Background. Histoacryl Blue (HAB), a tissue adhesive, has been shown to decrease laceration repair time, cause less pain to the child, eliminate the need for suture removal, and result in a similar short-term cosmetic outcome compared with conventional suturing. Reports suggest that poor correlation can exist between the short-term and long-term cosmetic outcomes for lacerations repaired by conventional suturing. Therefore, this study compares the long-term cosmetic outcome of HAB to conventional suturing for laceration repair in children.
Design. Prospective, randomized clinical trial.
Participants. Children presenting an urban pediatric emergency department for laceration repair between October 1994 and February 1995 were eligible. Patients less than 1 or more than 18 years old, those with lacerations more than 5 cm in length, or in areas of high tension or mobility were excluded.
Interventions. After routine wound management, including subcutaneous closure when deemed necessary, patients were randomized to receive skin sutures or HAB for cutaneous closure. Photographs taken at the 2-month and 1-year follow-up visits were evaluated for cosmetic appearance by two plastic surgeons blinded to the method of repair.
Results. Sixty-one children were enrolled: HAB (N = 30), suture (N = 31). Thirty HAB and 25 sutured patients were assessed at 2 months, while 17 HAB and 15 sutured patients were reevaluated at 1 year. Patients that followed-up at 2 months and 1 year were comparable to those with no follow-up in: treatment group (HAB vs suture), demographics, wound characteristics, and initial parental satisfaction. The two plastic surgeons graded the cosmetic appearance of the wounds repaired by HAB to be comparable to those repaired by conventional suturing at both the 2-month and 1-year follow-up.
Conclusions. The use of HAB is an ideal alternative to conventional suturing for the cutaneous closure of low tension lacerations in children with a long-term cosmetic outcome comparable to conventional suturing.
- HAB =
- Histoacryl Blue •
- CI =
- confidence interval
The use of cyanoacrylates as tissue adhesives for the cutaneous closure of lacerations has gained popularity in many countries outside of the United States.1 Histoacryl Blue (HAB) (N-Butyl-2-cyanoacrylate), a tissue adhesive, has been shown to cause limited tissue toxicity, provide good tensile strength, and have bactericidal and bacteriostatic properties.2-9Advantages of its use in the cutaneous closure of lacerations include its ease of application and the elimination of the need for follow-up suture removal.
This institution has previously reported the first study in the United States of the use of HAB for laceration repair in a children's emergency department.10,11 HAB was found to be an acceptable alternative to conventional cutaneous suturing with a comparable short-term cosmetic outcome at 2 months after repair. Parents perceived that their children experienced less pain with HAB than with conventional suturing, the procedure took less time, and the need for follow-up suture removal was eliminated.10,11
Previous reports have suggested that poor correlation exists between the short-term and long-term (>9 months) cosmetic appearance of lacerations repaired using conventional suturing.12Wounds evolve throughout the first year obtaining final appearance by 1 year after repair.13 Therefore, this study evaluated the long-term cosmetic outcome of lacerations repaired using a tissue adhesive in a children's emergency department.
METHODS AND MATERIALS
Children presenting to the urban pediatric emergency department at Egleston Children's Hospital of Emory University for laceration repair between October 1994 and February 1995 were eligible. Patients less than 1 or more than 18 years old, those with lacerations more than 5 cm in length, and those with lacerations located in areas subject to high tension or mobility were excluded. Wounds were closed by a team of investigators that included four emergency department physicians, and two physician extenders.
After obtaining informed consent, lacerations received routine wound management and placement of subcutaneous vicryl sutures if greater than 5 mm in depth. Patients were later randomized to receive either HAB or interrupted sutures (Prolene 5–0 or 6–0) for final cutaneous closure. Tetracaine, adrenaline, and cocaine was applied to lacerations requiring wound debridement, deep suturing, or cutaneous suturing. Lidocaine 1% (Astra, Westborough, MA) was used for additional anesthesia if needed for adequate local anesthesia.
Patients receiving HAB for cutaneous closure had the wound edges manually approximated before the tissue adhesive was applied drop-wise along the surface of the laceration. Wounds were then held in place for approximately 20 additional seconds to obtain adequate bonding.
Photographic documentation of wounds at the 2-month and 1-year follow-up visits were evaluated using a visual analogue scale by 2 facial plastic surgeons blinded to the method of repair (0 = best, 100 = worst).14,15 Fifteen families were unable to be contacted by telephone for the 1-year follow-up and of the remaining families, 12 patients did not show up and 2 refused stating that it was inconvenient.
Analyses were performed using the Epi Info (V6.0) [USD Inc, Stone Mountain, GA] statistical package. Continuous variables were assessed by the Kruskal-Wallis nonparametric test, and the Mantel-Haenzel χ2 test was used for the comparison of categorical variables. The intraclass correlation coefficient was used to assess the correlation between the visual analogue scores made by the two plastic surgeons. The study was approved by the Human Investigations Committee of Emory University School of Medicine (HIC #426–94).
Wounds were comparable in cosmetic appearance at 2 months according to surgeon A (median HAB 54.5 mm vs suture 59 mm; P = .75) while surgeon B (median HAB 42.5 mm vs suture 68 mm; P= .05) rated the HAB group significantly better. At the 1 year follow-up wounds appeared cosmetically comparable to both surgeon A (median HAB 42 mm vs suture 43 mm; P = .81) and to surgeon B (median HAB 49 mm vs suture 69 mm P = .85). The intraclass correlation between the visual analogue scores between the two plastic surgeons was .59 (95% confidence interval [CI], .40, .74) at 2 months and .63 (95% CI, .36, .80) at 1 year. No long-term complications were reported by the patients seen in follow-up or the remaining 15 patients with whom only telephone contact was made.
Tissue adhesives such as HAB have inherent advantages to their use in laceration repair including: 1) ease and rapidity of application, 2) elimination of the need for suture removal, and 3) decreased pain to the child.10,11 Given these savings, the final major parameter to consider is the long-term cosmetic outcome.
Evaluation of the wounds by two facial plastic surgeons blinded to the method of repair yielded a comparable if not better cosmetic outcome for the HAB group at the time of the 2-month follow-up. Some have suggested that long-term cosmetic outcomes (>9 months) of conventionally sutured wounds may vary significantly from short-term appearance.12,13 Therefore, this study set out to compare the long-term outcome of lacerations repaired with HAB versus conventional suturing. The final 1-year evaluation showed that the wounds repaired with HAB were cosmetically comparable to those in whom the final cutaneous closure was performed with conventional suturing.
The present study excluded lesions in high-tension regions or significant skin mobility. Therefore, the findings can not be generalized beyond low-tension wounds. However, the use of HAB for the repair of lacerations in low-tension areas is an acceptable alternative to conventional suturing with a comparable long-term cosmetic outcome.
The use of HAB is an ideal alternative to conventional suturing for the cutaneous closure of low-tension lacerations in children with a long-term cosmetic outcome comparable to conventional suturing.
- Received January 19, 1996.
- Accepted March 18, 1996.
Reprint requests to (H.K.S.) Department of Pediatrics, Egleston Children's Hospital, Division of Emergency Medicine, 1405 Clifton Rd, Atlanta, GA 30322.
Presented at the Ambulatory Pediatric Association annual meeting, Washington DC, May 6–10, 1996.
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- ↵Kamer FM, Joseph JH. Histoacryl. Its use in aesthetic facial plastic surgery. Arch Otolaryngol Head Neck Surgery. l989;115:193–197
- ↵Pani KC, Gladieux G, Brandes G, Kulkarni RK, Leonard F. The degradation of n-butyl alpha cyanoacrylate tissue adhesive. II. Surgery. l968;63:481–489
- ↵Galil KA, Schofield ID, Wright GZ. Scientific effect of N-Butyl-2-Cyanoacrylate (Histoacryl Blue) on the healing of skin wounds. J Can Dental Assoc. l984;50:565–569
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- Copyright © 1997 American Academy of Pediatrics