Grant funds provided byA continuing education activity sponsored by

Topical skin adhesive: Safe, strong, secure wound closure

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Topical Skin Adhesive:Strong, Safe, Secure Wound Closure

An Online Continuing Education ActivitySponsored By

Grant funds provided byFunds Provided By

Welcome to

Topical Skin Adhesive:Strong, Safe, Secure Wound Closure

(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time. Steps for Successful Course CompletionTo earn continuing education credit, the participant must complete the following steps:

1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration

form. 6. A certificate of completion will be available for you to print at the conclusion. Pfiedler Enterprises will maintain a record of your continuing education

credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

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Pfiedler Enterprises2101 S. Blackhawk St, Suite 220, Aurora, CO 80014

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OVERVIEWWound closure and healing are essential for achieving optimal outcomes for all surgicalpatients. The healing process is facilitated by proper closure of the surgical wound. Today,ongoing advancements in topical skin adhesives supplement the armamentarium of woundclosure techniques. Therefore, the perioperative nurse should remain knowledgeable aboutthe use of topical skin adhesives as a strong, secure and effective skin closure technique.This continuing education activity provides valuable information regarding the use oftopical skin adhesives in surgery, specifically the family of butyl- and octyl-cyanoacrylateskin adhesives. The key clinical considerations in wound closure and the wound healingprocess are briefly described. The history behind the development of skin adhesives isprovided, including a discussion of regulatory classification. The current indications andcontraindications for use, as well as the advantages and disadvantages of topical skinadhesives are presented. The steps involved in the application of topical skin adhesives,including patient preparation and instructions are outlined. Finally, the clinical benefitsassociated with the use of topical skin adhesives as reported in the literature are discussed.

OBJECTIVESAfter completing this continuing nursing education activity, the participant should be able to:

1. Discuss the clinical considerations in surgical wound healing.2. Differentiate two types of topical skin adhesives.3. Identify the advantages and disadvantages of topical skin adhesives for surgical patients.4. Explain the steps involved in the application of a topical skin adhesive.5. Identify patient care instructions regarding the use of topical skin adhesives.6. Describe the clinical benefits of topical skin adhesives as cited in the literature.

INTENDED AUDIENCEThis continuing education activity is intended for perioperative registered nurses who areinterested in learning more about the different topical skin adhesives and their benefits andmodes of application in the surgical practice setting.

CREDIT/CREDIT INFORMATIONState Board Approval for NursesPfiedler Enterprises is a provider approved by the California Board of Registered Nursing,Provider Number CEP14944, for 2.0 contact hour(s).

Obtaining full credit for this offering depends upon completion, regardless of circumstances,

from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

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IACET Pfiedler Enterprises has been accredited as an Accredited Provider by the International Association for Continuing Education and Training (IACET).

CEU Statements• As an IACET Accredited Provider, Pfiedler Enterprises offers CEUs for its programs

that qualify under the ANSI/IACET Standard.

• Pfiedler Enterprises is accredited by IACET to offer 0.2 CEUs for this program.

RElEASE AND ExPIRATION DATE:This continuing education activity was planned and provided in accordance with accreditation criteria. This material was revised in August 2015 and can no longer be used after August 2017 without being updated; therefore, this continuing education activity expires August 2017.

DISClAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity

SUPPORTFunds to support this activity have been provided by CardinalHealth

AUTHORS/PlANNING COMMITTEE/REVIEWERRose Moss, MN, RN, CNOR Westcliffe, CO Nurse Consultant/Author Moss Enterprises

Judith I. Pfister, RN, BSN, MBA Aurora, COProgram Manager/Planning CommitteePfiedler Enterprises Julia A. Kneedler, RN, MS, EdD Aurora, COProgram Manager/ReviewerPfiedler Enterprises

DISClOSURE OF RElATIONSHIPS WITH COMMERCIAl ENTITIES FOR THOSE IN A POSITION TO CONTROl CONTENT FOR THIS ACTIVITy Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor

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in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure

Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer

Rose Moss, RN, MN, CNOR No conflict of interest

Judith I. Pfister, MBA, RN Co-owner of company that receives grant funds from commercial entities

Julia A. Kneedler, EdD, RN Co-owner of company that receives grant funds from commercial entities

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INTRODUCTIONClosure of surgical wounds was initially accomplished with the use of sutures; underlying tissues were 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 in synthetic material along with standardization of traditional materials (eg, 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. 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.)

The ability to heal wounds is one of the most powerful defensive properties humans possess.2 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.

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 Skin3 The skin is the largest organ of the body and also serves as the first line of defense against infection. The skin provides protection and sensation, regulates fluid balance and temperature, and produces vitamins (eg, 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):

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

• Dermis – the 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 layer – this 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.

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Figure 1 – Anatomy of the Skin

• The skin is the largest organ of the body and also 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

Anatomy of the skin

Types of Wounds4

The three main causes of wounds are: 1. Traumatic – due to mechanical, thermal, or chemical destruction. 2. Chronic – caused by underlying pathophysiological conditions (eg, pressure

ulcers or venous leg ulcers). 3. Surgical – caused 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 (see Figure 2).

Figure 2 – Clinical Considerations in Wound Healing

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• The ability to heal wounds is one of the most powerful defensive properties humans possess

• Wound healing is a

complex, highly organized process by the body in response to tissue disruption caused by injury

Clinical considerations in wound healing

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Types of Wound Closure5 The three types of wound closure are primary, secondary, and tertiary intention; each of these is briefly described below.

• Primary intention – healing 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. 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 (eg, retention sutures).

Phases of Wound Healing Clean, full-thickness wound healing is an intricate biological process that occurs in four distinct, overlapping phases of healing: hemostasis, inflammation (also called the reactive stage), proliferative, and remodeling, as outlined below and depicted in Figure 3.6

• Phase 1 – Hemostasis Phase. This phase occurs immediately following injury; Consists of platelet aggregation and blood coagulation to seal severed vessels.

• Phase 2 – Inflammatory Phase. This phase begins approximately 30 minutes following the injury and typically persists for 24-48 hours. It is necessary to 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 3 – Proliferative Phase. This phase may begin as early as 24 hours following an injury and allows for new epithelium to cover the wound. Epithelial

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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 4 – Remodeling 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.

Figure 3 – The Wound Healing Process

Wound strength gradually increases during the healing process:

• Phase 1- Hemostasis Phase

– Immediately following injury

• Phase 2- Inflammatory Phase – Begins within minutes after an injury

• Phase 3- Proliferative Phase

– Begin within 24 hours of an injury

• Phase 4- Remodeling Phase – Begins after ~2-4 weeks, dependent

upon size and nature of the wound

Tissue repair phases and timescale

Wound strength gradually increases during the healing process.7 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.

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TOPICAl SKIN ADHESIVES Historical Review of Topical Skin Adhesives8

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 byproducts 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 (see Figure 4).

Figure 4 – Cyanoacrylates

methyl‐CA

ethyl‐CA

n‐butyl‐CA

2‐octyl‐CA

Consumer glues• SuperGlue®

• Krazy® Glue

Industrial plastic bonding• Permabond® 910

Earliest topical medical adhesives to the market• LiquiBand® Butyl• Histoacryl®• Indermil®

Newer CA formulations, introduced to the US market since1998• LiquiBand® OCTYL• SecureSeal®• SURGISEAL®• Dermabond® Advanced• Dermabond® Mini• Derma +Flex QS®

* formerly  OctySeal®, OctylBond®, and Sure+Close II®)

8 carbon chain

4 carbon chain

2 carbon chain

1 carbon chain

FDA Classification of Topical Skin Adhesives9

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),

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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.

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 (ie, 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.10

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 byproducts released into the tissues per unit of time. This slower release allows for more efficient tissue clearance of toxic byproducts with less ensuing tissue toxicity.11

Currently, two types of skin adhesives are being used in place of non-absorbable sutures and staples: n-butyl-cyanoacrylate and 2-octyl-cyanoacrylate.12

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n-Butyl-cyanoacrylate n-Butyl-cyanoacrylates have shorter molecular chain lengths; this allows the product to require a single 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, 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 and microbial barrier protection (see Figure 5).

Figure 5 – n-Butyl-cyanoacrylate in Skin Adhesive

• Has a shorter molecular chain length (4 carbon) • Dries in 30 seconds • All one-layer application • Has a low exothermic reaction • Once applied and allowed to dry, n-butyl-

cyanoacrylates have a flat, low-sheen finish • Texture is designed to simulate the natural flaking and

healing of a scab • Provides a waterproof and microbial barrier

n-Butyl-cyanoacrylate skin adhesives

2-Octyl-cyanoacrylate 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 longer molecular chain lengths. Once applied and allowed to dry, 2-Octyl-cyanoacrylates have a gel-like, 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 flexible, microbial protection (see Figure 6).

Figure 6 – 2-Octyl-cyanoacrylate Skin Adhesives

10 Days Postoperative 15 Days Postoperative 30 Days Postoperative5 Days Postoperative

Indications and Contraindications13 Topical skin adhesives may be applied topically to intact skin at the wound edges to hold the approximated skin surfaces (ie, 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 non-absorbable 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.

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

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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.14 In general, the use of tissue adhesives can significantly decrease healthcare costs and is preferred by patients.15 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 body’s 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.16

The advantages and disadvantages of topical skin adhesives are outlined below.

Advantages• Creates a microbial barrier;• Ease of use for physician and staff (less prep time and materials needed);• Eliminates the need for suture/staple removal; • Reduces the risk of needle sticks to the physician/nurse;• Increases patient satisfaction: patient can shower immediately, move more freely,

and requires no dressing to be concerned about getting wet; • Eliminates the need for a follow-up visit to the physician; • Less stress and discomfort for the pediatric patient;• Minimizes the need for a dressing and wound care; and• Lowers cost (less ancillary services and equipment used).

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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/ INSTRUCTIONSPatient Preparation In applying tissue adhesives, the most important concept is that they are for topical closure only.17 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. 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 (see Figure 7).

*2-Octyl-cyanoacrylates have a slower polymerization process, resulting in longer setting time.

Figure 7 – Application of Topical Skin Adhesives

• In applying tissue adhesives, the most important concept is that they are for topical closure only

• The wound should be clean and dry • Wound edges need to be approximated

and prior to adhesive application • ‘n-Butyl: Hold the skin edges for

approximately 30 seconds in order for the adhesive to polymerize

• 2-octyl: Have a slower polymerization process, resulting in longer setting time.

• Do not allow the adhesive to go directly into the wound

• If the wound needs added protection, a dry gauze dressing can be applied once the adhesive has fully dried

Application of topical skin adhesives

Skin Approximated Application

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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 off. It is important that the patient allows the skin adhesive to break down and not assist it in lifting from the incisional area. This will provide for the optimal degree of protection and healing to the incision site. 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.

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 healthcare 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.18 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 viscosity on application, and strength after hardening. Application of the adhesive is easy

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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.19 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 patient satisfaction.

Dowson et al, compared the efficacy of n-butyl-cyanoacrylate tissue adhesive with nonabsorbable monofilament sutures for laparoscopic port site closure.20 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. 78 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 seconds versus 125 seconds). Fewer dressings were required in the tissue adhesive group immediately postoperatively (21% versus 97%) and also at 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 of various degrees of cleft for an age group ranging from three months to five years to assess the quality of scars following the use of butyl-cyanoacrylate to close the skin during cleft lip repair.21 The author used 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 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.22 A multi-

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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 (21,201 patients), 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 pairwise 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.23 The authors reviewed the records of 680 patients whose cardiovascular surgery 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, the infection rate was 4.9% among the patients without the topical skin adhesive. 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 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.24 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 a various evaluation and assessment scales. The results demonstrated that both patients and panelists expressed an overall preference for the adhesive side 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 side 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 side according to the patients, but not according to the panelists. The authors concluded that 2-octyl-cyanoacrylate is a sound alternative for wound closure.

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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. Therefore, the perioperative nurse should be knowledgeable about wound closure and healing processes and the role of topical skin adhesives as a safe, strong, and secure wound closure technique in order to achieve optimal patient outcomes.

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GlOSSARyCyanoacrylate 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 or on the inside; 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.

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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.

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.

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REFERENCES1. Galli SKD, Constantinides M. Wound closure technique. http://emedicine.medscape.

com/article/1836438-overview. Accessed February 4, 2011.

2. Bak JR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis, MO: Elsevier Mosby; 2015:253-269.

3. Bak JR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis, MO: Elsevier Mosby; 2015:253-269.

4. Bak JR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis, MO: Elsevier Mosby; 2015:253-269.

5. Bak JR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis, MO: Elsevier Mosby; 2015:253-269.

6. Bak JR. Wound healing, dressings, and drains. In Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis, MO: Elsevier Mosby; 2015:253-269.

7. Terhune M. Materials for wound closure. http://emedicine.medscape.com/article/1127693-overview. Accessed July 23, 2015.

8. Dowson C, Gilliam A, Speake WJ, Lobo D, Beckingham I. A prospective, randomized controlled trial comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure after laparoscopic general surgical procedures. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2006;16(3):146-150.

9. Federal Register. Medical devices; general and plastic surgery devices; classification of tissue adhesive with adjunct wound closure device intended for topical approximation of skin. http://www.federalregister.gov/ articles/2010/11/10/2010-28356/medical-devices-general-and-plastic-surgery-devices-classification-of-tissue-adhesive-with-adjunct#p-10. Accessed July 23, 2015.

10. Dowson C, Gilliam A, Speake WJ, Lobo D, Beckingham I. A prospective, randomized controlled trial comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure after laparoscopic general surgical procedures. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2006;16(3):146-150.

11. Schwade ND. 2-octyl cyanoacrylate wound adhesives. http://emedicine.medscape.com/article/874047-overview. Accessed July 23, 2015.

12. Schwade ND. 2-octyl cyanoacrylate wound adhesives. http://emedicine.medscape.com/article/874047-overview. Accessed July 23, 2015.

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13. Schwade ND. 2-octyl cyanoacrylate wound adhesives. http://emedicine.medscape.com/article/874047-overview. Accessed July 23, 2015.

14. Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. The American Journal of Emergency Medicine. 2008; 26 (4): 490-496. http://www.ncbi.nlm.nih.gov/pubmed/18410821. Accessed July 23, 2015.

15. Schwade ND. 2-octyl cyanoacrylate wound adhesives. http://emedicine.medscape.com/article/874047-overview. Accessed July 23, 2015.

16. Managram AJ, Horan TC, Pearson ML, et. al. Guideline for the prevention of surgical infection, 1999.The Hospital Infection Control Practices Advisory Committee (CDC). Infection Control HospEpidemiol.1999; 20:247-280.

17. Schwade ND. 2-octyl cyanoacrylate wound adhesives. http://emedicine.medscape.com/article/874047-overview. Accessed July 23, 2015.

18. Graefe H, Wollenberg B, Brocks C. Application of skin adhesives in head and neck surgery: analysis of cosmetic results, applicability and cost-effectiveness of cyanoacrylate-based adhesives. HNO. 2008;56(9):947-954.

19. Krishnamoorthy BS, Najam O, Khan UA, Waterworth P, Fildes JE, Yonan N. Randomized prospective study comparing conventional subcuticular skin closure with dermabond skin glue after saphenous vein harvesting. Annals of Thoracic Surgery. 2009;88:1445-1449.

20. Dowson C, Gilliam A, Speake WJ, Lobo D, Beckingham I. A prospective, randomized controlled trial comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure after laparoscopic general surgical procedures. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2006;16(3):146-150.

21. Mourougayan V. Sutureless skin closure for cleft lip repair. The Cleft Palate- Craniofacial Journal. 2006;43(6):656-658.

22. Murrmann SG, Markowitz JS, Gutterman EM, Magee G. Postoperative outcomes associated with topical skin adhesives among women having hysterectomies. Surgical Infections. 2010;11(5):441-447.

23. Souza EC, Fitaroni RB, Januzelli DM, Macruz HM, Camacho JC, Souza MR. Use of 2-octyl cyanoacrylate for skin closure of sternal incisions in cardiac surgery: observations of microbial barrier effects. Current Medical Research and Opinion. 2008;24(1):151-155.

24. Nipshagen MD, Hage JJ, Beekman WH. Use of 2-octyl-cyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: a prospective, randomized intervention study. Plastic and Reconstructive Surgery. 2008;122(1):10- 18.

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