Healing of incisions closed with surgical adhesive tape

Healing COSTAN

W.

of Incisions Closed with Surgical Adhesive Tape

RERARD,

M.D., JOHN

EDWIN J.

B.

HERRMANN,

PULASKI.

M.D., STEPHEN C. WOODWARD,

M.D.,

llhshington,

D.

M.D.

AND

C.

From the Department of Surgical Metabolism and Pathology, DiGsion oj Basic Surgical Research, Walter Reed Army Institute oj Research, Walter Reed Army Medical Center, Washington, D, C.

have LMEROUS recommendations been LV made over the past twenty-five centuries to use adhesives and adhesive tapes for the closure of incised wounds [I]. In a detailed histoh~gic study of cutaneous heahng, GiIIman et al. [2] observed that “reactions at the suture needIe puncture wounds in the skin surface are of the same type and may even be of a similar order to those in the incision itself.” They urged a reassessment of methods for cIosure of skin incisions. In two subsequent publications [3,4] they reported favorabIe resuits with tape closure of forearm incisions in human volunteers. GoIden [r,~] has described a new microporous surgica1 adhesive tape* found to be strikingIy successfu1 as a repIacement for skin sutures in the apposition of wounds. Dunphy and Jackson [6] enumerated the advantages of nonsuture skin cIosure and reported favorabIe rest&s with this technic. Numerous additional cIinica1 triaIs have been [7]. Despite initiated and are continuing increasing use, studies of the physica characteristics of tape-closed incisiona wounds are lacking. We here report on the physica characteristics and morphology of incisions closed with tape and standard suture technic.

FIG.

ground RockIand diet,* fresh kale and tap water. The principles of Iaboratory animal care as promuIgated by the National Society for Medical Research were observed. After estabIishmcnt of intraperitoneal pentobarbita1 sedation (30 mg./kg.), each guinea pig was first cIipped and then chemicaIIyf depiIated on the dorsum. Under aseptic technic, each animal received a 5 cm. midline dorsal skin incision (through only the epidermis and dermis) centered at a point 5 cm. cauda1 to the occiput. In one group incisions were cIosed with five evenly spaced interrupted through-and-through sutures of No. 35 stainless stee1 wire. These wounds werr not manipulated further except for remova of sutures at seven days. In the other group, incisions were cIosed with yk inch adhesive stripst by a crisscross technic recommended for wounds under tension. (Fig. I.) These wounds were left undisturbed, but

METHODS Sixty Waiter Reed strain maIe guinea pigs weighing 200 to 300 gm. were paired by weight into two groups. The animals were maintained in separate cages on a standard ad libitum ration of * Steri-Strips,@ Minnesota ing Co., St. Paul, Minnesota.

Mining

I. Incision cIosed with adhesive strips

* A. E. Staley Mfg. Co., Decatur, III. t Nair,@ Carter Products, Inc., Cranbury, N. J. # Steri-Strips,@ Minnesota Mining and Manufacturing Co., St. Paul, Minn.

and Manufactur-

59’

American Journal

01 Surgery,

Volume

IO,-. April

1964

Eerard et aI.

FIG.

2.

AnimaI in position;

micrometer

adjusted

Frc. 3. Measurement

to zero

of skin thickness.

point. with compound tincture of benzoin for added adhesiveness, as recommended by GoIden [y]. On the fourteenth postoperative day, animals were sacrificed with an overdose of intraperitoneal pentobarbital. Wounds were assayed as foIIows: The dorsum of each anima1 was cIipped and shaven and gross appearance and Iength of the incision were noted. One cm. transverse incisions were made at each end of the wound and joined by blunt dissection in the subderma1 pIane. The anima1 was placed into a positioning device [8] and the thickness of the incision measured at six I cm. intervals over the Iength of the incision. The specia1 micrometer* used for this purpose was first “zeroed” on the stainIess stee1 guide bar to (Fig. 2) and then moved on a sliding support successive positions, at each of which thickness was recorded to the nearest ten-thousandth of an inch. (Fig. 3.) The average of these readings was converted to miIIimeters and expressed as “skin thickness.” A 5 cm. square of skin bisected IongitudinaIIy by the incision was then removed by sharp dissection in the subderma1 pIane. Each square was adjusted to its in situ dimensions on the base-pIate of a skin cutter [8] designed to cut the centra1 portion of the incision into five paraIle1 strips each 6 mm. wide. The incision was oriented perpendicurar to the bIades so that the heaIing wound bisected the center of each strip. The middle strip was used for histoIogic study and the adjacent strips tested for breaking strength. For the Iatter determination, each strip was cIamped with the incision equidistant between the jaws of a speciaIIy constructed device [8]. (Fig. 4.) The Iower jaw was connected via a meta arm to a motor geared to puI1 the jaw

all tapes were shed spontaneousIy by the seventh postoperative day. In both groups the skin IateraI to the incision was painted prior to wound cIosure

FIG. 4. Breaking strength device. For testing, is cIamped between upper and Iower jaws.

skin strip

* B. C. Ames, WaItham,

592

Mass.

HeaIing

of Incisions

at 0.2 inch per minute while the upper jaw was connected via a freely rotatabIe bead-chain (to prevent torsion effects) to a strain gauge.* As traction was exerted on the skin strip, the force measured by the strain gauge was recorded on a o to IO mv. strip-chart recordert calibrated in grams and the peak value, recorded just before the strip disrupted at the incision, taken as the “breaking force.” The cross sectional arca in square millimeters of each strip at the incision mas calculated as skin thickness in millimeters (at the incision) times the standard 6 mm. width of the strip. The breaking force, divided by the cross sectional area at the incision, yieIded tensile strength of the incision in grams per square millimeter. As stated earlier, the middle strip was used for histologic study. Following formahn-fixation and routine processing, sections were cut in an orientation perpendicular to both the skin surface and the incision. Hematoxylin-eosin and trichrome [9] stains were prepared for all specimens. RESULTS

Seventeen of the thirty tape-cIosed incisions had to be excIuded from the study because of shedding of tape and wound disruption within forty-eight hours postoperativeIy. Such animaIs and their pair-mates were discarded. The thirteen taped incisions intact at forty-eight hours healed uneventfuIIy and the resuIts presented are derived from these animaIs and their sutured controIs. At sacrifice, incisiona scars in both groups were a11 grossIy apparent as fme white lines. There was no hyperemia, eIevation or widening of incision with either type of cIosure. In the sutured group, cross hatching attributabIe to suture retention was rare and bare1.y discernibIe on cIose inspection. The taped area showed no evidence of skin reaction or irritation. In neither type of incision was there a measurabIe shortening from the origina 5 cm. Iength. There were no significant differences in skin thickness, breaking strength or tensiIe strength between sutured and taped wounds. (Table I.) HistoIogicaIIy, a11 specimens revealed a fairly uniform heaIing pattern and, except for occasiona suture-tracts in wounds cIosed with stee1 sutures, no significant differences between tape-cIosed and suture-cIosed incisions were noted. EpitheIiaI regeneration was routineIy complete; in some instances from both groups, minima1 acanthosis was apparent over the * Statham Instrument t Leeds and Northrup

Co., Puerto Rico. Co., PhiIadeIphia,

TABLE FOURTEEN

Group

Sutured.. _., Taped......’

DAY

No.

593

Tensile Strength (&/mm.“)

DORSAI

Breaking Strength (g.)

13

80

i

6

462

Z!I 32

13

76

i

8

412

k

P due..

>.60

>

36

;o

SKIN

Incision Thickness (mm.)

1 9x I 92 >

i

0.12

+

0.05

.60

site. Skin appendages were absent from the region of repair and the defect was bridged by fine, aniIine-bIue staining coIIagen fibriIs smoothIy interdigitating with the Iarger pre-existing coIIagen bundIes. The newIy formed connective tissue band appeared widest directIy beneath the epitheIium. At this IeveI reparative coIIagen was primariI\oriented paraIIe1 to the epitheIium, bridging the incision. Deeper, a more vertica1 fiber arrangement occurred. Inflammatory response was minima1 and nonspecific in both t>,pes of incision. incision

COMMENTS

The resuIts of this study indicate no significant differences in gross, histologic or physical properties of incisions adequately approximated with suture or tape. EvaIuation of tape cIosure in animaIs is diffrcuIt, however, due to rapid hair growth, movement and tension on the incision, inadvertent or purposeful tape remova1, and poor tape adhesion even on cIeanIy depiIated, dry, ether-prepared skin surfaces. In other preIiminary studies we have utiIized tape cIosure on rats, rabbits and even geneticaII:y hairIess mice. FaiIures were numerous, consIstentIy occurring earIy. The guinea pig was finaIIy seIected on the bases of body contour, ease and compIeteness of depilation, and its faiIure to remove the tape purposefully. Tape adhesion, however, was still weak and transient. Even with compound tincture of benzoin satisfactory wound approximation was maintained in Iess than 50 per cent of the animals. The animaIs those in which

Pa.

I

POSTOPERATIVE

excluded from the study were tape Ioss and wound disruption

Berard et a1. occurred within the first forty-eight hours after surgery. During this time the strength of a wound depends on the supporting materia1 and not on the wound tissue, since the processes which provide strength in a wound occur Iater [IO]. For this reason we do not believe that by discarding faiIures we have seIected at forty-eight hours onIy those animals destined for optima1 wound heaIing during the successive tweIve days. Other investigators [4] have attempted to solve the probIem of disruption by using wideIy spaced, fine, epiderma1 or subderma1 supporting sutures with tape. In our incisions, which were Iess than I mm. in thickness, such an approach was neither desirable nor practica1 as a method to evaluate tape cIosure. Secondary reinforcement is aIso unacceptabIe for the purpose of evaIuating heaIing in primariIy cIosed wounds. The resuIts cIearIy indicate, however, that the tape-cIosed wound heaIs as we11 as the sutured wound when grossIy observabIe approximation is attained and maintained. Reports of cIinica1 triaIs [5-71 do not indicate that comparabIe probIems of tape Ioss and wound disruption occur in man.

strength or tensiIe strength. Wounds cIosed with tape or suture were &ossIy indistinguishabIe from each other at fourteen days. Acknowledgment: The technica assistance of Messrs. John Diggs, Ernest SIoan and Lee Lewis and Pfc Clifford Rea, WiIbur Pumpaly, and George Nokes is gratefully acknowIedged. The photographs were prepared by the MedicaI Audio-VisuaI Department, Walter Reed Army Institute of Research, Waiter Reed Army MedicaI Center. REFERENCES 1. GOLDEN, T. Nonirritating, multipurpose surgical adhesive tape. Am. J. Surg., 100: 789, 1960. 2. GILLMAN, T., PENN, J., BRONKS, D. and Roux, M. A re-examination of certain aspects of the histogenesis of the heaIing of cutaneous wounds. Bril. J. Surg., 43: 141, 1955. 3. GILLMAN, T., PENN, J., BRONKS, D. and Roux, hl. CIosure of wounds and incisions with adhesive tape. Lancer, 2: 945, 1955. 4. GILL’MAN, T. and PENN, J. Skin wounds and surgical incisions: their effective cIosure with adhesive tape. Medical Proceedings. Mediese B.ydraes (suppl.), 2: I, 1956. 5. GOLDEN, T., LEVY, A. H.- Hnd O’CONNOR, W. T. Primarv heaIine: of skin wounds and incisions with a threadIe& suture. Am. J. Surg., rob: 603, 1962. 6. DUNPHY, J. E. and JACKSON, D. S. PracticaI appIications of experimental studies in the care of the primariIy cIosed wound. Am. J. Surg., 104: 273, 1962. 7. SEMINAR. CIinical resuIts with sutureIess skin closures. AtIantic City, N. J., October 16, 1962. 8. LEVENSON, S. M., CR~WLEY, L. V., ROSEN,- H., BERARD. C. W. and GEEVER. E. F. A Drocedure to’ evaluate experiment;1 wound heaIing. Presented at the AnnuaI Meeting of the American Association for the Surgery of Trauma, Hot Springs, Va., Oct. 31, 1962. g. GOMORI, G. A rapid one-step trichrome stain. Am. J. Clin. Patb., 20: 661, 1950. IO. HALEY, H. B. and WILUAMSON, M. B. AppIication of present knowIedge of wound healing to clinical surgery. S. Clin. Nortb America, 42: 13, 1962.

SUMMARY I. DorsaI skin incisions in two groups of guinea pigs were cIosed with tape and with stainIess stee1 sutures. AnimaIs were sacrificed at fourteen days and wounds studied grossly, histoIogicaIIy and physicaIIy. 2. TechnicaI probIems of evaIuating tapecIosure in animaIs compromise the decisiveness of any such study. In seventeen of thirty incisions cIosed with tape, tape-Ioss and wound disruption occurred within the first forty-eight hours. 3. Thirteen of thirty tape-cIosed wounds dispIayed primary heaIing. In such wounds there were no significant differences between the two groups in wound thickness, breaking

594