[ORIGINAL
RESEARCH]
Fast Absorbing Gut Suture versus Cyanoacrylate Tissue Adhesive in the Epidermal Closure of Linear Repairs Following Mohs Micrographic Surgery JUNE KIM, MD; bHARJOT SINGH MAAN, MD; cALICIA J. COOL, MD; d ALLISON M. HANLON, MD PhD; dDAVID J. LEFFELL, MD
a
a
Cascade Eye and Skin Center, University Place, Washington; bDepartment of Dermatology, University of Rochester Medical Center, Rochester, New York; c Advanced Dermatology, PC, Brooklyn, New York; dDepartment of Dermatology, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT Background: Cyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery. Objective: To compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery. Methods: Fourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome. Results: The present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures. Conclusion: Cyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167). (J Clin Aesthet Dermatol. 2015;8(2):24–29.)
issue adhesives have been used in surgical procedures for more than 50 years since cyanoacrylate was first discovered in 1949.1 These adhesives work by self-polymerizing in a spontaneous exothermic reaction. The first widely used variety, Nbutyl-2-cyanoacrylate, has been used with good cosmetic outcomes for a number of surgical procedures (blepharoplasty, lacerations, incisions).2–5 However, this adhesive did not gain widespread use because of its low
T
tensile strength and brittleness.6 In 1998, the United States Food and Drug Administration (FDA) approved 2octyl cyanoacrylate for superficial skin lacerations. This cyanoacrylate polymer was designed to be stronger and more flexible and has been used successfully in many studies.7,8 Fast absorbing gut is a plain gut suture that has been heat treated to enable rapid absorption. It is primarily used for epidermal suturing, where sutures are only
DISCLOSURE: The authors report no relevant conflicts of interest. Source of funding: Yale University, New Haven, Connecticut ADDRESS CORRESPONDENCE TO: Harjot Singh Maan, MD, Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave. BOX 697, Rochester, NY 14642; E-mail: [email protected]
24
[February 2015 • Volume 8 • Number 2]
24
required for five to seven days.9 Both cyanoacrylate and fast absorbing gut suture eliminate the need for an office visit for suture removal, which can represent a significant cost savings in patient and staff time as well as related healthcare resources. Both cyanoacrylate and fast absorbing gut suture are currently routinely used for epidermal closure following Mohs micrographic surgery (MMS). Physician preference currently dictates which epidermal closure method is chosen for a given surgery and depends on weighing advantages and disadvantages of each technique. Recently, one study reported that for defects on the trunk and extremities, tissue adhesive may not be as effective in achieving optimal cosmesis as fast absorbing gut.10 The purpose of this study was to compare the cosmetic outcome and patient satisfaction of cyanoacrylate tissue adhesive versus fast absorbing gut suture for the closure of surgical defects on the face following MMS.
METHODS Approval for this study was obtained from the Yale University School of Medicine Human Investigation Committee. A total of 14 patients undergoing routine MMS for nonmelanoma skin cancer of the face were asked to voluntarily participate in the trial on the day of scheduled surgery and were enrolled after written informed consent was obtained. To be enrolled, the patients had to be 18 years of age or older with a wound length of 3cm or greater, willing to comply with the protocol of standard postoperative care, and be able to attend a postoperative visit three months after surgery. Patients on systemic immunosuppressants and/or organ transplant recipients with a reported or suspected hypersensitivity to cyanoacrylate or fast absorbing gut suture or with a dermatologic disease in the target site that may interfere with examination were excluded from the study. Two of the authors (JK and DJL) served as primary surgeons during the study, and a primary surgeon performed the closure in each case. All wounds were closed using a linear, bilayered closure method, where the buried intradermal absorbing suture, 5-0 polyglactin 910 (Polysorb, Covidien) was placed along the length of the incision, consistent with standard surgical procedure. Each wound was measured and the length divided in half. Half of the surgical wound was randomly selected (by coin toss) for epidermal reapproximation with n-butyl and 2-octyl cyanoacrylate (GluSeal® Tissue Adhesive, Skinstitch Corporation), whereas the other half was repaired with fast absorbing gut suture (5-0 or 6-0, Fast Absorbing Plain Gut, Ethicon) in standard running fashion. Immediate postoperative photographs were taken. The entire length of the repair was reinforced with Steri-Strips (3M) that were removed after seven days. The patients then returned for followup at three months. High-resolution photographs were obtained of the wound at these follow-up visits. These
TABLE 1. Patient demographics PATIENT NUMBER
AGE (YEARS)
GENDER
SITE
LENGTH (cm)
1
76
M
Forehead
4
2
82
M
Cheek
3.5
3
84
F
Cheek
4.3
4
59
M
Temple
3
5
67
F
Cheek
4.1
6
89
F
Cheek
4.4
7
77
M
Temple
3.4
8
55
M
Temple
5
9
57
M
Cheek
5
10
64
F
Temple
3
11
54
M
Cheek
4
12
39
M
Cheek
3.5
13
60
M
Forehead
6.8
14
82
M
Temple
4.5
photographs were taken in the same clinic and under the same overhead lighting. Patient preference of closure method was also obtained at these visits. The high resolution photographs from the threemonth visit were presented to six blinded individuals (1 general dermatologist, 1 Mohs surgeon, 2 nurses, and 2 lay persons). A previously validated 10-point visual analog scale (VAS) ranging from 1 (poor) to 10 (excellent) was used to evaluate each half of the scar for overall cosmesis.11 Raters were instructed to take into account such variables as scar width, thickness, dyspigmentation, wound approximation, and contour irregularities. The treatment groups were compared
[February 2015 • Volume 8 • Number 2]
25
Figures 1A and 1B. A 77-yearold man with a 3.4cm MMS closure on the right temple. (A) Immediate postoperative appearance with cyanoacrylate applied to the inferior half of the wound, and the superior half sutured with 5-0 fast absorbing gut. (B) Appearance of the wound at the three-month follow-up revealed a rating of 8.2±1.2 for cyanoacrylate and 8.8±0.7 for fast absorbing gut suture on a 10-point visual analog scale.
A
B Figures 2A and 2B. A 76-yearold man with a 4cm MMS closure on the mid upper forehead. (A) Immediate postoperative appearance with cyanoacrylate applied to the superior half of the wound, and the inferior half sutured with 5-0 fast absorbing gut. (B) Appearance of the wound at the three-month follow-up revealed a rating of 6.2±1.3 for cyanoacrylate and 7±1.8 for fast absorbing gut suture on a 10point visual analog scale.
A
B
using a paired t-test. Statistical significance was defined as p
RESEARCH]
Fast Absorbing Gut Suture versus Cyanoacrylate Tissue Adhesive in the Epidermal Closure of Linear Repairs Following Mohs Micrographic Surgery JUNE KIM, MD; bHARJOT SINGH MAAN, MD; cALICIA J. COOL, MD; d ALLISON M. HANLON, MD PhD; dDAVID J. LEFFELL, MD
a
a
Cascade Eye and Skin Center, University Place, Washington; bDepartment of Dermatology, University of Rochester Medical Center, Rochester, New York; c Advanced Dermatology, PC, Brooklyn, New York; dDepartment of Dermatology, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT Background: Cyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery. Objective: To compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery. Methods: Fourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome. Results: The present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures. Conclusion: Cyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167). (J Clin Aesthet Dermatol. 2015;8(2):24–29.)
issue adhesives have been used in surgical procedures for more than 50 years since cyanoacrylate was first discovered in 1949.1 These adhesives work by self-polymerizing in a spontaneous exothermic reaction. The first widely used variety, Nbutyl-2-cyanoacrylate, has been used with good cosmetic outcomes for a number of surgical procedures (blepharoplasty, lacerations, incisions).2–5 However, this adhesive did not gain widespread use because of its low
T
tensile strength and brittleness.6 In 1998, the United States Food and Drug Administration (FDA) approved 2octyl cyanoacrylate for superficial skin lacerations. This cyanoacrylate polymer was designed to be stronger and more flexible and has been used successfully in many studies.7,8 Fast absorbing gut is a plain gut suture that has been heat treated to enable rapid absorption. It is primarily used for epidermal suturing, where sutures are only
DISCLOSURE: The authors report no relevant conflicts of interest. Source of funding: Yale University, New Haven, Connecticut ADDRESS CORRESPONDENCE TO: Harjot Singh Maan, MD, Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave. BOX 697, Rochester, NY 14642; E-mail: [email protected]
24
[February 2015 • Volume 8 • Number 2]
24
required for five to seven days.9 Both cyanoacrylate and fast absorbing gut suture eliminate the need for an office visit for suture removal, which can represent a significant cost savings in patient and staff time as well as related healthcare resources. Both cyanoacrylate and fast absorbing gut suture are currently routinely used for epidermal closure following Mohs micrographic surgery (MMS). Physician preference currently dictates which epidermal closure method is chosen for a given surgery and depends on weighing advantages and disadvantages of each technique. Recently, one study reported that for defects on the trunk and extremities, tissue adhesive may not be as effective in achieving optimal cosmesis as fast absorbing gut.10 The purpose of this study was to compare the cosmetic outcome and patient satisfaction of cyanoacrylate tissue adhesive versus fast absorbing gut suture for the closure of surgical defects on the face following MMS.
METHODS Approval for this study was obtained from the Yale University School of Medicine Human Investigation Committee. A total of 14 patients undergoing routine MMS for nonmelanoma skin cancer of the face were asked to voluntarily participate in the trial on the day of scheduled surgery and were enrolled after written informed consent was obtained. To be enrolled, the patients had to be 18 years of age or older with a wound length of 3cm or greater, willing to comply with the protocol of standard postoperative care, and be able to attend a postoperative visit three months after surgery. Patients on systemic immunosuppressants and/or organ transplant recipients with a reported or suspected hypersensitivity to cyanoacrylate or fast absorbing gut suture or with a dermatologic disease in the target site that may interfere with examination were excluded from the study. Two of the authors (JK and DJL) served as primary surgeons during the study, and a primary surgeon performed the closure in each case. All wounds were closed using a linear, bilayered closure method, where the buried intradermal absorbing suture, 5-0 polyglactin 910 (Polysorb, Covidien) was placed along the length of the incision, consistent with standard surgical procedure. Each wound was measured and the length divided in half. Half of the surgical wound was randomly selected (by coin toss) for epidermal reapproximation with n-butyl and 2-octyl cyanoacrylate (GluSeal® Tissue Adhesive, Skinstitch Corporation), whereas the other half was repaired with fast absorbing gut suture (5-0 or 6-0, Fast Absorbing Plain Gut, Ethicon) in standard running fashion. Immediate postoperative photographs were taken. The entire length of the repair was reinforced with Steri-Strips (3M) that were removed after seven days. The patients then returned for followup at three months. High-resolution photographs were obtained of the wound at these follow-up visits. These
TABLE 1. Patient demographics PATIENT NUMBER
AGE (YEARS)
GENDER
SITE
LENGTH (cm)
1
76
M
Forehead
4
2
82
M
Cheek
3.5
3
84
F
Cheek
4.3
4
59
M
Temple
3
5
67
F
Cheek
4.1
6
89
F
Cheek
4.4
7
77
M
Temple
3.4
8
55
M
Temple
5
9
57
M
Cheek
5
10
64
F
Temple
3
11
54
M
Cheek
4
12
39
M
Cheek
3.5
13
60
M
Forehead
6.8
14
82
M
Temple
4.5
photographs were taken in the same clinic and under the same overhead lighting. Patient preference of closure method was also obtained at these visits. The high resolution photographs from the threemonth visit were presented to six blinded individuals (1 general dermatologist, 1 Mohs surgeon, 2 nurses, and 2 lay persons). A previously validated 10-point visual analog scale (VAS) ranging from 1 (poor) to 10 (excellent) was used to evaluate each half of the scar for overall cosmesis.11 Raters were instructed to take into account such variables as scar width, thickness, dyspigmentation, wound approximation, and contour irregularities. The treatment groups were compared
[February 2015 • Volume 8 • Number 2]
25
Figures 1A and 1B. A 77-yearold man with a 3.4cm MMS closure on the right temple. (A) Immediate postoperative appearance with cyanoacrylate applied to the inferior half of the wound, and the superior half sutured with 5-0 fast absorbing gut. (B) Appearance of the wound at the three-month follow-up revealed a rating of 8.2±1.2 for cyanoacrylate and 8.8±0.7 for fast absorbing gut suture on a 10-point visual analog scale.
A
B Figures 2A and 2B. A 76-yearold man with a 4cm MMS closure on the mid upper forehead. (A) Immediate postoperative appearance with cyanoacrylate applied to the superior half of the wound, and the inferior half sutured with 5-0 fast absorbing gut. (B) Appearance of the wound at the three-month follow-up revealed a rating of 6.2±1.3 for cyanoacrylate and 7±1.8 for fast absorbing gut suture on a 10point visual analog scale.
A
B
using a paired t-test. Statistical significance was defined as p
