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Tissue adhesive (cyanoacrylate adhesive or surgical glue) has been available since the 1950s and has become increasingly popular as a wound-closure method in emergency settings. It achieves good cosmetic results (Farion et al, 2003) and results in low wound complication rates (Applebaum et al, 1993). The glue is supplied in small, single-use ampoules, which should not be resealed or reused, and has been shown on many occasions to be an acceptable alternative to sutures for simple, traumatic lacerations.
The glue is easy to apply from the sterile single-use vial in which it is supplied. The opened vial is squeezed gently to either spread a thin line of adhesive along the length of the clean, dry wound or to 'spot-weld' the wound by applying a series of dots along its length. The wound needs to be held together for 30 seconds to allow polymerisation to occur.
Gluing wounds is easy to perfect and the procedure is relatively painless (though polymerisation releases heat, which some patients find uncomfortable).
It is quicker than suturing or using adhesive strips and, as no local anaesthetic is needed, there is no danger of needlestick injury. The glue provides a waterproof seal and helps to prevent contamination with dirt and bacteria.
There has been much debate about the cost-effectiveness of this wound-closure method. Balanced against the relatively high cost of the glue itself is the fact that no instrument or local anaesthetic are required.
There are cost savings in terms of nursing time and, also, there is no need for the patient to return for removal of the glue since it will rub off when healing is complete. However, there is a slight increase in the rate of wound dehiscence with tissue adhesive compared with standard wound-closure methods (Farion et al, 2003).
Glue is not generally suitable over joints and areas of high tension as the adhesive can break and it is not useful where frequent washing is necessary as it peels off. It is not usually considered as a management option for extensive or complex wounds.
In the emergency setting, it is uncommon to repair deep tissue layers using adhesive and this restricts the use of this closure method to superficial wound layers.
It is possible to remove and reapply the glue if a mistake is made, but it is preferable not to do so and the assistance of another person to approximate the skin edges may be necessary.
Skin staples have been available for many years and are supplied in disposable, single-use sterile packs. To insert staples, the stapler is placed over the carefully apposed edges of a cleaned wound - if possible with the edges slightly everted. The handle is squeezed to release the staple into the wound.
Excessive pressure on the skin should be avoided as it may cause a poor cosmetic result and may make staple removal difficult. Staples are placed at intervals along the length of the wound. Once healing is achieved, the staples are removed with a special remover tool. Patient comfort and cosmetic results are similar to those achieved in sutured wounds.
Stapling is a quick method of wound closure and offers a low level of tissue reactivity and better resistance to infection than use of sutures (Edlich and Reddy, 2001).
Stapling can be performed without local anaesthetic and this reduces the risk of needlestick injury. Ritchie and Rocke (1989) believe this makes it safer for the user and so they advocate its use on these grounds.
However, some patients may not tolerate stapling without the use of local anaesthetic.
Several studies report the usefulness of stapling as a wound-closure method for simple scalp wounds in children (Khan et al, 2002; Kanegaye et al, 1997).
Staples are more expensive than sutures, particularly when local anaesthetic is used and when removal costs are considered.
MacGregor et al (1989) suggest that this is outweighed by the simplicity of the method and safety factors. However, McClelland and Nellis (1997) noted that the cost was enough to restrict the use of staples within their A&E department to wounds where there was a risk of needlestick injury (such as with confused, agitated or violent patients).
Skill is required to insert staples and failing to align tissue edges correctly can cause scar deformity. Staples will only close superficial skin layers; sutures may be necessary to approximate deeper tissues within a wound.