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Natl J Maxillofac Surg
Natl J Maxillofac Surg
NJMS
Natl J Maxillofac Surg
National Journal of Maxillofacial Surgery
0975-5950
2229-3418
Wolters Kluwer - Medknow India

NJMS-15-307
10.4103/njms.njms_102_22
Original Article
The surgical outcome of sutureless skin closures using Octyl-2-cyanoacrylate (Dermabond™) versus Steri-Strip™
Sah Neha
Punga Rohit 1
Kumar Ajay 2
Shivhare Peeyush 3
Singh Akhilesh Kumar 4
Sah Sonam 5
Shekhar Amlendu 2
Department of Oral and Maxillofacial Surgery, Dental College Azamgarh, Azamgarh, Uttar Pradesh, India
1 Department of Maxillofacial Surgery, School of Dental Sciences (SDS), Sharda University, Greater Noida, Uttar Pradesh, India
2 Oral Medicine and Radiology, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Dentistry, AIIMS, Patna, Bihar, India
4 Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
5 Department of Conservative Dentistry and Endodontics, Kalka Dental College, Ghaziabad, Uttar Pradesh, India
Address for correspondence: Dr. Neha Sah, Department of Oral and Maxillofacial Surgery, Dental College Azamgarh, Azamgarh, Uttar Pradesh, India. E-mail: dr.nehasah@gmail.com
May-Aug 2024
24 7 2024
15 2 307312
15 6 2022
27 10 2022
14 12 2022
Copyright: © 2024 National Journal of Maxillofacial Surgery
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Introduction:

Cosmesis is the primary concern for the patient undergoing facial surgery and there are numbers of well proven materials that are available such as adhesive tapes, subcuticular suture, skin adhesive or glue to achieve better cosmesis. The objective of our study was to assess the surgical outcome of sutureless skin closures using Octyl-2-cyanoacrylate (Dermabond™) versus Steri-Strip™.

Method:

The present prospective study was conducted in 20 patients. Patients were divided into two groups. After subcutaneous closure of wounds, either Dermabond™ or Steri-Strip™ was placed. The patients were assessed for wound complication (erythema, tenderness, dehiscence or any discharge), scar hypertrophy and cosmetic appearance also time consumed in surgical skin closure was evaluated. Wound assessment, scar hypertrophy and cosmetic appearance were assessed by using Chi-square test. Time closure was assessed by using Mann-whitney U test.

Result:

Twenty patients belonging to all age group were included in study. Ten patients undergone closure with Dermabond™ and ten with Steri-Strips™. Assessment of wound complications, cosmetic appearance and scar hypertrophy was done. There was no significant difference found between both the groups, but 2 patients had fair cosmetic outcomes at one month and 1 patient had fair scar hypertrophy at 6 month. However, excellent cosmetic outcome in terms of scar hypertrophy at 6 month was significantly more among group II.

Conclusion:

Octyl-2-cyanoacrylate (Dermabond™) and Steri-Strip™ provide similar outcomes in terms of wound complications. Cosmetic outcomes in terms of scar hypertrophy with steri-strip wound closure seem to be better and more economical.

Dermabond
steri-strip
tissue adhesive
wound closure
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pmcINTRODUCTION

The surgical wound would be an ideal when it is strong as normal tissue as, which of course is unattainable. To avoid infection, patient dissatisfaction or unacceptable cosmesis, the skin closure should provide proper support and strength so that correct healing and cosmetically attractive repair may occur.[1]

From centuries, ideal way for closure of a wound has been sought. Numerous wound closure technique like adhesive tapes, subcuticular suture, skin adhesive or glue (Octyl-2-cyanoacrylate or N-butyl 2-cyanoacrylate) taking into account the cosmesis and scar, are developed over the past few years. For instance, many studies states less pain and good cosmetic result with Steri-strip and glue over suturing. Also, in vitro studies tissue adhesive shows sealing out bacteria, which decreases the risk of wound infection.[1,2]

Cyanoacrylate as a tissue bonding have a long history of use outside the United States. Tissue adhesive cyanoacrylate was first invented in 1949 by a scientist Dr Harry Coover who was working for Kodak Laboratories at that time. In 1951, cyanoacrylate were rediscovered by Coover and Fred Joyner and it was first marketed as commercial product in 1958. During Vietnam War (1955-1975), adhesive glue was used by many soldiers.[3] Since 1970’s in Canada, Japan and Europe it has been used for CSF leak closure, incision or laceration repair or middle ear procedures. For a long time, it had not been approved by United States FDA for use but has been used in other countries including Canada and Europe for 40 years. 2-Octylcyanoacrylate was approved by Food and Drug Administration for use, in August 1998, in the United states. Short-chain cyanoacrylate compound like ethyl and methyl are more toxic to tissues and degrade faster than long-chain compound (2-Octylcyanoacrylate). Currently, 2-Octylcyanoacrylate in low and high-viscosity formulas (Dermabond™, Ethicon Inc, Somerville, NJ) is available and used commercially worldwide.[2] It is less toxic, have four times more strength than N-butyl.[3,4,5]

2-Octylcyanoacrylate is a long chain monomeric formulation which get polymerizes and hardened when exposed to moisture or water-containing substances/tissue. It forms film that bonds to underlying surfaces. Tissue adhesive should only apply on dermal layer as it is not absorbed by deep subcutaneous tissue and can cause foreign body reaction.[1,2]

Steri-strips (3M™ Steri-Strip™) are sterile, porous, non-woven backing coated with a pressure-sensitive, non-allergic, easy to apply and prevent maceration. Adhesive strips also cause less infection and scarring than staples or suture. These strips are reinforced with polyester filaments providing good tensile strength.[6,7] Also, Forrester JC et al.[8] did a comparison between adhesive strips and suture by tensiometry and scanning electron microscopy to test the efficacy of tape and states that wounds closed with adhesive strips showed equal or superior tensile strength compared with sutured wounds 10 days after wound closure.

This prospective study was undertaken in 20 pateints reported to our department to assess the surgical outcome of sutureless skin closures using Octyl-2-cyanoacrylate (Dermabond™) versus Steri-Strip™.

METHODS

The present prospective study was conducted in 20 patients in outpatient department of oral and maxillofacial surgery. The study was approved by the institutional ethical review board (IERB) with reference number PDMDC/RI/2015/935, dated 1/12/2015 and followed all the recommendation of Helsinki declaration. The study was conducted over a period of 1 year 4 month from Feb 2016–June 2017. The study was enrolled before 2018, thus CTRI registration was not possible. Informed and written consent was taken from the subjects.

Inclusion criteria were lacerations, scar revision, extra-oral approaches for open reduction and internal fixation (ORIF) and other patient undergoing maxillofacial surgery requiring skin incision whereas, medically compromised patients, presence of infection, patients allergic to cyanoacrylate, wound length >10 cm and skin margins under tension were exclusion criteria.

Based on the inclusion and exclusion criteria 20 patients were included in the study. The patients were divided into two groups having 10 patients in each group. Following subcutaneous closure of wounds, tissue adhesive glue (Dermabond™) was placed for skin closure in study Group I and Steri-Strip™ in Group II.

The patients were assessed for wound complication (erythema, tenderness, dehiscence or any discharge), scar hypertrophy and cosmetic appearance. Also, time consumed in surgical skin closure was evaluated. Entire methodology is summarized in Figure 1.

Figure 1 Flow chart diagram for Study Design

Materials used in study was Octyl-2-cyanoacrylate (Dermabond™, Ethicon Inc, Somerville, NJ) and Steri-Strip™ (3M™, USA) [Figures 2 and 3]. Application of both was done as per manufacturer recommendations.

Figure 2 DERMABOND™ (Ethicon Inc, Somerville, NJ)

Figure 3 3M™ STERI-STRIP™

Method of application of Dermabond™

Dermabond supplies as a single use packet. The wound edges were held together by gentle finger pressure and any exudate emerging on the surface was mopped to make sure that the surface remains absolutely dry. A thin layer was applied initially and allowed to polymerize for 30 seconds, then 1 or 2 additional layers of the glue was applied on the wound while maintaining the finger pressure. Care was taken so that the glue will not flow between the wound edges. The applied film was extended at least 3–4 mm on either side of the wound. Digital pressure was maintained till the Dermabond glue polymerizes.

Method of application of Steri-Strip™

After apposing skin edges using fingers or forceps, 1/4 inch wide strips was placed across the wound, ensuring tensionless application. Steri-strips was placed approximately 1⁄8 inch (3 mm) apart. Additional closures were applied parallel to the wound and approximately ½ inch (12 mm) from closure ends where necessary; this was proposed to reduce shear force beneath the strip ends.

Post-operative patient was evaluated in both the groups for wound complications on 3rd and 10th post-operative day; cosmetic appearance after one month; and scar hypertrophy after one, third and sixth month.

Scar hypertrophy was noted as:

Excellent: flat, linear scar.

Good: flat scar <2 mm.

Fair: minimally raised scar <5 mm.

Poor: >5 mm.

RESULTS

Twenty patients were enrolled between Feb 2016 and June 2017 age ranging between 14 and 36 years. Ten patients in group I and ten patients in group II were operated using extra-oral approaches to facial skeleton or scar revision. Out of 20 patients, 8 patients were male and 2 patients were female in group I.9 male and 1 female patients were in group II. The wounds were closed with tissue adhesive (Dermabond™) in group I and with Steri-Strip™in group II.

Basic study design is displayed in Figure 1. The software used for the statistical analysis was SPSS (Statistical package for social sciences) version 21.0 and Epi-info version 3.0. The statistical test used was Chi-square test and Mann-whitney U test. The P value was taken significant when less than 0.05 (P < 0.05).

The age difference was not significant between both the groups. The mean age in group I was 26.50 ± 6.10 and in group II was 29.30 ± 4.90. The comparison of mean time for procedure (in minutes) was done between Group I (Glue) and Group II (Steri-Strip™) using the Mann-whitney U test. In the present study, time consumed for closure was found to be significantly less in group II (Steri-Strip™) as compared to group I (Dermabond™) (P = 0.032). Wound assessment was measured post-operatively on 3rd day and 10th day in terms of erythema, tenderness, discharge or gapping between Group I (Glue) and Group II (Steri-Strip™) using the Chi-square test. On 3rd day, erythema was present in 7 patients in Group I and 8 in group II whereas tenderness was present in 4 patients in group I and 5 patients in group II. On 10th day tenderness was present in 2 patients in group I and 3 patients in group II. None of the wound sites shows any gapping or discharge from the wound. There was no significant difference found between group I and II in terms of wound complications.

After one month, cosmetic appearance was excellent in 4 patients of glue group, 5 patients in steri-strip group and fair in 2 patients of glue group, 1 patient of steri-strip™ group. At 6th month, excellent cosmetic outcomes in terms of scar hypertrophy were significant in group II (Steri-Strip™) (P = 0.037). 5 patients in group I (glue) and 8 patients in group II (steri-strip) showed excellent cosmetic outcome at six month. 2 patients showed fair cosmetic outcome at one month and 1 patient at six month in group I (glue).

DISCUSSION

Surgical wounds and incisions especially when present on visible area of the skin are always a source of worry for patients. The introduction of adhesive strips and skin adhesives is a better alternative to staples, sutures or clips for superficial skin closure to both patients and surgeon. Even Yamaguchi et al.[9] did a study to compare strength of octyl cyanoacrylate with those of sutures for skin wounds where they found it to be equal with that of sutures. Steri-strips and glue are advantageous as they are easy and quick to apply, painless, require minimal training and provide better cosmesis with minimal rate of infection, wound dehiscence or both.

The purpose of this study was to assess the surgical outcome of sutureless skin closures using Octyl-2- cyanoacrylate (Dermabond™) versus Steri-Strip™. 20 patients belonging to all age groups were included in the study. 10 patients undergone closure of incision by Dermabond™ while other10 patients by Steri-Strip™. The method of application of glue in our study was needle-syringe method [Figure 4]. The advantage of using this method is that it is very easy, simple, fast and less painful and does not flow uncontrollably into the depth of wound or does not impair healing by causing an inflammatory reaction. It meets many of the criteria necessary for an ideal wound closure device. However, its use is very expensive.[10,11,12] On the other hand reinforced Steri- Strip is inexpensive, easy, and simple to apply. For years, these adhesive strips have been used with sutures or staples to support the wound. Also, its use reported less erythema as localized area of tension is eliminated. In a study, Hirshman HP et al.[13] observed decrease infection risk when compared it with suture. Additionally, burden of removing sutures is removed. Also Glue and strips have added safety advantage over suturing is elimination of risk of needle stick injury.[6]

Figure 4 Dermabond application with needle-syringe method

Result of our study shows significant decrease in time required for closure of the wound in group II (Steri-strip). In our study, erythema and tenderness are expected in initial days after injury produced by incision and tissue manipulation and no significant difference found. In both the groups, there was no clinical sign of any pus or gapping in the wound. Also, Shamiyey A et al.[14] compare sutures, tissue adhesives and adhesive tape for skin closure after phlebectomy, none of the 26 of the wounds closed with adhesive tape had evidence of dehiscence or infection 10 days after closure. In another study, Kharasch et al.[15] evaluated 35 lacerations closed with Dermabond. At 1 week follow-up, 2 patients with wound dehiscence and 1 with wound infection were found.

Cosmetic appearance was fair in 2 patients of glue group and 1 patient of steri-strip™ group after 1 month. While Maartense et al.[16] showed significantly better cosmetic appearance as assessed by the surgeon blinded to the study group, for incisions closed with tissue adhesive when compared to adhesive tape. Mattick A et al.[17] in his study compare the tissue adhesive (Dermabond) with adhesive Steri-strips in paediatric laceration repair and suggest that the techniques are similar in efficacy and cosmetic outcome. Also Zempsky WT et al.,[7] in their study find Steri-Strip Skin Closures and Dermabond provide similar cosmetic outcomes.

Scar hypertrophy was significantly better among steri-strip group (P = 0.037) at 6th month. 5 patients in glue group and 8 patients in steri-strip group showed excellent cosmetic appearance 6th month. However, one patient shows fair cosmetic outcome in group I (Dermabond™). Wilson AD et al.[18] found 15 hypertrophic scars in the Steri-Strip group and 33 hypertrophic scars in the Dermabond group out of 307 cases in unilateral cleft lip repair. Krishnamoorthy B et al.[19] observed better results for the scar appearance and patient’s satisfaction for scar at 6 weeks with glue. Romero P et al.[20] evaluated a significant difference between the 2 groups with regard to the cosmetic score on day 90 of follow-up, favouring Steri-Strip™ wound closure.

Cosmesis is the long-term outcome of wound repair that matters most to patients. The present study indicates similar cosmetic appearance at 10th day and 1st month in both groups but excellent cosmetic appearance at 6th month was found in group II (Steri-strip) [Figure 5a and b]. None of the patients showed wound dehiscence or discharge from the wound. However, 2 patients who underwent for scar revision showed fair cosmetic outcome in group I (Dermabond™). There is possibility that this relatively less acceptable cosmetic appearance could be attributable to be pre-existing condition of soft tissues surrounding unsightly scar [Figure 6a and b].

Figure 5 (a): Post-operatively clinical photograph at 6th month with Dermabond™. (b): Post-operatively clinical photograph at 6th month with Steri-Strip™

Figure 6 (a) Pre-operatively clinical photograph of scar revision. (b) Post-operatively clinical photograph of scar revision with Dermabond™

CONCLUSION

During the course of study we found that both tissue adhesives and adhesive strips represent excellent alternatives for the sutureless closure of the wound. Henceforth, we conclude that cosmetic outcome with Steri-Strip™ wound closure seems to be better and more economical. However, a larger sample size may help to correlate the findings of present study for their wider acceptance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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