Simple superficial wounds that do not require deep-layer closure and do not have significant tension on the edges of the wound
Sites overlying or near joints or very near the eyes, moist or mucosal surfaces, or wounds under significant static or dynamic skin tension
Wounds involving deep structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) should be referred to a surgical specialist, as should those covering large areas or involving the face or hands.
Exudates, pain, tenderness, swelling, and foreign body reactions if tissue adhesive enters the wound
Dislodgement of glue and wound contamination if the glue closure is touched by a latex glove, gauze, or plastic instrument
Wound hygiene and closure techniques need not be sterile procedures. Although instruments that touch the wound (eg, forceps, needles, suture) must be sterile, clean nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients. Some operators prefer the better fit and better barrier protection of sterile gloves.
Clean procedure, barrier protection
Face mask and safety glasses (or a face shield), head caps, gowns, gloves
Sterile drapes, towels (for wound debridement and suturing)
Mild antiseptic cleaner such as chlorhexidine
Adhesive, ideally with tip applicator
Porous surgical tape
Wounds can be closed as rapidly as in one-sixth the time required for repair with sutures. Application is not only rapid, but painless, and it avoids suture marks adjacent to the wound.
Wounds closed with tissue adhesive have less tensile strength in the first 4 days than do sutured wounds, but after 1 week, the tensile strength and overall degree of inflammation in wounds closed with tissue adhesive and with sutures are equivalent.
Wounds covered with tissue adhesive or with bandages have equivalent rates of healing and complications, but there is a slightly higher risk for wound dehiscence in closures with tissue glue as compared with sutures.
Wounds near the eyes can sometimes be glued if the eyes are protected, such as with gauze or a layer of petroleum jelly.
Cosmetic results are similar to those obtained with suture repair.
Skin tension lines in the face are shown in the illustration Representative minimal skin tension lines Representative minimal skin tension lines Deep dermal sutures (which begin and end at the bottom of the wound so that the knot is deeply buried) can be used to appose the dermis and hypodermis of wounds under tension in cosmetically... read more .
Representative minimal skin tension lines
Direction of force is along each line. Cuts perpendicular to these lines are thus under greatest tension and most likely to widen.
Position the patient comfortably reclined or supine.
Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.
The laceration should be well lit, preferably with an overhead procedure light.
Step-by-Step Description of Procedure
(See How To Cleanse, Irrigate, Debride, and Dress Wounds How To Cleanse, Irrigate, Debride, and Dress Wounds Wound hygiene (eg, cleansing, irrigation, and debridement), including thorough examination of the wound and surrounding tissues, promotes uncomplicated healing of traumatic skin wounds and is... read more for step-by-step descriptions of wound preparation, anesthesia, and dressing and How to Repair a Laceration With Simple Interrupted Sutures How To Repair a Laceration With Simple Interrupted Sutures Uncomplicated epidermal closure is most often done using simple interrupted sutures. Each suture consists of a single, roughly circular (ie, simple) loop of suture material, individually tied... read more for instructions on how to handle the instruments, work with needles, and tie a surgeon's knot using instruments.)
Cleanse and dry the wound.
If a glue applicator tip is present (typically cotton-tipped), prepare it by squeezing the container to expel the adhesive through the applicator.
Hold the wound edges together with forceps, gauze pads, or fingers; an assistant may be helpful.
Squeeze the plastic container to apply droplets of tissue adhesive along the length of the wound’s surface, and extend it about 1 to 2 cm from each side of the wound.
Support and hold the edges of the wound together for at least 1 minute while the adhesive dries.
Apply 3 to 4 layers of adhesive, allowing each one to dry before applying another layer.
Once the adhesive has dried completely, protect the closure with a nonocclusive bandage. Do not apply ointment or an occlusive bandage.
Tissue adhesive serves as its own wound dressing and has an antimicrobial effect against gram-positive organisms. The material sloughs off on its own in 5 to 10 days; there is no need for follow-up.
Warnings and Common Errors
It is especially important to control bleeding from the wound. With poor hemostasis, the patient may experience overheating of polymerization resulting in a burning sensation or an actual burn.
Overheating of polymerization may also occur when excessive amounts of adhesive are applied too quickly.
If washed or soaked, the adhesive may peel off before the wound is healed.
Some substances, such as a latex-gloved finger, gauze, or plastic instruments, may adhere to the patient’s skin during adhesive application. There is no adhesion with vinyl gloves or tissue instruments.
Rapid or uncontrolled application may cause the adhesive to run, occasionally inadvertently gluing adjacent structures or material. Applying antibiotic ointment or petroleum jelly will dissolve the misplaced adhesive.
Tips and Tricks
Some wounds require 2 hands to achieve the best approximation of edges, so an assistant is sometimes helpful.
Wound closures can be reinforced by pulling the edges of the wound into apposition with a few strips of porous surgical tape before application of the adhesive.
Tissue adhesive can be removed with acetone. It can also be removed with antibiotic ointment or petroleum jelly.
Use high-viscosity tissue adhesives to help prevent low-viscosity adhesives from seeping into or trickling off the wound during application.