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Injury, Int. J. Care Injured 34 (2003) 564–567

Which tissue adhesive for wounds?

N.V. Doraiswamy∗, H. Baig, S. Hammett, M. Hutton Department of Paediatric Accident and Emergency, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, Scotland, UK

Accepted 11 July 2002

Abstract

We studied the three available tissue adhesives comparing their ease of technique, wound healing, satisfaction, merits and complications

when treating childhood lacerations. Children presenting with uncomplicated wounds <2.5 cm and <6 h since the injury were studied.

There were 17 children in each group. Resultswere compared for the individual tissue adhesive andthe technique—contact andnon-contact.

The application was considered pain free in 82% of the non-contact technique and 56% for the contact technique-pain in 18 and 44%,respectively (P = 0.062). Parents were satisfied in 88 and 94% for the contact and non-contact techniques, respectively (P = 0.505)

and the authors in 76 and 94% (P = 0.119). The glove stuck to the wound in nine instances and was damaged once while breaking the

container. The scab persisted in all scalp applications for 9–25 days. The adhesive effect was similar in all three. Indermil was considered

to be the best among the three. Non-contact, droplet instillation (rather than contact application as was suggested for Dermabond and

Histoacryl) was felt more comfortable.

© 2002 Elsevier Science Ltd. All rights reserved.

1. Introduction

Optimal wound healing requires well-approximated

wound edges. To approximate wound edges by suturing,local anaesthetic has to be injected. Children may be dis-

tressed by such a procedure, which is also time consuming.

Tissue adhesives (TAs) are alternatives to suturing and ster-

istrips for wound approximation. Three types of TAs are

available in the United Kingdom. This study is aimed at

comparing the three: N -butyl-1,2-cyanoacrylate (Histoacryl

blue), 2-octyl-cyanoacrylate (Dermabond) and Enbucrylate

(Indermil) regarding technique, wound healing, satisfaction,

merits and complications.

2. Patients and methods

Fifty-one children aged between 1 and 14 years presenting

with isolated and uncomplicated cuts of the scalp or face,

less than 6 h duration and less than 2.5 cm in length were

included in the study, with the consent of carers and children.

Seventeen children were treated with each TA. Hair was not

Presented in the XLVI Annual International Congress of British

Association of Paediatric Surgeons, Liverpool, UK, 20–23 July 1999.∗ Corresponding author. Tel.: +44-141-2010000;

fax: +44-141-2010839.

E-mail address: [email protected]

(N.V. Doraiswamy).

trimmed or shaved. After cleaning the wound with saline,

the TA was applied to a dry field, using gloved index and

thumb of the non-dominant hand to approximate the edges

of the wound.

2.1. Technique

TAs were applied according to the manufacturers’ instruc-

tions. (a) Dermabond: the outer container has to be squeezed

to break the inner container which releases the adhesive and

the adhesive is applied over the approximated wound edges

by smearing, in contact with the wound. (b) Histoacryl: the

adhesive is squeezed and smeared over the approximated

wound edges, by the spatulous tip. (c) Indermil: the adhe-

sive is squeezed and applied over the approximated wound

edges by droplet instillation, without contact.

The carers’ responses were recorded by direct questioningimmediately after the procedure. The authors recorded their

opinions individually.

Each author has used all the three TAs. Either one of the

two senior authors followed them up at intervals, up to 4

weeks.

2.2. Statistical analysis

Chi-square tests were used to compare the performance

of contact and non-contact techniques in terms of ease of

application, pain experienced by children and satisfaction

0020-1383/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved.

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Table 1

Comparison of three tissue adhesives

Details Contact Non-contact Total

Dermabond Histoacryl Both Indermil

Case 17 17 34 17 51

Difficult to apply 10 6 16 (47%) 2 (12%) 18 (35%)Easy to apply 7 11 18 (53%) 15 (88%) 33 (65%)

Carers’ dissatisfaction 1 3 4 (12%) 1 (6%) 5 (10%)

Satisfaction 16 14 30 (88%) 16 (94%) 46 (90%)

Staff dissatisfaction 4 4 8 (24%) 1 (6%) 5 (10%)

Satisfaction 13 13 26 (76%) 16 (94%) 42 (82%)

Pain 7 8 15 (44%) 3 (18%) 18 (35%)

No pain 10 9 19 (56%) 14 (82%) 33 (65%)

Table 2

Comparison of complications/problems of the three tissue adhesives

Complication Dermabond Histoacryl Indermil Total

Cases in each group 17 17 17 51

Glove stuck to wound 5 (29%) 4 (24%) – 9 (18%)

Damage to glove 1 (6%) – – 1 (2%)

Scalp application 12 12 12 36 (71%)

Scab 12 (100%) 12 (100%) 12 (100%) 36 (71%)

of staff and carers with the outcome. Where the expected

values are small (<5) in a cell, Fisher’s exact test was used.

3. Results

3.1. Technique

The proportion of difficulties encountered by staff in ap-

plying TA by the contact method was greater than those

using the non-contact method. Forty-seven percent of cases

treated with the contact method had difficulties whereas

in the non-contact group only 12% experienced difficulties

(Chi-square P = 0.013).

3.2. Satisfaction

For children treated by the contact method, four car-ers were dissatisfied whereas in the non-contact group one

carer was dissatisfied with the outcome (Fisher’s exact P =

0.653). Levels of dissatisfaction among staff were eight for

the contact technique and one for the non-contact technique

(Fishers’ exact P = 0.241) (Table 1).

3.3. Pain

Pain was experienced by 44% of children treated with the

contact TAs and only 18% of those receiving the non-contact

technique (Chi-square P = 0.062) (Table 1).

3.4. Complications/problems

(a) A glove was stuck to the wound, in nine cases, due to

patient movement and spread of TA around the wound, as

contact application resulted in pain/discomfort. (b) A glovewas torn while squeezing the outer container on one occa-

sion, but without any injury to the finger. (c) A scab was

noted in all scalp applications, persisting for a period of

9–25 days (Table 2).

4. Discussion

Cyanoacrylates were first discovered in 1949 and were

used as TA by Coover et al. [1] TA has been used in facial

plastic surgery [2], scalp wounds [3], otorhinolaryngology

[4] and lacerations in children [5] and has been noted to be

an alternative to suturing for paediatric lacerations [6]. His-

toacryl blue ( N -butyl-1,2-cyanoacrylate) has been available

for several years [5], but Indermil and Dermabond were in-

troduced to the UK market in 1996 and 1998, respectively.

Therefore, this study was done comparing the three TAs

available in the UK.

All parents preferred TA to suturing under local anaesthe-

sia or steristrips. TAs were used in scalp and facial injuries

in all children. There was no appreciable difference in the

‘gluing’ effect among the three TAs. The application of TA

was not easy in 15 (29%) (Table 1), as there was movement

of patient’s head during application and all were less than 5

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566 N.V. Doraiswamy et al. / Injury, Int. J. Care Injured 34 (2003) 564–567

Fig. 1. Part of a glove, which was stuck to the tissue adhesive at the site of application.

Fig. 2. Dry scab at 14 days after the application of tissue adhesive.

years of age. Contact applications, as instructed by the man-

ufacturers, caused pain/discomfort to children and resulted

in movement of the wound area—for both Dermabond and

Histoacryl (Table 1). The expression of pain was the reason

for unsatisfactory response for both carers and staff. Pain

was not measured but was judged by facial/verbal expres-

sion and/or crying. A glove was stuck to the area because of

(a) movement of the wound area due to pain/discomfort, and

felt by the authors to be due to contact application, (b) ex-

cessive tissue adhesive and (c) gloved fingers too close to the

edges of the wound. The glove was trimmed and left at that

site (Fig. 1), as any attempt to remove the glove or ungloved

finger forcibly might re-open the wound; this occurred in

the initial stage of the study. In all the scalp wounds, dry

scab was noted (Fig. 2) and persisted for 9 to 25 days, in

spite of washing hair repeatedly.

5. Conclusion

The use of TA was, in general, satisfactory to all

concerned—children, carers and staff. The glue effect was

similar in all the three TAs. Non contact instillation of TA

was superior to contact application. It was advantageous

to use gloved fingers to approximate the wound edges. In

the unfortunate event that the glove was stuck to the TA,

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it can be cut and left at the wound site, without disrupting

the wound while attempting to release the stuck glove. Use

of glove also helped to prevent adhesion of user’s finger

directly to the edges of the wound as the ‘glued’ finger on

removal might disrupt the approximated wound edge.

TA is useful for scalp and facial injuries in children. Al-

though not statistically significant, there is a large differencein the proportions of children experiencing pain using con-

tact TAs (44%) compared to non-contact TA (18%).

The authors felt that Indermil was the choice among the

three TAs. Parents should be warned of the persistence of

scab for scalp wounds for a maximum of 3.5 weeks, in spite

of washing hair.

Acknowledgements

We thank Ethicon, Braun and Kendall & Company for

providing the tissue adhesives for this study. Our sincere

thanks are due to Mrs. Claire Donati for the secretarial

assistance, Mrs. Cathy Clark for the illustrations and Mr.

David Young for statistical analysis.

References

[1] Coover HN, Joyner FB, Sheere NH, Wicker TR. Chemistry and

performance of cyanoacrylate adhesives. J Soc Plast Surg Eng1959;15:5–6.

[2] Kamer FM, Joseph JH. Histoacryl—its use in aesthetic facial plastic

surgery. Arch Otolaryngol Head Neck Surg 1989;115:193–7.

[3] Morton RJ, Gibson MF, Sloan JP. The use of Histoacryl tissue

adhesive for the primary closure of scalp wounds. Arch Emerg Med

1988;5:110–2.

[4] Ronis ML, Harwick JD, Fung R, Dellavecchia M. Review of

cyanoacrylate tissue glues with emphasis on their otorhinolaryn-

gological applications. Laryngoscope 1984;2:210–3.

[5] Bruns TB, Simon HK, McLario DJ, Sullivan KM, Wood RJ, Anand

KJS. Laceration repair using a tissue adhesive in a Children’s

Emergency Department. Pediatrics 1996;98:673–5.

[6] Quinn JV, Drzewiecki A, Li MM, et al. A randomised controlled trial

comparing a tissue adhesive with suturing in the repair of pediatric

lacerations. Ann Emerg Med 1993;22:1130–5.

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