Comparison of various methods and materials for treatment of skin laceration by a 3-dimensional measuring technique in a pig experiment

BACKGROUND: The ability to obtain an objective comparison of scar formations by reproducible and quantitatively measurable results have posed a longstanding problem. This was especially troublesome when conclusions were to be drawn about the materials and methods applied. Two-dimensional methods (photography) gave no plastic impression about the spatial coherences in an examined scar. However, a quantifiable and reproducible recording of volumes and a 3-dimesional visualization of scars should provide the basis of any evaluation of methods and materials. METHODS: The OPTOCAT 3-dimensional scanning technique that was used was provided by the Breuckmann GmbH Company (Meersburg, Germany), and it permits a 3-dimensional, contact-free recording of data. The experiment animal was the Goettinger minipig. A total of 10 animals were used to examine the process of wound healing and scar development in full skin incisions. Every animal was incised 20 times with a 10-cm long and 20 times with a 2-cm long wound. In our investigation, comparable suture materials (skin adhesive, absorbing and nonabsorbing suture materials) of the companies Braun (Histaocryl, Monosyn, Safil, Premilene) and Ethicon (Dermabond, Monocryl, Vicryl, Prolene) as well as various suture techniques were used (continuous, mattress suture, and over-and-over/interrupted suture; each once with and once without an intracutaneous suture). In the course of the trial, numerous images of all wounds-a total 1200-were taken. Thanks to the 3-dimensional software, the resulting scar volumes of lacerations, which received different wound management, were quantifiably recorded, compared, and evaluated. RESULTS: In total, dehiscence occurred in 2.5% of all treated wounds. The greatest share (15%) fell to wounds treated with Histoacryl skin adhesive. In the end, skin adhesive, mattress, and interrupted suture all delivered similar results. An additional intracutaneous suture had, with an increasing wound length, a positive effect on the intention/wound healing, especially in connection with the application of skin adhesive. Except the combination of continuous absorbable suture and intracutaneous suture, the scar volume dwindled over time and adapted to the surrounding skin level. Continuous sutures were, by comparison, more inclined to an increased scarring (absorbable suture > nonabsorbable suture). It did not escape our notice that in case of small wounds, all various suturing materials and methods led to almost identical results. With respect to scarring, no significant difference regarding the suturing material was proven. CONCLUSIONS: If possible, the wound closure, treated with common suturing techniques and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increasing length of the wound. Under certain circumstances, skin adhesive is an adequate substitute for common suturing materials and methods. The final decision about the method and material is as much closely related to the length and localization of the wound as to time exposure, efficiency, and the comfort of the patient. SUMMARY: For objective comparison of intention and scarring, a scanning technique was used that permits a quantifiable, contact-free, single-session recording of volume differences. For this purpose, various suture materials and methods were used. Altogether, it could be shown that, if possible, wound closure treated with common suturing techniques, and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increase in wound length. At the same time and under certain circumstances, skin adhesive poses an adequate substitute for the common suturing materials and methods. In the end, however, the final decision about the choice of method and material should be made depending on the localization and expanse of the wound as well as on the comfort of the patient (eg, absorbable suture/nonabsorbable suture), the time of exposure (eg, skin adhesive vs suture), and the economic efficiency (eg, producer of suture material).     

Use of adhesive surgical tape with the absorbable continuous subcuticular suture

Background: The absorbable continuous subcuticular suture is frequently used to close surgical incisions where the aim is healing by primary intention. A form of adhesive surgical tape is commonly also placed over the wound but this combination closure seems to have its development based on anecdotal, rather than experimental evidence. The present study reviews the scientific literature on the development of sutureless wound closure and presents the current evidence for the use of combination wound closure. Methods: Review was undertaken of the medical literature using the PubMed Internet database and cross‐referencing major ­articles on the subject. The following combinations of key words were searched: skin closure, wound closure, suture technique, sutureless, adhesive tape, op‐site, staples, subcuticular suture, complication, infection and scars. Results: Taped closure alone has advantages of lower wound infection rates and greater wound tensile strength, but disadvantages of epidermal reaction, skin edge inversion, doubtful safety and time required for meticulous surgical technique. The use of the continuous absorbable subcuticular suture allows accurate skin edge approximation, which increases the safety margin. The combination closure has a slightly superior cosmetic result to sutureless techniques but no study has been performed to compare the results of combination subcuticular suture and tape, with tape or subcuticular suture alone. Conclusions: There is no evidence in the scientific literature to justify or support the practice of closing a surgical wound with both subcuticular suture and adhesive surgical tape.     

A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery

BACKGROUND: Recent studies suggest that the use of tissue adhesive for closure of both traumatic lacerations and incisional surgical wounds leads to cosmetic outcome comparable to conventional sutures. To date, no studies have investigated tissue adhesive in breast surgery and costs. Our aim was to compare the tissue adhesive 2-octylcyanoacrylate (OCA) with standard suture in breast surgery. METHODS: A prospective randomized study was conducted in which 151 patients were assessed for eligibility, and 133 were randomly allocated to skin closure with OCA adhesive or monofilament suture. Cosmetic outcome with blinded assessment, wound management by the patients, complication rates, and economic outcome were recorded. RESULTS: There was no difference in cosmetic score in the 2 groups, nor in complications at the early, 6-month, and 1-year follow-up. Patient satisfaction with the wound closed with OCA was rated significantly higher when compared with standard suture (P <.0001). The application of the tissue adhesive was significantly faster than that for standard suture (P <.001). In economic terms total costs were less in the tissue adhesive group, mainly due to lower postoperative costs of physician and assistant services (P <.001). CONCLUSIONS: OCA is effective and reliable in skin closure for breast surgery, yielding similar cosmetic results to standard suture. OCA is faster than standard wound closure and offers several practical advantages over suture repair for patients. Cost analysis has found that OCA adhesive can significantly decrease health care costs.     

Optimal closure of surgical wounds in forefoot surgery: are adhesive strips beneficial?

A subcuticular suture is an ideal closure method of surgical wounds where the aim is healing by primary intention. The addition of adhesive strips over the subcuticular suture appears to be based on anecdotal, rather than experimental evidence. We performed a prospective study to compare the postoperative wound complications of combination closure with subcuticular closure alone. The wounds of 60 consecutive patients undergoing foot surgery were assessed clinically for wound complications at one week postoperatively. Patients who had a combined closure were more likely to develop wound complications. They were also twice as likely to return to clinic for a further wound check. The addition of adhesive strips to such a closure appears to offer no clinical benefit, and can be detrimental to wound healing. We recommend meticulous closure of surgical wounds with continuous, absorbable, subcuticular suture without adhesive strips, for an optimal outcome.     

Use of a skin adhesive (octyl-2-cyanoacrylate) and the optimum reinforcing combination for suturing wounds.

The adhesion strength of a skin adhesive, octyl-2-cyanoacrylate (Dermabond), was measured under various conditions using porcine skin. The combined use of a skin adhesive and a skin closure tape (n = 5) was significantly stronger than a single application of skin adhesive (n = 5) (p < 0.01). We have tentatively named the wound closure in which a skin adhesive and reinforcement material were combined the Reinforcing Combination Method. To obtain optimum conditions, further studies were done for sequence of application, type of reinforcement material, a number of layers, and width of the suture. The optimum condition for the reinforcement combination was established by applying one layer of skin adhesive over a skin closure tape, over one layer of skin adhesive, with a suture width of 4 cm. This reinforcement combination might be useful in clinical practice.     

TwinFix带线锚钉辅助改良Kessler法修补陈旧性跟腱断裂

目的 探讨TwinFix带线锚钉辅助改良Kessler法修补陈旧性跟腱断裂的临床疗效.方法 采用TwinFix带线锚钉辅助改良Kessler法修补陈旧性跟腱断裂患者11例,术中用改良Kessler法对位缝合跟腱断端,再用2枚TwinFix带线锚钉辅助固定断裂跟腱.术后予患侧下肢屈膝90°、踝跖屈30°位长腿石膏托固定,3周后改踝跖屈石膏托固定.结果 11例均获随访,时间3～18个月.患者均未发生切口延期愈合、感染、皮肤坏死和跟腱再断裂等并发症.采用Arner-Lindholm评分标准评价疗效:优7例,良3例,差1例.结论 TwinFix带线锚钉辅助改良Kessler法手术操作简便,是修补陈旧性跟腱断裂的有效方法.     

Use of a skin adhesive (octyl-2-cyanoacrylate) and the optimum reinforcing combination for suturing wounds

The adhesion strength of a skin adhesive, octyl-2-cyanoacrylate (Dermabond?), was measured under various conditions using porcine skin. The combined use of a skin adhesive and a skin closure tape (n=5) was significantly stronger than a single application of skin adhesive (n=5) (p<0.01). We have tentatively named the wound closure in which a skin adhesive and reinforcement material were combined the Reinforcing Combination Method. To obtain optimum conditions, further studies were done for sequence of application, type of reinforcement material, a number of layers, and width of the suture. The optimum condition for the reinforcement combination was established by applying one layer of skin adhesive over a skin closure tape, over one layer of skin adhesive, with a suture width of 4?cm. This reinforcement combination might be useful in clinical practice.     

Novel adhesive skin closures improve wound healing following saphenous vein harvesting

BACKGROUND AND AIMS: New techniques for skin closure that minimize tissue inflammation and avoid foreign material may decrease morbidity following saphenous vein harvesting. The 3M Steri-Strip S surgical skin closure system is a new, noninvasive method of wound closure, which consists of polymeric components coated with a pressure-sensitive skin adhesive. This prospective, randomized study was undertaken to compare the results of the noninvasive skin closure method to the traditional subcuticular skin closure technique on saphenous vein harvest sites. METHODS: Twenty-six patients undergoing coronary artery bypass surgery with saphenous vein harvesting were prospectively randomized to skin closure using 3M Steri-Strip S Surgical Skin Closure System or subcuticular suture closure with a skin sealant. Wounds were evaluated on postoperative days 7 and 2l for erythema, edema, pain, cosmesis, and the time taken to close the incision. RESULTS: Skin closure with 3M Steri-Strip S was significantly faster, resulted in significantly less erythema, edema, and significantly improved cosmesis. CONCLUSIONS: 3M Steri-Strip S Skin Closure improves wound healing of saphenous vein sites, compared to traditional subcuticular skin closure techniques.     

A single blind, prospective, randomized trial comparing n-butyl 2-cyanoacrylate tissue adhesive (Indermil) and sutures for skin closure in hand surgery

Fifty patients underwent a variety of hand operations and were randomized for wound closure either with tissue adhesive (Indermil) or sutures. The two treatment groups had similar demographic characteristics and similar outcomes at the 2 and 6 week postoperative assessments which were performed by a designated tissue viability nurse blinded to the method of closure. Five minor wound dehiscences occurred: three in the adhesive group and two in the suture group. No infection occurred in either group. In conclusion, the study demonstrates tissue adhesive is as effective as suture in this type of hand surgery.     

A prospective, randomized comparison of skin adhesive and subcuticular suture for closure of pediatric hernia incisions: cost and cosmetic considerations

Purpose

In this study, we compared the skin adhesive 2-octylcyanoacrylate to subcuticular suture for closure of pediatric inguinal hernia incisions to determine if skin adhesive improves wound cosmesis, shortens skin closure time, and lowers operative costs.

Methods

We prospectively randomized 134 children undergoing inguinal herniorrhaphy at our institution to have skin closure with either skin adhesive (n = 64) or subcuticular closure (n = 70). Data collected included age, sex, weight, type of operation, total operative time, and skin closure time. Digital photographs of healing incisions were taken at the 6-week postoperative visit. The operating surgeon assessed cosmetic outcome of incisions using a previously validated visual analog scale, as well as an ordinate scale. A blinded assessment of cosmetic outcome was then performed by an independent surgeon comparing these photographs to the visual analog scale. Operating room time and resource use (ie, costs) relative to the skin closure were assessed. Comparisons between groups were done using Student's t tests and χ² tests.

Results

Children enrolled in the study had a mean ± SE age of 3.7 ± 0.3 years and weighed 16 ± 0.8 kg. Patients were predominantly male (82%). Patients underwent 1 of 3 types of open hernia repair as follows: unilateral herniorrhaphy without peritoneoscopy (n = 41; 31%), unilateral herniorrhaphy with peritoneoscopy (n = 55; 41%), and bilateral herniorrhaphy (n = 38; 28%). Skin closure time was significantly shorter in the skin adhesive group (adhesive = 1.4 ± 0.8 minutes vs suture = 2.4 ± 1.1 minutes; P = .001). Mean wound cosmesis scores based on the visual analog scale were similar between groups (adhesive = 78 ± 21; suture=78 ± 18; P = .50). Material costs related to herniorrhaphy were higher for skin adhesive (adhesive = $22.63 vs suture = $11.70; P < .001), whereas operating room time costs for adhesive skin closure were lower (adhesive = $9.33 ± 5.33 vs suture = $16.00 ± 7.33; P < .001). Except for a 7% incidence of erythema in both groups, there were no complications encountered.

Conclusions

There is no difference in cosmetic outcome between skin adhesive and suture closure in pediatric inguinal herniorrhaphy. Material costs are increased because of the high cost of adhesive relative to suture. This is partially offset, however, by the cost savings from reduction in operating room time.     

The use of sterile adhesive tape in the closure of arthroscopic puncture wounds: a comparison with a single layer nylon closure.

A prospective trial was undertaken comparing the wound healing and infection rates in arthroscopic arthrotomy wounds closed by sterile adhesive tapes on interrupted Nylon skin sutures. Two hundred and thirty consecutive arthroscopic procedures had arthrotomy wounds closed by a single layer skin closure of either interrupted Nylon (n = 62) or sterile adhesive tapes (n = 168). All wounds healed by primary intention. Only one wound developed a superficial infection around a Nylon suture and no patient developed a synovial herniation. It is concluded that closure of arthroscopic puncture wounds with sterile adhesive tape is effective and convenient for wound management.     

A prospective randomized trial comparing 2-octyl cyanoacrylate to conventional suturing in closure of laparoscopic cholecystectomy incisions

OBJECTIVE: To compare 2-octyl cyanoacrylate (Dermabond) with conventional suturing for closure of laparoscopic cholecystectomy (LC) wounds in a prospective randomized controlled trial. SUBJECTS: Twenty-five consecutive patients underwent LC at a teaching hospital in the United Kingdom. Patients were randomly allocated to have skin closed with 2-octyl cyanoacrylate or absorbable suture. METHODS: Fifty-one wounds underwent skin closure with absorbable subcuticular suture (3/0 polydiaxanone) and 48 wounds were closed with tissue adhesive. The time to close the wounds, including the placement of dressings, was recorded. At 6 to 8 weeks, the incisions were evaluated with the Hollander wound evaluation scale (HWES). Using a visual analogue scale (VAS), the wounds were also rated by a plastic surgeon who was blinded to the method of closure. RESULTS: The wounds were closed significantly faster in the Dermabond group (mean 165 seconds versus 356 seconds, P = 0.03). There were no differences in the percentage of wounds achieving optimal scores on the HWES (suture 64.7% versus tissue adhesive 60.4%, P = 0.42) nor on the mean VAS (suture 62 mm versus tissue adhesive 59 mm, P = 0.45). CONCLUSION: The tissue adhesive 2-octyl cyanoacrylate is a safe and fast method for closure of LC wounds, with cosmetic results comparable to suturing.     

Optimal closure method of five-millimeter trocar sites

BACKGROUND: Although many surgeons use absorbable sutures for skin closure of 5-mm trocar sites, effective alternative materials exist. We compared 5-mm trocar site closures using a vicryl suture (VS), cyanoacrylate tissue adhesive (CTA), or skin tape (ST). METHODS: Patients rated wound pain and appearance at 1 and 6 weeks after surgery. Seven surgeons masked to the closure method rated wound photographs at these time points using the Hollander wound evaluation scale. Logistic regression analysis was used to evaluate the ratings of each closure group. RESULTS: The 137 wounds of 48 patients undergoing laparoscopic procedures were randomized among three closure method groups. Patient demographics and procedure type were similar for all groups. Long closure times (>30 seconds) was significantly higher for VS compared with CTA and ST. Patients favored VS over ST and CTA at 1 week with respect to pain and wound appearance (P = 0.04 and P = 0.02, respectively). They rated CTA closures more likely to have pain and poor wound appearance at 6 weeks (P = 0.05 and P = 0.03, respectively). Surgeons rated VS less likely (P = 0.02) and CTA more likely (P = 0.003) to show moderate to severe scar formation. Vicryl suture was less likely to have wound separation and edge inversion (P = 0.017 and P = 0.006, respectively). Cyanoacrylate tissue adhesive was more likely to yield step-off (P = 0.03), contour irregularities (P = 0.005), separation (P = 0.004), excessive distortion (P = 0.001), and edge inversion (P = 0.03). CONCLUSIONS: Although VS closure time of 5-mm trocar sites takes longer than CTA and ST, VS scar formation and comfort is superior to CTA and ST. Cyanoacrylate tissue adhesive yields poor results with respect to both wound healing and pain.     

Removal of adhesive wound dressing and its effects on the stratum corneum of the skin: comparison of eight different adhesive wound dressings

In recent years, adhesive wound dressings have been increasingly applied postoperatively because of their ease of use as they can be kept in place without having to cut and apply surgical tapes and they can cover a wound securely. However, if a wound dressing strongly adheres to the wound, a large amount of stratum corneum is removed from the newly formed epithelium or healthy periwound skin. Various types of adhesives are used on adhesive wound dressings and the extent of skin damage depends on how much an adhesive sticks to the wound or skin surface. We quantitatively determined and compared the amount of stratum corneum removed by eight different wound dressings including polyurethane foam using acrylic adhesive, silicone‐based adhesive dressing, composite hydrocolloid and self‐adhesive polyurethane foam in healthy volunteers. The results showed that wound dressings with silicone adhesive and self‐adhesive polyurethane foam removed less stratum corneum, whereas composite hydrocolloid and polyurethane foam using acrylic adhesive removed more stratum corneum.     

应用组织胶关闭切口的生物力学研究

目的 对新型免缝组织胶关闭皮肤切口进行效果观察及生物力学评价.方法 分别制作组织胶涂抹切口模型、5-0丝线缝合切口模型,术后30 min、3d、7d距伤口约1 cm处切取一段长约2.5 cm切口组织,进行生物力学检测.结果 术后7d观察组织胶闭合切口为线形,无针眼遗留.术后30 min、3d时组织胶闭合模型抗拉强度低于丝线组(P＜0.05),而7d时两者间差异无统计学意义(P＞0.05).结论 组织胶关闭切口后强度可靠,效果确切,可大大节省手术时间,是临床应用中较为理想的切口关闭材料.     

Prospective Randomized Blind Controlled Trial Comparing Sutures, Tape, and Octylcyanoacrylate Tissue Adhesive for Skin Closure After Phlebectomy

BACKGROUND: The patient's view of the outcome after phlebectomy is mainly dependent on the cosmetic result. OBJECTIVE: To compare 5-0 monofilament sutures with tapes and tissue adhesive for wound closure after varicose vein surgery. METHODS: Seventy-nine patients undergoing varicose vein surgery were prospectively randomized in three groups (tissue adhesive, sutures, tape) for skin closure and compared. The follow-up 1 year postoperatively was done by a senior dermatologist who was blinded in the method of skin closure. RESULTS: The cosmetic outcome showed little advantage for the suture group. Taping the incisions is faster than suturing them but without significance; closure with tissue adhesive takes nearly the double of time. The closure for one incision with tissue adhesive is 40 times more expensive than with tapes and 14 times more expensive than with sutures. CONCLUSION: This study failed to demonstrate an advantage of tissue adhesive and tapes over monofilament sutures for skin closure after phlebectomy.     

Application of intradermal sutures on the skin

There were analyzed the results of treatment of 87 patients, in whom intradermal sutures were applied while doing the cutaneous wounds closure: continuous removable suture, adjusted according to Holsted method, continuous nonremovable Hoisted suture, separate nonremovable vertical suture of Abudy, separate cutaneous horizontal nonremovable suture. Peculiarities of postoperative cicatrix formation, its aesthetic qualities were studied up. While adjusting separate nonremovable intradermal sutures, using biodegrading thread made of polydyoxanone, the qualitative, minimally wide cicatrix is formed, promoting reduction of the patients treatment duration due to absence of necessity to remove cutaneous sutures, preventing screwing of the wound edges and possibility of kelloid cicatrix formation due to minimal trauma occurrence of the skin layers.     

A method of suturing the operation wound in patients with obesity

A method of multistoried closing the wound with the help of 2-4 adapting horizontal mattress sutures onto the subcutaneous fatty tissue and one suture onto the skin was used in 58 patients with the III degree of obesity for suturing the postoperative wound in the area of the frontal abdominal wall. No specific complications resulting from the used technique of suturing the wound were noted. Long-term results of treatment showed a good cosmetic effect.     

A model for quantitative evaluation of skin damage at adhesive wound dressing removal

The removal of adhesive wound dressings from the wound surface involves a risk of damaging the intact stratum corneum and regenerating epithelium. Pain associated with the removal of wound dressings is a major issue for patients and medical personnel. Recently, wound dressings coated with a silicone adhesive have been developed to reduce such skin damage and pain on removal and they have received good evaluation in various clinical settings. However, there is neither a standard method to quantify whether or not the integrity of the stratum corneum and regenerating epithelium is retained or if both structures are damaged by the removal of wound dressings, nor are there standardised values with which to assess skin damage. We applied six different types of adhesive wound dressing on plain copy paper printed with black ink by a laser printer, removed the dressings, examined the adhesive‐coated surface of the wound dressings using a high‐power videoscope, and examined the stripped areas. Wound dressings coated with a silicone adhesive showed significantly less detachment of the stratum corneum and regenerating epithelium, followed by those coated with polyurethane, hydrocolloid, and acrylic adhesives. The assessment method utilised in this study revealed distinct differences between wound dressing types, but less variation in the evaluation outcome of each type. This assessment method may be useful for the evaluation of adhesive wound dressings, particularly during product development. However, further studies will be needed to examine the effectiveness of this assessment method in the clinical setting because the adherent properties of polyurethane and hydrocolloid adhesives may be altered by the absorption of water from the skin.     

Comparative study of leg wound skin closure in coronary artery bypass graft operations.

A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients). All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4.5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.