, University of
sutures versus nonabsorbable sutures.
Ottawa, Ottawa, Ontario, Canada.
Dr. Amy C. Plint is supported in part by a salary award from the Canadian
Institute of Health Research.
This research has been presented in abstract form at the Pediatric Academic
METHODS
Society Meeting, May 2005, Washington, DC.
Research was conducted while Dr. Tawfik Al-Abdullah was a member of the
Study Selection
Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Randomized controlled trials evaluating absorbable
Canada. versus nonabsorbable suture materials in the management of
Address correspondence and reprint requests to Amy C. Plint, MD, Division traumatic lacerations or surgical wounds were considered for
of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401
Smyth Ave, Ottawa, Ontario K1H 8L1. E-mail: plint@cheo.on.ca. inclusion regardless of language or type of publication. Studies
Copyright n 2007 by Lippincott Williams & Wilkins that included subjects from the emergency department, an
ISSN: 0749-5161/07/2305-0339 outpatient clinic setting, or the operating room were eligible for

Pediatric Emergency Care
Volume 23, Number 5, May 2007 339

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Al-Abdullah et al Pediatric Emergency Care
Volume 23, Number 5, May 2007

FIGURE 1. Flow of studies through the review.
inclusion. There were no restrictions placed on the location of
the wounds or the age of study subjects. This review did not
consider any trials that evaluated deep tissue suturing alone (ie,
without skin closure). Studies were included if they evaluated
any of the following outcomes: cosmetic outcome, patient
satisfaction, pain during the procedure, time needed to
complete the procedure, the ease of the procedure, and the
occurrence of any complications (infection, wound dehiscence,
excessive induration and redness). If cosmetic outcome was the
only outcome measured, it had to be determined using a
validated cosmetic score and assessed by a blinded evaluator
for the study to be included. For occurrence of infection, only
wounds described by the authors as definitely infected were
included in the analysis.
Study Identification
Searches of MEDLINE (January 1966 to July 2004),
EMBASE (January 1988 to July 2004), and the Cochrane
Wounds Group Specialized Trial Register were conducted
using the following terms: laceration, wounds, incision, skin
abrasion, absorbable, nonabsorbable, polybutester, monofil-
ament, multifilament, polyfilament, synthetic, nonsynthetic,
braid, nonbraid, polyethalone, polydioxanone, PDS, polyglac-
tic, vicryl, polyglycolic, nylon, ethilon, polypropylene,
prolene, catgut, chromic, polyglyconate, maxon, silk, derma-
lon, surgilene, ethibond, ethiflex, dacron, and novafil. The
complete search strategy is available from the authors on
request. In addition, 1 reviewer (TA) used the following
methods to search for relevant articles: searches of relevant
bibliographic databases and review of the reference lists of all
selected articles.
Study Inclusion
Two reviewers (TA and AP) independently examined
the title and abstracts of trials to identify those with potential
relevance. With the full text of these articles, 2 reviewers
independently assessed each study for inclusion using a
standardized form with eligibility criteria. Disagreements
were resolved by further discussion or consulting a third party.
Assessment of Methodological Quality
Study quality for English language studies was
assessed by 2 independent reviewers (TA and AP). Study
quality was evaluated using the Jadad scale.12 This scale
provides scoring for randomization (0 – 2 points), double-
blinding (0 – 2 points), and account for withdrawals (1 point),
with scores ranging from 0 to 5. A score of 3 was considered
high quality. Concealment of allocation was assessed as
adequate, inadequate, or unclear using the methodology

TABLE 1. Study, Intervention, Patient and Wound Characteristics, and Jadad Score of Included Trials

Yr of Sample Patient Wound Deep Type of Jadad

Study Country Publication Size Intervention Age Location Sutures Wound Score
Holger et al14* United States 2004 86* Fast-absorbing plain >5 yrs Face Some Traumatic 3
gut vs nylon wounds
15
Karounis et al Canada 2004 95 Plain catgut vs nylon Children Multiple Some Traumatic 3
areas wounds
Mouzas and UK 1975 104 Polyglycolic acid All ages Multiple No Traumatic 1
Yeadon16 (Dexon) vs silk, areas
nylon, polyethylene
Edwards and UK 1995 93 Polydiaxone (PDS) Adult Limbs Yes Surgical 1
Elson17 vs nylon
Parell and United States 2003 44 Polyglyactin 910 Adult Head and Yes Surgical 1
Becker18 (vicryl) vs prolene neck
Lundblad and Norway 1989 166 Polyglycolic acid Adult Trunk Yes Surgical 2
Simensen19 (Dexon) vs Nylon
Murphy et al20 Ireland 1995 114 Polyglyconate (maxon) Adult Trunk Yes Surgical 2
vs polypropylene
(prolene)
*This study also included a third arm that had wounds closed with a tissue adhesive giving a total study size of 145 patients. These patients were not
included in the meta-analysis. Of 86 patients in the 2 suture arms, only 57 patients were available for outcome assessment.

340 n 2007 Lippincott Williams & Wilkins

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Pediatric Emergency Care
Volume 23, Number 5, May 2007
described by Schulz et al.13 Study quality for the Norwegian
report was assessed by 1 reviewer (TA) through a translator.
Data Collection and Analysis
Data from English language studies were extracted by 1
reviewer (TA) to standardized data form and then checked for
accuracy by a second reviewer (AP). Data were extracted from
the Norwegian report by a single reviewer (TA) through a
translator. All data were collated and entered in Review
Manager 4.2 (The Cochrane Collaboration, Oxford, England).
Continuous outcomes (eg, Cosmetic Visual Analog
Score [CVAS], pain score) are expressed as weighted mean
differences (WMDs) with 95% confidence intervals (95%
CIs). Dichotomous data (eg, infection rate, Wound Evalu-
ation Score [WES]) are expressed as odds ratios (ORs) with
95% CIs. Studies were pooled using random-effects models.
A priori subgroup analyses included the effect of body part;
face versus body; and extent or type of laceration. Planned
sensitivity analyses included assessment of the effect of
methodological quality of included trials, withdrawals/losses
to follow-up, and funding source. Heterogeneity was exam-
ined using x2 tests.
RESULTS
Description of Studies
Three hundred thirty-eight citations were identified
through MEDLINE and EMBASE (the full list of references
is available from authors). No additional studies were
identified through the Cochrane Registry, citation searches,
or trial bibliographies. Twenty-four articles were selected as
potentially relevant, and 7 of these studies14 – 20 met our
eligibility criteria (Fig. 1) and are summarized in Table 1.
The sample size of the included studies ranged from 44
to 166 patients. Six studies14 – 18,20 were published in
English, and one was published in Norwegian.19 Four
studies included only adult patients,17 – 20 2 studies were
restricted to children,14,15 and 1 study included both adults
and children.16
Table 2 details the outcomes examined in the included
studies. Two of 6 studies examined overall cosmetic
outcome.14,15 The cosmetic scores used in these studies
were the WES and the CVAS. The WES is a previously
validated score21 and assesses 6 clinical variables (absence
of step off, contour irregularities, wound margin separation,
edge inversions, excessive distortion, and overall cosmetic
appearance) with each variable being given a score of 0 or 1.
A score of 6 is considered optimal. The CVAS is a 100-mm
line, with 0 being ‘‘worst scar imaginable’’ and 100 being
the ‘‘best score imaginable.’’ The CVAS has been shown to
be a reliable and valid outcome measure of long-term
cosmesis with excellent intrarater and interrater agreement.22
Three studies17 – 19 reported scar hypertrophy as a measure
of cosmetic outcome, 2 descriptively17,19 and one using a
nonvalidated 3-point scale.18 Other outcomes examined
were wound infection (n = 7), wound dehiscence (n = 2),
redness (n = 3), swelling (n = 2), and patient satisfaction
(n = 1).
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Suture Systematic Review
The methodological quality, as measured by the Jadad
score, is summarized in Table 1. None of the studies were
double-blinded because of the nature of the interventions (ie,
it is impossible to insert placebo sutures), thus Jadad quality
scores ranged from 1 to a maximum of 3. All studies had
unclear allocation concealment, and only 2 studies reported
funding sources.14,15
Cosmetic Outcome
Two studies,14,15 both of which enrolled only children,
examined overall cosmetic outcomes of traumatic lacera-
tions.14,15 Short- and long-term cosmetic outcomes (as
determined by the proportion of patients with a WES score
of 6) was examined in 1 study.14 Although both point
estimates favored nonabsorbable sutures, the differences
were not significant (OR, 1.71; 95% CI, 0.75; 3.86 for short-
term cosmesis; and OR, 1.43; 95% CI, 0.49; 4.20 for long-
term cosmesis). Two studies examined long-term cosmesis
using the CVAS, although follow-up was not available for all
patients (63/95 enrolled patients15 and 57/86 enrolled
patients14). Long-term cosmesis, as measured by the CVAS,
was not different between groups with a WMD of 5.1 (95%
CI, 0.37 to 19.14) (Fig. 2A). One study14 examined patient
satisfaction with the final cosmetic outcome using a VAS
and found no difference between groups, with a WMD of
3.6 (95%, 12.3 to 5.1) (Fig. 2A).
Three studies reported scar hypertrophy alone at the
site of sutures17 – 19 as 1 component of cosmetic outcome.
There was no significant difference between absorbable
and nonabsorbable suture with an OR of 0.80 (95% CI,
0.26– 2.42) (Fig. 2B).
Tests for heterogeneity were all nonsignificant, except
for long-term cosmetic outcome, which may reflect the
different time points that the outcome was assessed at (4 –5
months for 1 study and 9 –12 months for the other).
Infection
All studies reported examining the rate of wound
infection, although only 6 reported results. Pooled studies
showed no difference in infection rate between absorbable
and nonabsorbable sutures with an OR of 1.00 (95% CI,
0.39– 2.56). For studies that specifically examined traumatic
lacerations,15,16 there was no significant difference between
the absorbable and nonabsorbable sutures with an OR of 0.42
(95% CI, 0.07 to 2.51). There was no evidence of
heterogeneity. The results of these comparisons are demon-
strated in Figure 2B.
Other Outcomes
Two studies report14,15 examining wound dehiscence,
but only one15 reported results. There was no significant
difference between absorbable and nonabsorbable sutures
with an OR of 0.16 (95% CI, 0.02 to 1.45). Three studies
described redness at wound site after suturing.16 – 18 There
was no significant difference between absorbable and
nonabsorbable sutures with an OR of 0.44 (95% CI,
0.09– 2.32). Two studies reported swelling or edema at the
341
 342
TABLE 2. Outcome Measures Used in the Included Trials
Al-Abdullah et al

Wound Patient
Study Overall Cosmesis Hypertrophy Pain Infection Dehiscence Redness Swelling Satisfaction
Holger et al14 CVAS at 9 – 12 mo NR NR Assessed at d Assessed at d NR NR VAS at
by physician 4 – 5 by a PA or 4 – 5 by PA or 9 – 12 mo
evaluator blinded physician* physician*
to group assignment Defined as treated Not defined Completed
with antibiotics by patient
Karounis WES by RN at NR NR Assessed at d Assessed at d NR NR NR
et al15 5 – 10 d 5 – 10 by RN 5– 10 by RN
WES and CVAS Defined as purulent Separation
at 4 – 5 mo by PS discharge, excessive of wound
blinded to group erythema, pain, edges
assignment and fever
Mouzas and NR NR NR Assessed at d 2 – 3 NR Assessed Assessed at NR
Yeadon16 and d 7 – 10 at d 2 –3 d 2 – 3 and
and 7 – 10 7 – 10
Defined as redness Defined as Defined as
of >2 sutures and redness swelling
presence of edema at >2 more around >2
sutures adjacent
sutures
Edwards and NR Not defined As verbally Not defined NR Not defined NR NR
Elson17 Assessed at reported Assessed at d Assessed at
mean of by patient 3 and 14 d 3 and 14
8.5 mo on removal postoperatively postoperatively
postoperatively of sutures
Parell and NR Reviewed at 3 NR Not defined NR 3-point scale 3-point NR
Becker18y and 6 mo scale
3 point scale
Lundblad and NR 3 mo, >5 mm NR 3 and 6 mo, not NR NR NR NR
Simensen19 width defined
Murphy et al20 NR NR NR Defined as positive NR NR NR NR
wound culture at
d 3, 5, 7, 10, or 14
*Reported as an outcome measure but no data reported in the results.
y
All patients received antibiotics prior to surgery.

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NR indicates not reported; PS, plastic surgeon; RN, registered nurse; PA, physician assistant.
Pediatric Emergency Care
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Pediatric Emergency Care
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FIGURE 2. A, Comparison of long-term cosmetic outcome
and patient satisfaction with scar between wounds treated
with absorbable and nonabsorbable suture material. B,
Comparison of scar hypertrophy, infection, wound dehis-
cence, redness, and swelling between wounds treated with
absorbable and nonabsorbable suture material.
site of suture,16,18 and there was no significant difference
between absorbable and nonabsorbable sutures with an OR
of 1.18 (95% CI, 0.50 –2.80). The results of these
comparisons are demonstrated in Figure 2B. None of the
selected studies reported pain at the time of applying the
suture, the ease of suture placement, or patient satisfaction
during the procedure.
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Suture Systematic Review
Subgroup Analysis, Publication Bias,
and Sensitivity Analysis
Subgroup analysis was possible only for infection rate
among the type of laceration (traumatic vs nontraumatic).
Given the wide variability in the study protocols, insufficient
number of trials, and lack of reported information, we could
not conduct further subgroup analyses (such as by suture
type, laceration site, patient age). Given the small number of
studies, graphic or statistical tests for publication bias were
not conducted.
DISCUSSION
This systematic review demonstrates that nonabsorb-
able sutures seem no better than absorbable sutures in the
management of wound repair. No significant difference was
found in the short- or long-term cosmetic outcomes between
wounds closed with nonabsorbable and absorbable sutures.
However, only 2 studies used a well-validated outcome
measure in assessing cosmetic outcome,14,15 although 3
studies did examine scar hypertrophy.17 – 19 No comparisons
could be made between types of sutures, wound location,
or patient age and cosmetic outcome because of the wide
variability in study protocols, insufficient number of trials,
and lack of reported information.
Although cosmesis is important to both patients and
providers, other important outcomes, such as infection and
wound dehiscence, need be considered in the comparison of
suture materials for laceration repair. All studies examined
wound infection, and no difference was found between
absorbable and nonabsorbable sutures. As well, no difference
was found in wound dehiscence rates, although this outcome
was examined in only 1 study.
One of the main advantages of absorbable sutures over
nonabsorbable sutures is eliminating follow-up visits to
remove the sutures. One economic analysis comparing the
economic cost of absorbable sutures, nonabsorbable sutures,
and tissue adhesives in the repair of pediatric facial
lacerations has been published.23 This analysis examined
the differential costs related to equipment use, pharmaceu-
tical use, health care worker time, and parental loss of
income for follow-up visits, and assumed that overhead
expenses for the ED, registration costs for the ED visit, and
parental time off work for the initial ED visit were equal.
Although tissue adhesives were the most cost-effective, the
costs associated with the use of absorbable sutures was about
$30 less per patient than nonabsorbable sutures. Given that
this study was based on 1993 Canadian health care costs, the
differential costs between absorbable and nonabsorbable
sutures will likely have only increased. Besides the
difference in cost of absorbable and nonabsorbable sutures,
the lack of a return visit may have benefits for the child.
Although we know of no study that has measured the distress
associated with suture removal, we do know that many
children find having sutures placed a traumatic experi-
ence.24,25 Clinical experience suggests that some children
also find suture removal distressing, and avoiding this would
spare the children further emotional distress.
343
Al-Abdullah et al
LIMITATIONS
A number of limitations need to be addressed. Our
review is limited by the low methodological quality of the
studies as assessed by the Jadad score. As it is impossible to
blind the participants or physicians involved in administering
the intervention, the highest Jadad score possible was 3. Only
2 studies scored 3, and only these studies clearly reported
that the outcome assessor was blinded to group alloca-
tion.14,15 No study adequately described the method of
allocation concealment. Furthermore, only 2 studies used a
validated cosmetic score.14,15
Ideally, it would have been useful to examine surgical
wounds and traumatic wounds independently. The small
number of studies however made this impossible, except with
regard to wound infection. The influence of specific suture
materials, wound location, and patient age on wound outcomes
is also important, but variability across studies, small sample
sizes, and lack of detail in the studies made this analysis
impossible. As well, this meta-analysis may also be underpow-
ered to detect some rare outcomes such as wound dehiscence.
CONCLUSIONS
In conclusion, there is a lack of large, methodologi-
cally sound RCTs comparing absorbable with nonabsorbable
sutures in the repair of surgical wounds and traumatic
lacerations. Although our analysis demonstrates that nonab-
sorbable sutures seem to be no better in terms of cosmetic
outcome or complications than absorbable sutures for wound
repair, a large, methodologically sound RCT is needed to
adequately answer this question. Absorbable sutures do offer
the advantage of not needing to be removed thus saving time
and health care dollars.
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