Cutaneous Wound Closure Materials: An Overview and ...

When selecting skin closure materials, a surgeon must consider various factors including the wound type, its location, the material availability, and the patient's overall health condition. This review provides evidence-based insights into the appropriate usage of diverse skin closure techniques to assist surgeons in making informed decisions about wound management.

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Dermasurgeons encounter a wide array of wounds requiring closure each day. With many skin closure options available in the market, identifying a method that not only promises excellent cosmetic results but is also practical and cost-effective can be a challenging task. An optimal wound closure technique should ideally be economical, efficient, simple to execute, and capable of producing an aesthetically pleasing outcome. The primary aims in managing wounds and skin incisions are to achieve rapid closure while ensuring the formation of a functional and visually acceptable scar. While sutures are the conventional choice in surgical procedures, comprehensive reviews contrasting various suture types and their characteristics remain scarce. Advancements in acute wound healing research have led to the emergence of alternative technologies, including staples and tissue adhesives (such as glues and adhesive tapes), thus allowing medical professionals to transition from tedious suturing techniques to more straightforward, operator-independent solutions. This shift can minimize infection risks by effectively sealing wounds, employing an extensive range of skin closure materials. Consequently, researchers across both medical and applied science domains have explored diverse materials, tissues, and methodologies to develop effective wound closure strategies, including laser-assisted tissue bonding (LTB).

This review entailed a thorough literature search by two independent authors via electronic databases such as Pub Med, the Cochrane Database, Google Scholar, and Ovid. Articles published in English focusing on skin closure materials were considered. The search terms included a comprehensive list covering sutures, adhesive materials, and various types of sutures, both absorbable and non-absorbable. Reference lists from relevant studies and systematic reviews were also consulted to augment search results.

DISCUSSION

Tissue adhesives

Suturing remains the predominant method for wound closure, although newer alternatives, including adhesive paper tape and tissue adhesives, have been introduced in recent years. The use of cyanoacrylate tissue adhesives was pioneered by a German chemist in the early 1960s and was applied clinically by a British plastic surgeon shortly thereafter. Octyl-2-cyanoacrylate (OCA) received FDA approval for clinical use in 1998. This adhesive has a rapid action, typically beginning to set within ten seconds of application. Upon contact with partially ionized water on the skin, the stabilizer is neutralized, leading to the polymerization process. Remarkably, OCA boasts a breaking strength five times greater than that of monofilament nylon sutures. The introduction of High-Viscosity OCA (HVOCA)—a thicker formulation—helps to mitigate the risk of the adhesive migrating away from the wound, thus enhancing cosmetic results. The adhesive typically sloughs off as the skin re-epithelializes, usually over a span of 5 to 10 days. Nevertheless, the premature loss of the adhesive may occur with excessive cleansing or the use of topical ointments. Numerous studies have corroborated the efficacy of OCA across a variety of surgical settings, reinforcing its utility in skin closure procedures. Prior to applying any adhesive, it is vital to evaluate the wound to determine whether subcutaneous sutures are necessary to alleviate tension, minimize dead space, and achieve optimal skin eversion.

Table 1

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Uses

For years, tissue adhesives have been instrumental in both major and minor surgical procedures requiring skin closure. Their applications span a multitude of indications, including the fixation of implants, closure of cerebrospinal fluid leaks, and the embolization of blood vessels. Tissue adhesives have found increasing applications in facial wound management, surgical interventions on the hands, blepharoplasty, laparoscopic surgeries, and even in hair transplantation and lacrimal punctum closures.

Advantages

Tissue adhesives exhibit numerous advantages when compared to sutures and other closure techniques. They typically present lower infection rates, contribute to reduced operating room time, yield favorable cosmetic outcomes, and are cost-effective and user-friendly. Moreover, they facilitate immediate wound sealing, enabling a quicker return to everyday activities, while eliminating risks associated with needle-stick injuries and the need for postoperative removal. Additionally, tissue adhesives tend to be more suitable for pediatric use. Notably, OCA has demonstrated a commendable safety profile, with no recorded instances of adverse effects or carcinogenicity associated with its use. Recent investigations indicate that OCA not only inhibits bacterial growth but also serves as a preventative measure against Gram-positive bacterial infections in surgical wounds. Given these attributes, surgeons may consider utilizing tissue adhesives as a viable alternative to traditional suturing methods.

Disadvantages

Despite the benefits, OCA is not without its limitations, including its higher cost—often exceeding the price of traditional sutures by fourfold. Careful patient selection is imperative, as OCA is exclusively intended for external applications. Additionally, utilizing OCA necessitates meticulous technique; any marginal gaps between skin edges or the presence of bleeding can compromise its adhesion. Such small gaps can inadvertently allow the adhesive to seep through, hindering the normal epithelialization process and thereby obstructing proper wound healing.

Contraindications

There are several contraindications to the application of tissue adhesives. These include cases involving infection, gangrene, ulceration, incisions displaying oozing or bleeding, or where the incision's tension requires sutured approximation. Other contraindications are partial-thickness skin loss, existing burns, animal bites, application across mucosal surfaces or mucocutaneous junctions, regions with high humidity, and high-tension areas like joints. Tissue adhesives are also inadvisable for patients with a higher propensity for delayed healing, such as diabetics or those with collagen vascular diseases, as well as individuals who are allergic to OCA.

Comparison

A prospective, randomized trial conducted by Maartense et al. compared wound closure techniques utilizing OCA, adhesive paper tape, and poliglecaprone in elective laparoscopic surgery. The results indicated that OCA significantly decreases operating room time, albeit at a higher expense compared to adhesive tape, which proved to be the quickest and cheapest method. Although the cosmetic results were markedly better for OCA relative to adhesive tape, there were no significant differences in infection or dehiscence rates observed in a recent Cochrane review evaluating HVOCAs against sutures. Another study demonstrated comparable cosmetic results between adhesive tape closures and tissue glue in treating facial lacerations in children, indicating the diversity in suturing alternatives available today. Furthermore, studies have suggested that conventional suturing may yield superior cosmetic results in specific wound types involving tension and excision compared to OCA. Overall, as research continues, there’s an increasing recognition of the potential benefits offered by various suturing methods, leading to ongoing exploration into their respective outcomes—for instance, with respect to wound healing rates and complications.

Adhesive tapes

The utilization of suture-less skin closure was investigated by Gillman, with surgical adhesive tapes typically made from an adhesive backing incorporating iso-octo-acrylate and N-vinyl-pyrrolidone. An ideal surgical tape is characterized by being non-allergenic, non-irritating, water-resistant, and vapor-permeable while conforming well to the skin surface. These adhesive tapes are frequently employed as adjunctive support following the removal of staples or sutures, in combination with buried dermal sutures or absorbable running subcuticular sutures for low-tension wounds. Optimal application involves the strategic parallel alignment of the tape after the surface has been coated with additional adhesive aids to maximize adherence over time. Key considerations for effective tape application include dry skin, precise edge alignment, strict hemostasis, and the proper distribution of tension across the tape to prevent blistering.

Table 2

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Advantages

Suture-less closure with adhesive tape can eliminate local skin tension, lower operational costs, and minimize time spent in the operating room. Additionally, this technique facilitates quicker restoration of tensile strength that could match or surpass that of traditional sutured wounds within ten days. The uniform distribution of tension along the incision length serves to avert post-operative "railroad track" scarring typically linked with sutures. Microporous strips encourage gas and moisture exchange, creating an environment unfavorable for bacterial growth and contributing to reduced infection rates. Studies have reinforced that wound closures using adhesive tapes demonstrate strong resistance to infection, establishing an overall favorable safety profile.

Disadvantages

Historically, adhesive tapes experienced hesitancy in routine adoption due to variable and inconsistent adhesive properties. This can result in gradual loss of adhesion, leading to wound dehiscence. Operator-specific skill and knowledge heavily influence the consistency of adhesiveness. Challenges remain in ensuring accurate edge approximation with tape, alongside potential issues surrounding time savings in operating rooms. Concerns have also been raised regarding the potential for skin injuries during tape application or removal; consequently, enhancements in adhesive formulations have been explored to achieve greater consistency and secure application.

Sutures

Wound closure techniques utilizing sutures date back to ancient Egypt, with various suture materials evolving over centuries, including animal tendons and vegetable fibers. Philip Syng Physick's 19th-century development of absorbable sutures marked significant progress in this domain. Within surgical documentation, the pursuit of the "ideal" suture material continues, with modern requirements emphasizing inertness in tissue, lack of foreign body reaction, and favorable handling properties. Key factors in choosing sutures involve strength, infection risk, and tissue support needed for the closure. The choice of suture materials available to surgeons is extensive. Decisions in suture application are shaped by established biological properties, surgical techniques, and the healing characteristics of target tissues. Surgeon preferences and material availability also play significant roles.

Types of sutures

The classification of sutures today includes permanent versus absorbable, natural versus synthetic, and multi-filament versus monofilament designs. Multi-filament sutures are user-friendly and possess beneficial knot-tying properties, however, they may introduce a higher risk of infection when braiding traps bacteria. Conversely, monofilament sutures exhibit reduced tissue reactivity, making them ideal for certain applications, though they can be difficult to handle and may require greater force to process through tissues.

Table 3

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Absorbable suture materials

Absorbable sutures are defined by their degradation typically within 60 days after implementation. These materials are absorbed with minimal tissue reaction, maintaining appropriate rates for the required duration of tissue support. For practical applications, absorbable sutures are often concealed in the dermis and subcutaneous layers to mitigate wound tension. While absorbable sutures have historically been deemed unsuitable for skin closure due to scarring issues, a range of synthetic materials such as polyglycolic acid and polyglactin alternatives have emerged to address these concerns.

Table 4

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Table 5

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Non-absorbable suture materials

Non-absorbable sutures offer high resistance to degradation in living tissues, making them invaluable in skin closure procedures. Examples of natural fibers used include silk, surgical steel, and cotton, while synthetic non-absorbable monofilament options such as nylon and polypropylene are widely implemented in dermatological applications. Non-absorbable braided sutures tend to yield higher infection rates compared to their non-braided counterparts. Research has shown that contaminated wounds subjected to braided Vicryl® sutures exhibited a 100% infection rate, contrasting with significantly reduced incidence rates associated with non-braided sutures.

Table 6

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Surgeons have diverse preferences regarding suture choices, weighing the advantages of absorbable sutures against their need for removal post-procedure. Non-absorbable sutures necessitate periodic follow-up appointments for removal, raising costs and inconveniences for patients. Comparatively, absorbable sutures alleviate these concerns while providing handling ease and favorable reactive properties, often at lower costs. Ongoing studies affirm no substantial differences in wound appearance or infection rates, indicating that clean facial wounds maintain low susceptibility levels, irrespective of the utilized closure methodology.

Vicryl, a commonly used synthetic absorbable suture made from glycolide and lactide, is notably effective, with a newly formulated Vicryl Rapide ensuring rapid absorption rates. Further evaluations comparing these materials in various surgical contexts provide valuable insights, demonstrating that careful choices can enhance patient outcomes considerably.

The use of disposable mechanical skin staplers provides a fast and efficient method for closing lengthy wounds, significantly reducing closure times; however, one must account for additional time required for staple removal. The Insorb® dermal stapler represents an innovative advancement approved by the FDA that offers unique closure strategies.