Cyanoacrylate tissue adhesives are liquid monomers that polymerize into a stable bond when they come into contact with wounds. They are applied topically to the apposed wound edges and should not be introduced into the wound. The tissue adhesives offer many advantages over standard wound closure devices: They may be applied rapidly and painlessly to any easily approximated laceration. Because they slough off spontaneously within 5 to 10 days, they do not require a follow-up visit for suture removal. This is particularly important in the young child, for whom removal of sutures may be as anxiety provoking as the initial placement. The tissue adhesives are roughly equivalent in strength to 5-0 sutures but should not be used alone for wounds otherwise requiring stronger wound closure devices (such as high-tension wounds). They can be used in conjunction with deep sutures. The cyanoacrylates form an occlusive dressing that serves as a barrier to microbial penetration (1) and have been shown to have inherent antibacterial properties and reduce infection rates in experimental animal models (2). Clinical trials comparing wounds closed with octylcyanoacrylate to those closed by sutures have consistently demonstrated similar scar appearance (3,4,5).

The disadvantages of tissue adhesives are that (a) they have less tensile strength than 5-0 sutures and staples and thus cannot be used for wounds under high tension and (b) they are less resistant to moisture than sutures and staples and thus must be used with caution in patients who will be swimming or exposed to water.

Application of tissue adhesives is a manual skill that is easily acquired (6). In contrast, 1 to 2 years of experience are required before a practitioner becomes proficient at suturing traumatic lacerations (7). Tissue adhesives can be stored and are easily applied in the office, urgent care, or emergency department setting.

Cyanoacrylate tissue adhesives are indicated for the closure of noncontaminated wounds that are under minimal tension. They should be used only when the wound edges can be easily approximated. Most wounds occur in the head and neck, and this area has low wound infection rates and low tension, making cyanoacrylates the ideal wound closure device. Octylcyanoacrylates may also be safely used on the torso and in areas of the extremities that are not subject to significant tension. In areas that are subject to moderate tension, placement of deep sutures may allow easy approximation of skin edges and subsequent skin closure with tissue adhesives. Even when deep sutures are placed, tissue adhesives offer advantages because they will still reduce time requirements and eliminate the need for follow-up and suture removal. Tissue adhesives are also useful for closing various skin flaps, where the addition of sutures may further compromise vascular supply. Finally, tissue adhesives may be used to close lacerations over fragile skin that is easily torn by sutures, such as the skin over the lower leg, especially in elderly patients.

Cyanoacrylates are contraindicated for patients with allergies to cyanoacrylate or formaldehyde, a breakdown product. Tissue adhesives are also contraindicated when there is an
increased risk of infection or poor wound healing, such as in areas of poor vascularity. They are contraindicated in wounds that cannot be easily apposed, with or without deep sutures. Relative contraindications to application of tissue adhesives include wounds involving mucocutaneous borders, areas with dense hair, and areas routinely exposed to bodily fluids.

Proper wound selection, evaluation, and preparation prior to closure are critical (8,9). The wound should be cleaned, irrigated, and débrided as necessary (Chapter 107). A topical anesthetic will minimize discomfort if applied prior to wound cleaning. The clinician should make sure that the wound edges are apposed so that the adhesive does not enter the wound. When adhesive is placed between the wound edges, it prevents epithelialization and may result in inflammatory reactions (10). Tissue adhesives should be applied to relatively dry skin. Hemostasis can be obtained by applying pressure with sterile gauze or by dripping a topical epinephrine solution (alone or in combination with lidocaine) into the wound. When hemostasis cannot be obtained, the wound should be closed with sutures or staples instead.

Patient positioning at the time of tissue adhesive application is important to prevent run of tissue adhesive away from the wound. Restraint may also be necessary in the young child who is unable to hold still for the procedure (Chapter 3). The patient should be positioned so that the wound surface is parallel to the floor. This will greatly reduce runoff. Important structures (e.g., the eye) adjacent to the wound should be covered with dry gauze to prevent tissue adhesive migration into the area. The wound may also be surrounded by a rim of petrolatum gel or topical antibiotic ointment to block adhesive runoff. Another “trick” is to gently squeeze and release pressure on the vial to control the amount of adhesive that is expressed. Avoiding excessive expression of the adhesive also minimizes the chances that the practitioner’s fingers will get stuck to the wound. If the practitioner’s gloved hand has come in contact with the adhesive and might be getting stuck to the patient’s skin, the other hand should be used to reinforce wound apposition while the original hand is gently pulled away from the wound.