- Email: [email protected]
Wound closure materials
Oral Maxillofacial Surg Clin N Am 14 (2002) 95 – 104
Wound closure materials Robert Gassner MD, DMD, PhD* Department of Oral and Maxillofacial Surgery, University of Innsbruck, Innsbruck, Austria Department of Oral and Maxillofacial Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Proper wound closure is part of successful overall wound care after the assessment of patient and sustained wound, anesthesia, debridement, and irrigation of the wound. Postoperative care enhances excellent outcome or reduces impaired healing situations. Wound healing disturbances mostly result from neglecting one or more of these steps in wound care regardless of the kind of wound closure material used. The principles of wound care have remained remarkably the same over the years. Although most lacerations heal without sequelae regardless of management, mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality [29,66]. Wounds are one of the most commonly encountered problems in the emergency department. They rival respiratory tract infections as the most common reason people seek medical care [44,55]. Five years ago almost 11 million wounds were treated in emergency departments throughout the United States. At an average charge of $200 per patient, this translates to more than $2 billion annually. When nonemergency or elective incisions are included, approximately 90 million skin-suturing procedures are performed each year [70]. The goals of wound management are simple: avoid infection and achieve a functional and esthetically pleasing scar [66]. These goals are achieved by reducing tissue contamination, debriding devitalized tissue, restoring perfusion in poorly perfused wounds, and establishing a wellapproximated closure.
* Department of Oral and Maxillofacial Surgery, University of Pittsburgh, G-33 Salk Hall, Pittsburgh, PA 15261, USA. E-mail address: [email protected] (R. Gassner).
Most lacerations require primary closure. Primary closure results in more rapid healing and reduced patient discomfort than does secondary closure. The most commonly used method for closing lacerations is suturing. Most wound care practices are empirical or based on animal wound models; few are based on well-designed clinical trials. Most studies of laceration management have focused on the wound infection rate as the primary outcome, despite the fact that wound infections are relatively uncommon (less than 5% of lacerations) [30]. Although all traumatic lacerations should be considered contaminated, most have low bacterial counts (fewer than 100 organisms per gram of tissue), well below the infectious inoculum of 105 or more organisms per gram [59]. Most infected lacerations heal without complications other than the occasional unsightly scar. Patients are most concerned with the cosmetic appearance of their healed lacerations [54], and the focus of physician’s and dentist’s wound research is shifted toward measuring wound cosmesis as the primary outcome, neglecting pressure on development of new biomaterials for wound closure.
History of wounds Humans have managed wounds from the beginning of civilization. The earliest reports of the use of artificial materials come from the Edgar Smith papyrus, which details the use of sutures and wound closure devices around 4000 BC [50]. Initial treatments for wounds consisted of herbal balms or draughts, with application of leaves or grasses as bandages [20]. Ointments were made from a wide variety of animal, vegetable, and mineral substances. Wounds were mostly left open, although wound
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closure using the jaws of ants was used by some cultures [74]. The world’s oldest suture was placed by an embalmer on the abdomen of a mummy in approximately 1100 BC [39]. During the Middle Ages, pus was believed to be necessary for healing; as a result, various agents were used to promote suppuration. Advances in the fields of anesthesiology and surgery during the past two centuries have led to the development of many of the practices that are currently prevalent [29,66]. These advances are based on thorough debridement and cleansing of wounds and the use of aseptic wound closure techniques. Only recently has wound care been investigated systematically in the laboratory and in clinical arenas.
Epidemiology of wounds Approximately one third of lacerations occur in adults between the ages of 19 and 35 years [30], predominantly of male gender. Most wounds are found either on the head or neck (50%). The most frequent mechanism of injury is application of a blunt force, such as a falling against obstacles. Other agents of injury include sharp instruments, glass, and wooden objects [30]. Although mammalian and human bites continue to receive much attention, they are a relatively rare cause of wounds.
A detailed history of allergies to any agents is essential (e.g., anesthetic agents and antibiotics, latex products). Tetanus immunization status should be verified.
Wound assessment Besides discussion on the necessity of sterile conditions for treatment of wounds [6], powder-free gloves reduce the risk of any foreign body reactions or infections that theoretically may result from the introduction of talc particles into the wound. The wound is examined meticulously in all cases. Proper lighting and control of bleeding are required to identify any injury to vital structures (such as nerves and tendons) and foreign bodies that may contaminate and lead to chronic infection and delayed healing [29,66]. Failure to diagnose foreign bodies is the fifth leading cause of litigation against emergency physicians [29]. Other common wound-related causes of litigation include the development of wound infections and missed injuries of tendons and nerves. Crush injuries, which tend to cause greater devitalization of tissue, are more susceptible to infection than are wounds that result from the more common shearing forces [10].
Anesthesia of the wound Patient assessment Increased wound infection rates or delayed healing exists for patients with diabetes mellitus, obesity, malnutrition, chronic renal failure, advanced age, and use of steroids [12]. All of these risk factors, together with the use of chemotherapeutic agents and other immunosuppressive agents, may delay wound healing by affecting inflammation and the synthesis of new wound matrix and collagen [31]. Healing also may be impaired in inherited and acquired connective-tissue disorders, such as EhlersDanlos syndrome, Marfan syndrome, osteogenesis imperfecta, and protein and vitamin C deficiencies. The tendency of the patient to form keloids should be ascertained because this may result in a poor scar [66]. Keloids extend beyond the boundaries of the original injury and are largely determined by genetic or racial predisposition. Conversely, hypertrophic scars, which remain within the boundaries of the original injury, usually result from a tissue deficiency or from the fact that the wounds are not parallel to the lines of minimal skin tension [66].
For adequate evaluation and management before wound closure, many lacerations require anesthesia. There are two major classes of local anesthesia: esters and amides. Several possibilities for patientfriendly administration of local anesthesia exist, including warming of the anesthetic solution to body temperature, slowing the rate of injection, and injecting the local anesthesia through the wound edges of the laceration instead of through the intact surrounding skin. Use of smaller needles and subcutaneous rather than intradermal injection also has been suggested to result in less pain [35,63]. Buffering of the local anesthesia with sodium bicarbonate at a ratio of 1:10 provides a more rapid and less painful onset of anesthesia.
Wound preparation, debridement, and irrigation Cleaning the wound is an important step before wound closure. Although scrubbing with a highporosity sponge in highly contaminated wounds achieves beneficial effects, such as bacteria and
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particulate matter removal, deleterious effects may occur caused by intense scrubbing that results in further tissue damage. Nonviable tissue may impair the ability of the laceration to resist infection. Surgical debridement of any crushed or devitalized tissue is one of the most fundamental aspects of wound preparation [25,66]. Eyebrow hair should not be removed because it may result in abnormal regrowth. Removal of other hair surrounding a laceration may help facilitate meticulous wound closure. Because many bacteria normally reside in hair follicles, shaving of the hair before repair may increase wound infection rates [66]. Devitalized tissue such as fat, muscle, and skin that remains further impairs the ability to resist infection [25]. Removing such tissue mechanically and surgically is an essential part of wound management. Mechanical debridement may be performed by surgical excision, scrubbing with a surgical sponge, or high-pressure irrigation [66]. Considerable debate exists regarding the exact methods of irrigation, especially on irrigation impact pressures and the nature of the irrigant solutions [25,29,66]. Normal saline solution remains the most cost-effective and readily available choice [15,28]. Because of their tissue toxicity, detergents, hydrogen peroxide, and concentrated forms of povidone-iodine should not be used to irrigate wounds [15,28]. In highly vascularized areas that contain loose areolar tissue, such as the eyelid, high pressures should be avoided [45]. Irrigation may not be required for all low-risk wounds in the face [28].
Wound closure More than 40 different types of sutures exist to close wounds and incisions [66]. It seems to be irrelevant how the wound is held together as long as good healing and esthetics result [41,61]. The time during which wound closure is safe must be tailored individually on the basis of causation, location, and host factors. When wounds are not closed because of a high risk of infection, delayed primary closure should be considered after 3 to 5 days, when the risk of infection decreases, especially if they are large, may have a poor cosmetic outcome, or are associated with discomfort or inconvenience [66]. Most wounds should be closed primarily to reduce patient discomfort and speed healing. Wounds at low risk for infection can be closed 12 to 24 hours after the injury, but for wounds at high risk (contaminated wounds, those in locations with poor vascular supply, and those in immunocompromised patients), primary
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closure should take place within approximately 6 hours. There is a direct relation between the time from the injury to closure of the laceration and the risk of subsequent infection, but the length of this ‘‘golden period’’ is highly variable [5]. Each individual wound must be considered separately, taking the time from the injury until presentation into account in addition to laceration location, contamination, risk of infection, and importance of cosmetic appearance before deciding the form of wound closure. Wounds that are not closed primarily because of a high risk of infection should be considered for delayed primary closure after 3 to 5 days, when the risk of infection decreases.
Options for wound closure The ideal wound closure material permits a precise wound closure, is easily and rapidly applied, is painless, is inexpensive and of low risk to patients and providing persons, and results in minimal scarring with a low infection rate. Sutures Sutures are the most commonly used wound closure material. Nonabsorbable sutures, such as nylon and polypropylene, retain most of their tensile strength for longer than 60 days, are relatively nonreactive, and are appropriate for closure of the outermost layer of the laceration [42,57,71]. Removal of nonabsorbable sutures is required. Absorbable sutures are generally used for closure of structures deeper than the epidermis. In general, synthetic absorbable sutures are less reactive and have greater tensile strength than sutures from natural sources, such as catgut. They increase the time during which the healing wound retains 50% of its tensile strength from less than 1 week to as long as 2 months. Chromic gut lasts for up to 2 weeks and is associated with tissue reactivity. Polyglactin and polyglycolic acid maintain tensile strength for 20 to 28 days and are associated with minimal tissue reactivity. Some synthetic absorbable sutures (e.g., polydioxanone, polyglyconate) preserve their tensile strength for as long as 2 months, which makes them useful in areas with high dynamic and static tension. Use of these sutures should be limited to deeper structures because they may become extruded over time (Table 1) [42,57,71]. Although use of absorbable sutures is generally reserved for subcuticular tissues, rapidly dissolving forms may be used to close the wounds in children
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Table 1 Characteristics of absorbable sutures Suture material
Wound tensile strength
Knot security
Tissue reactivity
Security (d)
Polyglactin (Vicryl) Polyglycolic acid (Dexon) Polyglyconate (Maxon) Polydioxanone (PDS) Chromic gut Surgical gut
Good Good Excellent Excellent Average Average
Good Excellent Average Average Average Poor
Low Low Least Least High High
30 30 45 – 60 45 – 60 10 – 14 5–7
and thereby avoid the discomfort associated with suture removal [29,66,68]. Generally, synthetic and monofilament sutures are preferred over natural and braided sutures because they result in lower rates of infection (Table 2) [29,66]. Staples Staples can be applied more rapidly than sutures. They are associated with a lower rate of foreign body reaction and infection [58]. In general, staples are considered particularly useful for scalp, trunk, and extremity wounds and when saving time is essential (e.g., mass casualties, patients with multiple trauma wounds) [7,58]. They do not allow as precise a closure as sutures, however, and are slightly more painful to
remove. In animal models, staples are associated with lower rates of bacterial growth and lower infection rates than sutures [7]. In clinical series, these effects may be statistically significant but are of limited clinical significance [27]. Comparing suture and staple repair of simple pediatric scalp lacerations stapling resulted in shorter wound closure times, shorter overall times for wound care and closure, and fewer expenses in terms of equipment and total cost based on equipment and physician time [34]. Adhesive tapes Advocates of adhesive tapes proclaim the superiority of tape wound closure because of the resistance to infection of the underlying wound that is greater than
Table 2 Pros and cons of common wound closure materials Technique
Advantages
Disadvantages
Suture
Classic method Careful closure Most resilient tensile strength Lowest dehiscence rate Risk of needle stick
Requires removal Requires anesthesia Greatest tissue reactivity Most expensive method Slowest method
Staples
Rapid application Low tissue reactivity Low cost Low risk of needle stick
Sloppy closure Interferes with older generation imaging technology (CT, MR image)
Tissue adhesives
Rapid application Patient comfort Resistant to infection No need for removal Low cost No risk for needle stick
Less tensile strength than sutures Dehiscence in high-tension areas (such as joints) Cannot be used on hands No bathing or swimming
Surgical tapes
Rapid application Patient comfort Lowest tissue reactivity Lowest infection rates Low cost No risk for needle stick
Frequently falls off Less tensile strength than sutures Highest rate of dehiscence Includes toxic components Cannot be used in the hair Cannot be wetted
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in wounds that contain sutures, staples, or tissue adhesives [16,51]. This unique resistance to infection of tape-closed wounds is attributed to the absence of the sutural, tissue adhesive, or staple foreign bodies in the wound. These wounds require the use of adhesive adjuncts (e.g., tincture of benzoin) that increase local induration and wound infection. Because adhesive adjuncts are toxic to wounds, care should be taken that they do not access the wound. Although the various surgical tapes have different degrees of adhesion, porosity, breaking strength, and elasticity, tapes alone cannot maintain wound integrity in areas subject to tension [60,62]. They have been used in an estimated 1 billion patients but are more often used after suture removal to decrease tension on the wound until they fall off [66]. Tape wound closure is preferred in children because of low discomfort during application. Tissue adhesives The skin of wounds also can be closed by tissue adhesives. They should be applied only topically. Tissue adhesives cannot be used intraorally and cannot replace deep sutures. Approximately 30% of laceration repairs and closure of many surgical incisions may be amenable to skin closure with tissue adhesives; thus, they are not a replacement for sutures but do offer an alternative [55]. Modern tissue adhesives contain cyanoacrylates. Cyanoacrylates were first synthesized in 1949 and used clinically in 1959 as agents to glue skin wounds [29]. Monomeric cyanoacrylates polymerize in the presence of hydroxyl ions, which can be found in water and blood, thereby bonding with the skin. The ethylene portion of the molecule polymerizes. The initial derivatives were methyl-2- and ethyl-2-cyanoacrylates. These derivatives were effective, but the shorter alkyl chains degraded rapidly into cyanoacetate and formaldehyde. These products had significant tissue toxicity that resulted in acute and chronic inflammation. With longer alkyl chains, the toxicity decreases as a result of slower degradation, which limits the accumulation of byproducts. N-butylcyanoacrylates are less toxic than shorter-chain cyanoacrylates and maintain a stronger bond. Longer-chain N-2-butylcyanoacrylate adhesive has been used for wound closure in Canada and Europe for more than 20 years. Throughout this time no adverse effects have been reported [36]. A study in 1985 reported that isobutyl-2-cyanoacrylate implanted into a rat peritoneum induced sarcomas. This study was conducted in rats prone to sarcomas and was never duplicated; nevertheless, it did result in a lack of Food and Drug Administration approval for
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use in the United States [73]. Butylcyanoacrylates do have limitations. After polymerization, the adhesive is brittle and can fragment if flexed. Because of these limitations, butyl compounds have been used for areas that do not cross wound creases and for shorter wounds [29,55]. 2-Octylcyanoacrylate, formulated with plasticizers, is even more stable, has greater flexibility, and maintains a stronger bond. It degrades much more slowly, which leads to its classification as nontoxic. 2-Octylcyanoacrylates (e.g., Dermabond, Ethicon, New Brunswick, NJ) were approved for use in the United States in 1998. Within the first month of availability, more than 3 million units of Dermabond were ordered [29,55]. Studies have shown wound breaking strength to be equal to that of suture-repaired wounds at 5 to 7 days, but the day 1 breaking strength is only approximately 10% to 15% that of a wound closed with 5-0 monofilament sutures [47,76]. Wounds are evaluated and cleaned in a standard fashion. If the wound edges are traumatized or involve multiple tissue layers, appropriate debridement or buried sutures or both are necessary. For more superficial wounds, no buried sutures are needed. The wound edges are manually approximated with fingers or forceps while care is taken not to apply the adhesive between the edges. Interposing the glue into the wound results in greater scarring. The wound is held in position for 30 seconds to complete polymerization. Besides displaying three-dimensional tensile strength, the tissue adhesives act as their own dressing. The wound is waterproof and can be wet in a shower, although soaking may result in decreased strength or peeling of the dressing. Experimentally they have antimicrobial effects against gram-positive organisms and the potential to decrease the rate of wound infections [52,53]. The adhesive holds well on the face, and it usually stays on for 7 to 14 days then sloughs off with the epidermis. There is no need for follow-up for suture removal, which makes this method of care attractive. In general, cyanoacrylates are less expensive than sutures and staples, and patients prefer them [48]. Using tissue adhesives for wound repair is a manual skill, like suturing, and requires careful application. Being a topical closure, wound healing is impaired when adhesive gets between the wound edges, which prevents epithelialization and promotes foreign-body reactions [18,72]. When used properly for topical wound closure, tissue adhesives result in fewer foreign-body reactions than sutures do and can decrease infection rates in contaminated wounds [52]. Histologic studies report no differences in wound healing characteristics between sutured and tissue adhesive repaired wounds [32,47,52].
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Prospective, randomized trials comparing Histoacryl Blue (a butyl-2-cyanoacrylate from Braun, Germany) with 5-0 or 6-0 sutures for repair of small facial lacerations revealed equivalent cosmetic outcome at 3 months and at 1 year [29,56,65,66]. The assessment of wounds 3 months after injury and wound repair provided a good measure of long-term cosmetic outcome [56]. The short-term infection rate was slightly higher for Histoacryl Blue but not statistically different, and the wound dehiscence rate was statistically equivalent. The time to wound closure was more than 50% shorter for the group treated with 2-octylcyanoacrylate. Subset analysis of the data suggested that small lacerations aligned against lines of minimal tension may benefit most from the use of tissue adhesive rather than sutures [65]. Octylcyanoacrylate provides the greatest threedimensional tensile strength of all the cyanoacrylates and is a needleless alternative to sutures for closure of most facial lacerations. It provides excellent cosmetic appearance comparable to that achieved with sutures [4,43,49,56]. If lacerations cannot be approximated manually and skin edges cannot be held together without a lot of tension, the use of tissue adhesives is inappropriate. Adequate strength to the wound closure requires three or four coats of 2-octylcyanoacrylate, which is associated with heat release during polymerization as an exothermic reaction. When tissue adhesives result in suboptimal wound closure or must be removed for some other reason, bathing or application of antibiotic ointment or petroleum jelly may accelerate removal. Acetone can be used when more rapid removal is necessary [29,66]. Opponents of tissue adhesives for wound repair note that adhesives seem to act as a barrier between the growing edge of the incision [16,17,41]. This barrier prevents intimate apposition of the wound edges and delays wound healing. The breaking strength of wounds closed with adhesives is believed to be significantly lower than that of taped wounds without the adhesive. Tissue adhesives also potentiate the development of infection in contaminated wounds. Although this technique may be efficient, the use of tissue adhesives—nonabsorbable compounds whose long-term toxicity has not been proved efficacious—is an appropriate substitute for suturing wounds [16,17,41]. If the cyanoacrylate adhesive gains access to the wound, it remains there despite an increased resistance to wound infection. When wounds that contain tissue adhesives become infected, magnification loupes are necessary to identify and remove the adhesive deposits from the wound. Design and development of absorbable adhesives are of utmost importance to allow wound repair
without infection and with the most esthetically pleasing scar. When comparing 2-octylcyanoacrylate and nonabsorbable sutures or staple repair for wounds in children, the tissue adhesive 2-octylcyanoacrylate was revealed to be an acceptable alternative to conventional methods of wound repair with comparable cosmetic outcome [8]. The use of tissue adhesives has been reported in blepharoplasty [24] and has emerged in the management of corneal trauma [38]. Cyanoacrylates also have been used experimentally in skin, bone, and cartilage grafting, corneal and eyelid surgery, and occlusion of esophageal varices and cerebrospinal fluid leaks [29,66]. Autologous fibrin tissue adhesive made from the patient’s own blood and commercial fibrin sealants might offer a possibility for treatment of intraoral lacerations and wounds but require further examination and proof. Fibrin tissue glue proposes to be an alternative mode of managing hemostasis and wound healing. There is much inconsistency in the data secondary to the use of various fibrin sealant preparations, different animal models and clinical situations, and different application techniques. A consequence to this is the likelihood that different fibrin sealant preparations may be preferred for different clinical situations [11,40]. Comparing fibrin glue, as a bioadhesive, with traditional sutures in closing mucosa over exposed mandibular plates in a cat-model revealed fibrin glue to be safe and well tolerated in cats. Glue application required a shorter operative time and was associated with fewer occurrences of granulation and ulceration when compared with suture fixation. Further studies are indicated to titrate the concentration of fibrin [21]. A prospective, randomized, blinded study using fibrin sealant at the wound site revealed significantly reduced pain and decreased chance of experiencing emesis after tonsillectomy [23]. Wound healing might be enhanced by combining platelet concentrates and fibrin adhesive [67]. Dressings Nonadherent wound dressing for at least 24 to 48 hours has a shielding effect until enough epithelialization is present to protect the wound from gross contamination [64]. Maintaning a moist environment around the wound also has been shown to speed the rate of epithelialization [26,75]. For burns in which the traditional split-thickness skin graft is not available, coverage of open wounds is the fundamental problem. Topical antibiotic dressings and porcine skin have been used extensively [46]. The use of
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xenografts was limited as a temporizing measure, because of intense foreign body reactions and eventual rejections accompanied by a high rate of graft infection. New generations of synthetic skin equivalents have been shown to be superior, with a considerable reduction in the partial-thickness burn healing rate and hospitalization in a clinical trial [14]. These skin equivalents have a bilayered structure. Examples include Apligraf (Novartis, East Hanover, NJ), with live keratinocytes on an acellular dermal matrix, and Integra (Integra LifeScience, Plainsboro, NJ), which consists of reconstituted collagen and danaparoid sodium (chondroitan sulfate) backed by a polymer layer. Both products are currently in use as biologic dressings for the coverage of burn wounds [19,46]. Postoperative care In general, decontamination is far more important than using antibiotics. Antibiotics should be reserved for human and animal bites and for intraoral lacerations and open fractures [13,69]. Avoiding exposure of the wound to sun reduces the likelihood of complications such as hyperpigmentation [66]. Sutures or staples should be removed after approximately 7 days. Periorbitally placed sutures should be removed sooner (within 3 – 5 days) to avoid formation of unsightly sinus tracts. Sutured or stapled wounds should be kept clean and gently cleansed after 24 to 48 hours. Patients with tissue adhesives in place may shower, but they should avoid bathing and swimming. Prolonged moisture loosens the adhesive bond. Gentle blotting to dry the area is preferred to repeated wiping [3,29]. Elevation of the injured area decreases edema formation. Patients should be instructed to observe the wound for erythema, warmth, swelling, and drainage because these findings may indicate infection. Use of standardized wound care instructions improves patients compliance and understanding.
Future prospects Wound healing is no longer considered to consist of three distinctive phases (inflammation, proliferation, and remodeling). It is a dynamic process with overlapping sequences of coordinated cellular events that involve multiple cell types and a cascade of cytokines and growth factors that control the processes of cell migration, proliferation, matrix synthesis, and turnover [33,46]. New biomaterials will emerge as structures that combine several functions within the same device
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and display mechanical support function and sitespecific drug delivery release for application of growth factors and antibiotics to the wound. Finally, biodegradation of the polymer matrix requires the design of custom-made materials with a range of material properties [37]. A way of research is directed toward modifying existing nondegradable polymers into biodegradable, photodegradable, or hydrolyzable polymers by chemical alteration or inclusion of additives (e.g., sensitizers and biopolymers) and developing methods to exploit native biodegradable polymers [2]. Besides directly biodegradable materials [poly(lactic acid), poly(caprolactone), poly(glycolic acid), and related polymers], hydrolyzable polymers (e.g., polyesters, polyanhydrides, and polycarbonates) and modified biopolymers (cellulose, starch) are of particular potential [2]. Currently, although multiple growth factors have been tested clinically, the only growth factor approved by the Food and Drug Administration for clinical use is recombinant human platelet-derived growth factor-BB. This growth factor was used in diabetic foot ulcers and culminated in three pivotal trials that involved more than 1000 patients, who demonstrated consistent 10% improvement over controls in the complete healing of ulcers [46]. Marketed as 0.01% Regranex gel (becaplermin), plateletderived growth factor is currently only approved for the indication of diabetic ulcers, although other studies are ongoing [22]. The variability in healing and the multiple factors that impair healing (ischemia, bacteria, aging, and suboptimal nutrition) undoubtedly explain much of the difficulty in demonstrating a therapeutic effect with growth factors [46]. Laser-assisted skin closure was shown to improve the wound healing process in male hairless rats when compared to control wounds closed with conventional suture techniques. Laser-assisted skin closure led to an acceleration and improvement of wound healing with earlier continuous epidermis and dermis and a thinner resulting scar [9]. Clinical application of biomaterials research will steadily increase in the future of wound closure procedures [50]. Because currently used biomaterials for wound closure display proinflammatory signs and foreign body reaction instead of sound biodegradation, new biodegradable polymers will emerge and change the field of currently widespread and wellaccepted biomaterials such as poly(glycolic acid) and poly(lactic acid). A promising field is nontoxic biodegradable peptide-based polyurethanes with carbohydrate-sidechains as soft extender [1,78]. They are superior to most existing polymers because of
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significant higher biocompatibility that allows cell growth of various types. They do not display noticeable foreign body reactions, antibody responses, inflammatory reactions, or necrosis of the surrounding tissue and permit covalent binding of substrates to be released as bioactive forms to the wound out of sutures, adhesives, and wound dressings. Currently, conventional nonbiodegrading polyurethanes are used extensively in biomedical applications [1,78]. Future advances in wound closure will involve the development of improved suture biomaterials and wound closure tapes, absorbable adhesives, and wound dressings [16]. Nontoxic absorbable materials will revolutionize wound care. Closure of wounds without the need for sutures will be a major advancement, an opportunity to improve care for patients, especially children, and reduce pain and anxiety caused by treatment [77].
References [1] Agarwal S, Gassner R, Piesco N, Ganta S. Tissue biodegradable urethanes for biomedical applications. In: Lewandrowski K-U, Trantolo DJ, Wise DL, Gresser DJ (editors). Tissue engineering and biodegradable equivalents: scientific and clinical applications. New York: Marcel Dekker; 2002. [2] Albertsson AC, Karlsson S. Degradable polymers for the future. Acta Polymer 1995;46:114 – 23. [3] Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317 – 20. [4] Barefoot J, Toriumi D, Thorn M, et al. Food and Drug Administration Physician Advisory Panel Presentation. Rockville, MD; January 31,1998. [5] Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med 1988;17:496 – 500. [6] Bodiwala GG, George TK. Surgical gloves during wound repair in the accident and emergency department. Lancet 1982;2:91 – 2. [7] Brickman KR, Lambert RW. Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med 1989;18:1122 – 5. [8] Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatr 1998;132:1067 – 70. [9] Capon A, Souil E, Gauthier B, et al. Laser assisted skin closure (LASC) by using a 815-nm diode-laser system accelerates and improves wound healing. Lasers Surg Med 2001;28:168 – 75. [10] Cardany CR, Rodeheaver G, Thacker J, et al. The crush injury: a high risk wound. J Am Coll Emerg Phys 1976;5:965 – 70.
[11] Clark RA. Fibrin sealant in wound repair: a systematic survey of the literature. Expert Opin Investig Drugs 2000;9:2371 – 92. [12] Cruse PJE, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973;107:206 – 9. [13] Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23:535 – 40. [14] Demling RH, DeSanti L. Management of partial thickness facial burns. Burns 1999;25:256 – 61. [15] Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990;19:704 – 8. [16] Edlich RF. Tissue adhesives. Ann Emerg Med 1998; 32:274 – 5. [17] Edlich RF. Tissues adhesives: revisited. Ann Emerg Med 1998;31:106 – 7. [18] Edlich RF, Thul J, Prusak M, et al. Studies in the management of the contaminated wound. VII. Am J Surg 1971;117:394 – 7. [19] Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous stasis ulcers and lack of clinical rejection with an allogenic cultured human skin equivalent: human skin equivalent investigators group. Arch Dermatol 1998;134:293 – 300. [20] Forrest RD. Early history of wound treatment. J R Soc Med 1982;75:198 – 205. [21] Gaboriau HP, Belafsky PC, Pahlavan N, et al. Closure of mucosal defects over exposed mandibular plates using fibrin glue. Arch Facial Plast Surg 1999;1:191 – 4. [22] Galiano RD, Zhao LL, Clemmons DR, et al. Interaction between the insulin-like growth factor family and the integrin receptor family in tissue repair processes: evidence in a rabbit ear dermal ulcer model. J Clin Invest 1996;98:2462 – 8. [23] Gross CW, Gallagher R, Schlosser RJ, et al. Autologous fibrin sealant reduces pain after tonsillectomy. Laryngoscope 2001;111:259 – 63. [24] Greene D, Koch RJ, Goode RL. Efficacy of octyl-2cyanoacrylate tissue glue in blepharoplasty: a prospective controlled study of wound-healing characteristics. Arch Facial Plast Surg 1999;1:292 – 6. [25] Haury B, Rodeheaver G, Vensko J, et al. Debridement: an essential component of traumatic wound care. Am J Surg 1978;135:238 – 42. [26] Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature 1963;200:377 – 8. [27] Hollander JE, Giarrusso E, Cassara G, et al. Comparison of staples and sutures for closure of scalp lacerations. Acad Emerg Med 1997;4:460 – 1. [28] Hollander JE, Richman PB, Werblud M, et al. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1988;31:73 – 7. [29] Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:356 – 67. [30] Hollander JE, Singer AJ, Valentine S, et al. Wound registry: development and validation. Ann Emerg Med 1995;25:675 – 85.
R. Gassner / Oral Maxillofacial Surg Clin N Am 14 (2002) 95–104 [31] Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: the influence of ultra-violet radiation of the operating rooms and various other factors. Ann Surg 1964;160:32 – 81. [32] Howell JM, Newsome J, Bresnahan K. Histologic effect of butyl-2-cyanoacrylate on skin lacerations. Acad Emerg Med 1996;3:426 – 7. [33] Hudson JW. Wound healing. Oral and Maxifollacial Surgery Clinics of North America 1996;8:457 – 599. [34] Kanegaye JT, Vance CW, Chan L, et al. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr 1997;130:808 – 13. [35] Krause RS, Moscatti R, Filice M, et al. The effect of injection speed on the pain of lidocaine infiltration. Acad Emerg Med 1997;4:1032 – 5. [36] Kung A. Evaluation of the undesirable side-effects of the surgical use of histoacryl glue with special regard to possible carcinogenicity. Basel, Switzerland: RCC Institute for Contract Research in Toxicology and Ecology, Project 064315; 1986. [37] Langer R. New methods of drug delivery. Science 1990;28:232 – 6. [38] Macsai X, Marian S. The management of corneal trauma: advances in the past twenty-five years. Cornea 2000;19:617 – 24. [39] Majno G. The healing hand: man and wound in the ancient world. Cambridge, MA: Harvard University Press; 1975. [40] Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconst Surg 2001;107:229 – 37. [41] Manstein CH. What’s wrong with Dermabond? Plast Reconst Surg 1999;104:1587 – 8. [42] Markovchick V. Suture materials and mechanical aftercare. Emerg Med Clin North Am 1992;10:673 – 88. [43] Maw JL, Quinn JV, Wells GA, et al. A prospective comparison of octylcyanoacrylate tissue adhesive and sutures for the closure of head and neck incisions. J Otolaryngol 1997;26:26 – 30. [44] McCaig LF. National hospital ambulatory medical care survey: 1992 emergency department summary. Vital Health Stat 1994;245:1 – 12. [45] Moscati R, Mayrose J, Fincher L, et al. Comparison of normal saline with tap water for wound irrigation. Am J Emerg Med 1998;16:379 – 81. [46] Mustoe TA, Han H. The effect of new technologies on plastic surgery. Arch Surg 1999;134:1178 – 83. [47] Noordiz JP, Foresman PA, Rodeheaver GT, et al. Tissue adhesive wound repair revisited. J Emerg Med 1994;12:645 – 9. [48] Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr 1995;126: 892 – 5. [49] Pirisi A. Cosmetically, tissue adhesives are as good as sutures for closing wounds. Lancet 1998;352:1834. [50] Pulapura S, Kohn J. Trends in the development of
[51] [52]
[53]
[54] [55]
[56]
[57]
[58]
[59]
[60]
[61] [62] [63]
[64]
[65]
[66]
[67]
[68]
103
bioresorbable polymers for medical applications. J Biomater Appl 1992;6:216 – 50. Quinn J. Tissue adhesives. Ann Emerg Med 1998; 32:274. Quinn JV, Maw JL, Ramotar K, et al. Octylcyanoacrylate tissue adhesive wound repair versus suture wound repair in a contaminated wound model. Surgery 1997; 122:69 – 72. Quinn JV, Osmond MH, Yurack JA, et al. N-2-butylcyanoacrylate: risk of bacterial contamination with an appraisal of its antimicrobial effects. J Emerg Med 1995;13:581 – 5. Quinn JV, Wells GA. An assessment of clinical wound evaluation scales. Acad Emerg Med 1998;5:583 – 6. Quinn J, Wells G, Sutcliffe T, et al. Randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997; 277:1527 – 30. Quinn JV, Wells GA, Sutcliffe T, et al. Tissue adhesive vs. suture wound repair at one year: randomized clinical trial correlating early, three-month, and one year cosmetic outcome. Ann Emerg Med 1998;32:645 – 9. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturing techniques. Semin Dermatol 1994; 13:20 – 6. Ritchie AJ, Rocke LG. Staples versus sutures in the closure of scalp wounds: a prospective, double-blind, randomized trial. Injury 1989;20:217 – 8. Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res 1973;14:426 – 30. Rodeheaver GT, Halverson JM, Edlich RF. Mechanical performance of wound closure tapes. Ann Emerg Med 1983;12:203 – 7. Rosen P, Barkin R. Emergency medicine. St. Louis: Mosby-Year Book; 1998. Rothnie NG, Taylor GW. Sutureless skin closure: a clinical trial. BMJ 1963;26:1027 – 30. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med 1998;31:36 – 40. Schauerhamer RA, Edlich RF, Panek P, et al. Studies in the management of the contaminated wound. VII. Susceptibility of surgical wounds to postoperative surface contamination. Am J Surg 1971;122:74 – 7. Simon HK, Zempsky WT, Bruns TB, et al. Lacerations against Langer’s lines: to glue or suture? J Emerg Med 1998;16:185 – 9. Singer AJ, Hollander JE, Quinn JV. Current concepts: evaluation and management of traumatic lacerations. N Engl J Med 1997;337:1142 – 8. Sonnleitner D, Huemer P, Sullivan DY. A simplified technique for producing platelet-rich plasma and platelet concentrate for intraoral bonegrafting techniques: a technical note. Int J Oral Maxillofac Implants 2000; 15:879 – 82. Start NJ, Armstrong AM, Robson WJ. The use of chromic catgut in the primary closure of scalp wounds in children. Arch Emerg Med 1989;6:216 – 9.
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[69] Steele MT, Sainsbury CR, Robinson WA, et al. Prophylactic penicillin for intraoral wounds. Ann Emerg Med 1989;18:847 – 52. [70] Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1994 emergency department summary. Advance data from vital and health statistics. No. 275. Hyattsville, MD: National Center for Health Statistics; 1996. DHHS publication no. (PHS) 96-1250. [71] Swanson NA, Tromovitch TA. Suture materials, 1980s: properties, uses, and abuses. Int J Dermatol 1982;21: 373 – 8. [72] Toriumi DM, Raslam WF, Friedman M, et al. Variable histotoxicity of histoacryl when used in a subcutaneous site. Laryngoscope 1991;101:339 – 43. [73] Toriumi DM, Watson D. Cyanoacrylate tissue adhe-
[74] [75]
[76]
[77] [78]
sives for superficial skin closure. Cur Opin Otolaryng Head Neck Surg 1999;7:214. Wheeler WM. Ants: their structure and behavior. New York: Columbia University Press; 1960. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962;193:293 – 4. Yaron M, Halperin M, Huffer W, et al. Efficacy of tissue glue for laceration repair in an animal model. Acad Emerg Med 1995;2:259 – 63. Zempsky WT, Simon H. Tissue adhesives. Ann Emerg Med 1998;32:275. Zhang JY, Beckman EJ, Piesco NP, et al. A new peptide-based urethane polymer: synthesis, biodegradation, and potential to support cell growth in vitro. Biomaterials 2000;21:1247 – 58.
Wound closure materials Robert Gassner MD, DMD, PhD* Department of Oral and Maxillofacial Surgery, University of Innsbruck, Innsbruck, Austria Department of Oral and Maxillofacial Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Proper wound closure is part of successful overall wound care after the assessment of patient and sustained wound, anesthesia, debridement, and irrigation of the wound. Postoperative care enhances excellent outcome or reduces impaired healing situations. Wound healing disturbances mostly result from neglecting one or more of these steps in wound care regardless of the kind of wound closure material used. The principles of wound care have remained remarkably the same over the years. Although most lacerations heal without sequelae regardless of management, mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality [29,66]. Wounds are one of the most commonly encountered problems in the emergency department. They rival respiratory tract infections as the most common reason people seek medical care [44,55]. Five years ago almost 11 million wounds were treated in emergency departments throughout the United States. At an average charge of $200 per patient, this translates to more than $2 billion annually. When nonemergency or elective incisions are included, approximately 90 million skin-suturing procedures are performed each year [70]. The goals of wound management are simple: avoid infection and achieve a functional and esthetically pleasing scar [66]. These goals are achieved by reducing tissue contamination, debriding devitalized tissue, restoring perfusion in poorly perfused wounds, and establishing a wellapproximated closure.
* Department of Oral and Maxillofacial Surgery, University of Pittsburgh, G-33 Salk Hall, Pittsburgh, PA 15261, USA. E-mail address: [email protected] (R. Gassner).
Most lacerations require primary closure. Primary closure results in more rapid healing and reduced patient discomfort than does secondary closure. The most commonly used method for closing lacerations is suturing. Most wound care practices are empirical or based on animal wound models; few are based on well-designed clinical trials. Most studies of laceration management have focused on the wound infection rate as the primary outcome, despite the fact that wound infections are relatively uncommon (less than 5% of lacerations) [30]. Although all traumatic lacerations should be considered contaminated, most have low bacterial counts (fewer than 100 organisms per gram of tissue), well below the infectious inoculum of 105 or more organisms per gram [59]. Most infected lacerations heal without complications other than the occasional unsightly scar. Patients are most concerned with the cosmetic appearance of their healed lacerations [54], and the focus of physician’s and dentist’s wound research is shifted toward measuring wound cosmesis as the primary outcome, neglecting pressure on development of new biomaterials for wound closure.
History of wounds Humans have managed wounds from the beginning of civilization. The earliest reports of the use of artificial materials come from the Edgar Smith papyrus, which details the use of sutures and wound closure devices around 4000 BC [50]. Initial treatments for wounds consisted of herbal balms or draughts, with application of leaves or grasses as bandages [20]. Ointments were made from a wide variety of animal, vegetable, and mineral substances. Wounds were mostly left open, although wound
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closure using the jaws of ants was used by some cultures [74]. The world’s oldest suture was placed by an embalmer on the abdomen of a mummy in approximately 1100 BC [39]. During the Middle Ages, pus was believed to be necessary for healing; as a result, various agents were used to promote suppuration. Advances in the fields of anesthesiology and surgery during the past two centuries have led to the development of many of the practices that are currently prevalent [29,66]. These advances are based on thorough debridement and cleansing of wounds and the use of aseptic wound closure techniques. Only recently has wound care been investigated systematically in the laboratory and in clinical arenas.
Epidemiology of wounds Approximately one third of lacerations occur in adults between the ages of 19 and 35 years [30], predominantly of male gender. Most wounds are found either on the head or neck (50%). The most frequent mechanism of injury is application of a blunt force, such as a falling against obstacles. Other agents of injury include sharp instruments, glass, and wooden objects [30]. Although mammalian and human bites continue to receive much attention, they are a relatively rare cause of wounds.
A detailed history of allergies to any agents is essential (e.g., anesthetic agents and antibiotics, latex products). Tetanus immunization status should be verified.
Wound assessment Besides discussion on the necessity of sterile conditions for treatment of wounds [6], powder-free gloves reduce the risk of any foreign body reactions or infections that theoretically may result from the introduction of talc particles into the wound. The wound is examined meticulously in all cases. Proper lighting and control of bleeding are required to identify any injury to vital structures (such as nerves and tendons) and foreign bodies that may contaminate and lead to chronic infection and delayed healing [29,66]. Failure to diagnose foreign bodies is the fifth leading cause of litigation against emergency physicians [29]. Other common wound-related causes of litigation include the development of wound infections and missed injuries of tendons and nerves. Crush injuries, which tend to cause greater devitalization of tissue, are more susceptible to infection than are wounds that result from the more common shearing forces [10].
Anesthesia of the wound Patient assessment Increased wound infection rates or delayed healing exists for patients with diabetes mellitus, obesity, malnutrition, chronic renal failure, advanced age, and use of steroids [12]. All of these risk factors, together with the use of chemotherapeutic agents and other immunosuppressive agents, may delay wound healing by affecting inflammation and the synthesis of new wound matrix and collagen [31]. Healing also may be impaired in inherited and acquired connective-tissue disorders, such as EhlersDanlos syndrome, Marfan syndrome, osteogenesis imperfecta, and protein and vitamin C deficiencies. The tendency of the patient to form keloids should be ascertained because this may result in a poor scar [66]. Keloids extend beyond the boundaries of the original injury and are largely determined by genetic or racial predisposition. Conversely, hypertrophic scars, which remain within the boundaries of the original injury, usually result from a tissue deficiency or from the fact that the wounds are not parallel to the lines of minimal skin tension [66].
For adequate evaluation and management before wound closure, many lacerations require anesthesia. There are two major classes of local anesthesia: esters and amides. Several possibilities for patientfriendly administration of local anesthesia exist, including warming of the anesthetic solution to body temperature, slowing the rate of injection, and injecting the local anesthesia through the wound edges of the laceration instead of through the intact surrounding skin. Use of smaller needles and subcutaneous rather than intradermal injection also has been suggested to result in less pain [35,63]. Buffering of the local anesthesia with sodium bicarbonate at a ratio of 1:10 provides a more rapid and less painful onset of anesthesia.
Wound preparation, debridement, and irrigation Cleaning the wound is an important step before wound closure. Although scrubbing with a highporosity sponge in highly contaminated wounds achieves beneficial effects, such as bacteria and
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particulate matter removal, deleterious effects may occur caused by intense scrubbing that results in further tissue damage. Nonviable tissue may impair the ability of the laceration to resist infection. Surgical debridement of any crushed or devitalized tissue is one of the most fundamental aspects of wound preparation [25,66]. Eyebrow hair should not be removed because it may result in abnormal regrowth. Removal of other hair surrounding a laceration may help facilitate meticulous wound closure. Because many bacteria normally reside in hair follicles, shaving of the hair before repair may increase wound infection rates [66]. Devitalized tissue such as fat, muscle, and skin that remains further impairs the ability to resist infection [25]. Removing such tissue mechanically and surgically is an essential part of wound management. Mechanical debridement may be performed by surgical excision, scrubbing with a surgical sponge, or high-pressure irrigation [66]. Considerable debate exists regarding the exact methods of irrigation, especially on irrigation impact pressures and the nature of the irrigant solutions [25,29,66]. Normal saline solution remains the most cost-effective and readily available choice [15,28]. Because of their tissue toxicity, detergents, hydrogen peroxide, and concentrated forms of povidone-iodine should not be used to irrigate wounds [15,28]. In highly vascularized areas that contain loose areolar tissue, such as the eyelid, high pressures should be avoided [45]. Irrigation may not be required for all low-risk wounds in the face [28].
Wound closure More than 40 different types of sutures exist to close wounds and incisions [66]. It seems to be irrelevant how the wound is held together as long as good healing and esthetics result [41,61]. The time during which wound closure is safe must be tailored individually on the basis of causation, location, and host factors. When wounds are not closed because of a high risk of infection, delayed primary closure should be considered after 3 to 5 days, when the risk of infection decreases, especially if they are large, may have a poor cosmetic outcome, or are associated with discomfort or inconvenience [66]. Most wounds should be closed primarily to reduce patient discomfort and speed healing. Wounds at low risk for infection can be closed 12 to 24 hours after the injury, but for wounds at high risk (contaminated wounds, those in locations with poor vascular supply, and those in immunocompromised patients), primary
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closure should take place within approximately 6 hours. There is a direct relation between the time from the injury to closure of the laceration and the risk of subsequent infection, but the length of this ‘‘golden period’’ is highly variable [5]. Each individual wound must be considered separately, taking the time from the injury until presentation into account in addition to laceration location, contamination, risk of infection, and importance of cosmetic appearance before deciding the form of wound closure. Wounds that are not closed primarily because of a high risk of infection should be considered for delayed primary closure after 3 to 5 days, when the risk of infection decreases.
Options for wound closure The ideal wound closure material permits a precise wound closure, is easily and rapidly applied, is painless, is inexpensive and of low risk to patients and providing persons, and results in minimal scarring with a low infection rate. Sutures Sutures are the most commonly used wound closure material. Nonabsorbable sutures, such as nylon and polypropylene, retain most of their tensile strength for longer than 60 days, are relatively nonreactive, and are appropriate for closure of the outermost layer of the laceration [42,57,71]. Removal of nonabsorbable sutures is required. Absorbable sutures are generally used for closure of structures deeper than the epidermis. In general, synthetic absorbable sutures are less reactive and have greater tensile strength than sutures from natural sources, such as catgut. They increase the time during which the healing wound retains 50% of its tensile strength from less than 1 week to as long as 2 months. Chromic gut lasts for up to 2 weeks and is associated with tissue reactivity. Polyglactin and polyglycolic acid maintain tensile strength for 20 to 28 days and are associated with minimal tissue reactivity. Some synthetic absorbable sutures (e.g., polydioxanone, polyglyconate) preserve their tensile strength for as long as 2 months, which makes them useful in areas with high dynamic and static tension. Use of these sutures should be limited to deeper structures because they may become extruded over time (Table 1) [42,57,71]. Although use of absorbable sutures is generally reserved for subcuticular tissues, rapidly dissolving forms may be used to close the wounds in children
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Table 1 Characteristics of absorbable sutures Suture material
Wound tensile strength
Knot security
Tissue reactivity
Security (d)
Polyglactin (Vicryl) Polyglycolic acid (Dexon) Polyglyconate (Maxon) Polydioxanone (PDS) Chromic gut Surgical gut
Good Good Excellent Excellent Average Average
Good Excellent Average Average Average Poor
Low Low Least Least High High
30 30 45 – 60 45 – 60 10 – 14 5–7
and thereby avoid the discomfort associated with suture removal [29,66,68]. Generally, synthetic and monofilament sutures are preferred over natural and braided sutures because they result in lower rates of infection (Table 2) [29,66]. Staples Staples can be applied more rapidly than sutures. They are associated with a lower rate of foreign body reaction and infection [58]. In general, staples are considered particularly useful for scalp, trunk, and extremity wounds and when saving time is essential (e.g., mass casualties, patients with multiple trauma wounds) [7,58]. They do not allow as precise a closure as sutures, however, and are slightly more painful to
remove. In animal models, staples are associated with lower rates of bacterial growth and lower infection rates than sutures [7]. In clinical series, these effects may be statistically significant but are of limited clinical significance [27]. Comparing suture and staple repair of simple pediatric scalp lacerations stapling resulted in shorter wound closure times, shorter overall times for wound care and closure, and fewer expenses in terms of equipment and total cost based on equipment and physician time [34]. Adhesive tapes Advocates of adhesive tapes proclaim the superiority of tape wound closure because of the resistance to infection of the underlying wound that is greater than
Table 2 Pros and cons of common wound closure materials Technique
Advantages
Disadvantages
Suture
Classic method Careful closure Most resilient tensile strength Lowest dehiscence rate Risk of needle stick
Requires removal Requires anesthesia Greatest tissue reactivity Most expensive method Slowest method
Staples
Rapid application Low tissue reactivity Low cost Low risk of needle stick
Sloppy closure Interferes with older generation imaging technology (CT, MR image)
Tissue adhesives
Rapid application Patient comfort Resistant to infection No need for removal Low cost No risk for needle stick
Less tensile strength than sutures Dehiscence in high-tension areas (such as joints) Cannot be used on hands No bathing or swimming
Surgical tapes
Rapid application Patient comfort Lowest tissue reactivity Lowest infection rates Low cost No risk for needle stick
Frequently falls off Less tensile strength than sutures Highest rate of dehiscence Includes toxic components Cannot be used in the hair Cannot be wetted
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in wounds that contain sutures, staples, or tissue adhesives [16,51]. This unique resistance to infection of tape-closed wounds is attributed to the absence of the sutural, tissue adhesive, or staple foreign bodies in the wound. These wounds require the use of adhesive adjuncts (e.g., tincture of benzoin) that increase local induration and wound infection. Because adhesive adjuncts are toxic to wounds, care should be taken that they do not access the wound. Although the various surgical tapes have different degrees of adhesion, porosity, breaking strength, and elasticity, tapes alone cannot maintain wound integrity in areas subject to tension [60,62]. They have been used in an estimated 1 billion patients but are more often used after suture removal to decrease tension on the wound until they fall off [66]. Tape wound closure is preferred in children because of low discomfort during application. Tissue adhesives The skin of wounds also can be closed by tissue adhesives. They should be applied only topically. Tissue adhesives cannot be used intraorally and cannot replace deep sutures. Approximately 30% of laceration repairs and closure of many surgical incisions may be amenable to skin closure with tissue adhesives; thus, they are not a replacement for sutures but do offer an alternative [55]. Modern tissue adhesives contain cyanoacrylates. Cyanoacrylates were first synthesized in 1949 and used clinically in 1959 as agents to glue skin wounds [29]. Monomeric cyanoacrylates polymerize in the presence of hydroxyl ions, which can be found in water and blood, thereby bonding with the skin. The ethylene portion of the molecule polymerizes. The initial derivatives were methyl-2- and ethyl-2-cyanoacrylates. These derivatives were effective, but the shorter alkyl chains degraded rapidly into cyanoacetate and formaldehyde. These products had significant tissue toxicity that resulted in acute and chronic inflammation. With longer alkyl chains, the toxicity decreases as a result of slower degradation, which limits the accumulation of byproducts. N-butylcyanoacrylates are less toxic than shorter-chain cyanoacrylates and maintain a stronger bond. Longer-chain N-2-butylcyanoacrylate adhesive has been used for wound closure in Canada and Europe for more than 20 years. Throughout this time no adverse effects have been reported [36]. A study in 1985 reported that isobutyl-2-cyanoacrylate implanted into a rat peritoneum induced sarcomas. This study was conducted in rats prone to sarcomas and was never duplicated; nevertheless, it did result in a lack of Food and Drug Administration approval for
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use in the United States [73]. Butylcyanoacrylates do have limitations. After polymerization, the adhesive is brittle and can fragment if flexed. Because of these limitations, butyl compounds have been used for areas that do not cross wound creases and for shorter wounds [29,55]. 2-Octylcyanoacrylate, formulated with plasticizers, is even more stable, has greater flexibility, and maintains a stronger bond. It degrades much more slowly, which leads to its classification as nontoxic. 2-Octylcyanoacrylates (e.g., Dermabond, Ethicon, New Brunswick, NJ) were approved for use in the United States in 1998. Within the first month of availability, more than 3 million units of Dermabond were ordered [29,55]. Studies have shown wound breaking strength to be equal to that of suture-repaired wounds at 5 to 7 days, but the day 1 breaking strength is only approximately 10% to 15% that of a wound closed with 5-0 monofilament sutures [47,76]. Wounds are evaluated and cleaned in a standard fashion. If the wound edges are traumatized or involve multiple tissue layers, appropriate debridement or buried sutures or both are necessary. For more superficial wounds, no buried sutures are needed. The wound edges are manually approximated with fingers or forceps while care is taken not to apply the adhesive between the edges. Interposing the glue into the wound results in greater scarring. The wound is held in position for 30 seconds to complete polymerization. Besides displaying three-dimensional tensile strength, the tissue adhesives act as their own dressing. The wound is waterproof and can be wet in a shower, although soaking may result in decreased strength or peeling of the dressing. Experimentally they have antimicrobial effects against gram-positive organisms and the potential to decrease the rate of wound infections [52,53]. The adhesive holds well on the face, and it usually stays on for 7 to 14 days then sloughs off with the epidermis. There is no need for follow-up for suture removal, which makes this method of care attractive. In general, cyanoacrylates are less expensive than sutures and staples, and patients prefer them [48]. Using tissue adhesives for wound repair is a manual skill, like suturing, and requires careful application. Being a topical closure, wound healing is impaired when adhesive gets between the wound edges, which prevents epithelialization and promotes foreign-body reactions [18,72]. When used properly for topical wound closure, tissue adhesives result in fewer foreign-body reactions than sutures do and can decrease infection rates in contaminated wounds [52]. Histologic studies report no differences in wound healing characteristics between sutured and tissue adhesive repaired wounds [32,47,52].
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Prospective, randomized trials comparing Histoacryl Blue (a butyl-2-cyanoacrylate from Braun, Germany) with 5-0 or 6-0 sutures for repair of small facial lacerations revealed equivalent cosmetic outcome at 3 months and at 1 year [29,56,65,66]. The assessment of wounds 3 months after injury and wound repair provided a good measure of long-term cosmetic outcome [56]. The short-term infection rate was slightly higher for Histoacryl Blue but not statistically different, and the wound dehiscence rate was statistically equivalent. The time to wound closure was more than 50% shorter for the group treated with 2-octylcyanoacrylate. Subset analysis of the data suggested that small lacerations aligned against lines of minimal tension may benefit most from the use of tissue adhesive rather than sutures [65]. Octylcyanoacrylate provides the greatest threedimensional tensile strength of all the cyanoacrylates and is a needleless alternative to sutures for closure of most facial lacerations. It provides excellent cosmetic appearance comparable to that achieved with sutures [4,43,49,56]. If lacerations cannot be approximated manually and skin edges cannot be held together without a lot of tension, the use of tissue adhesives is inappropriate. Adequate strength to the wound closure requires three or four coats of 2-octylcyanoacrylate, which is associated with heat release during polymerization as an exothermic reaction. When tissue adhesives result in suboptimal wound closure or must be removed for some other reason, bathing or application of antibiotic ointment or petroleum jelly may accelerate removal. Acetone can be used when more rapid removal is necessary [29,66]. Opponents of tissue adhesives for wound repair note that adhesives seem to act as a barrier between the growing edge of the incision [16,17,41]. This barrier prevents intimate apposition of the wound edges and delays wound healing. The breaking strength of wounds closed with adhesives is believed to be significantly lower than that of taped wounds without the adhesive. Tissue adhesives also potentiate the development of infection in contaminated wounds. Although this technique may be efficient, the use of tissue adhesives—nonabsorbable compounds whose long-term toxicity has not been proved efficacious—is an appropriate substitute for suturing wounds [16,17,41]. If the cyanoacrylate adhesive gains access to the wound, it remains there despite an increased resistance to wound infection. When wounds that contain tissue adhesives become infected, magnification loupes are necessary to identify and remove the adhesive deposits from the wound. Design and development of absorbable adhesives are of utmost importance to allow wound repair
without infection and with the most esthetically pleasing scar. When comparing 2-octylcyanoacrylate and nonabsorbable sutures or staple repair for wounds in children, the tissue adhesive 2-octylcyanoacrylate was revealed to be an acceptable alternative to conventional methods of wound repair with comparable cosmetic outcome [8]. The use of tissue adhesives has been reported in blepharoplasty [24] and has emerged in the management of corneal trauma [38]. Cyanoacrylates also have been used experimentally in skin, bone, and cartilage grafting, corneal and eyelid surgery, and occlusion of esophageal varices and cerebrospinal fluid leaks [29,66]. Autologous fibrin tissue adhesive made from the patient’s own blood and commercial fibrin sealants might offer a possibility for treatment of intraoral lacerations and wounds but require further examination and proof. Fibrin tissue glue proposes to be an alternative mode of managing hemostasis and wound healing. There is much inconsistency in the data secondary to the use of various fibrin sealant preparations, different animal models and clinical situations, and different application techniques. A consequence to this is the likelihood that different fibrin sealant preparations may be preferred for different clinical situations [11,40]. Comparing fibrin glue, as a bioadhesive, with traditional sutures in closing mucosa over exposed mandibular plates in a cat-model revealed fibrin glue to be safe and well tolerated in cats. Glue application required a shorter operative time and was associated with fewer occurrences of granulation and ulceration when compared with suture fixation. Further studies are indicated to titrate the concentration of fibrin [21]. A prospective, randomized, blinded study using fibrin sealant at the wound site revealed significantly reduced pain and decreased chance of experiencing emesis after tonsillectomy [23]. Wound healing might be enhanced by combining platelet concentrates and fibrin adhesive [67]. Dressings Nonadherent wound dressing for at least 24 to 48 hours has a shielding effect until enough epithelialization is present to protect the wound from gross contamination [64]. Maintaning a moist environment around the wound also has been shown to speed the rate of epithelialization [26,75]. For burns in which the traditional split-thickness skin graft is not available, coverage of open wounds is the fundamental problem. Topical antibiotic dressings and porcine skin have been used extensively [46]. The use of
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xenografts was limited as a temporizing measure, because of intense foreign body reactions and eventual rejections accompanied by a high rate of graft infection. New generations of synthetic skin equivalents have been shown to be superior, with a considerable reduction in the partial-thickness burn healing rate and hospitalization in a clinical trial [14]. These skin equivalents have a bilayered structure. Examples include Apligraf (Novartis, East Hanover, NJ), with live keratinocytes on an acellular dermal matrix, and Integra (Integra LifeScience, Plainsboro, NJ), which consists of reconstituted collagen and danaparoid sodium (chondroitan sulfate) backed by a polymer layer. Both products are currently in use as biologic dressings for the coverage of burn wounds [19,46]. Postoperative care In general, decontamination is far more important than using antibiotics. Antibiotics should be reserved for human and animal bites and for intraoral lacerations and open fractures [13,69]. Avoiding exposure of the wound to sun reduces the likelihood of complications such as hyperpigmentation [66]. Sutures or staples should be removed after approximately 7 days. Periorbitally placed sutures should be removed sooner (within 3 – 5 days) to avoid formation of unsightly sinus tracts. Sutured or stapled wounds should be kept clean and gently cleansed after 24 to 48 hours. Patients with tissue adhesives in place may shower, but they should avoid bathing and swimming. Prolonged moisture loosens the adhesive bond. Gentle blotting to dry the area is preferred to repeated wiping [3,29]. Elevation of the injured area decreases edema formation. Patients should be instructed to observe the wound for erythema, warmth, swelling, and drainage because these findings may indicate infection. Use of standardized wound care instructions improves patients compliance and understanding.
Future prospects Wound healing is no longer considered to consist of three distinctive phases (inflammation, proliferation, and remodeling). It is a dynamic process with overlapping sequences of coordinated cellular events that involve multiple cell types and a cascade of cytokines and growth factors that control the processes of cell migration, proliferation, matrix synthesis, and turnover [33,46]. New biomaterials will emerge as structures that combine several functions within the same device
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and display mechanical support function and sitespecific drug delivery release for application of growth factors and antibiotics to the wound. Finally, biodegradation of the polymer matrix requires the design of custom-made materials with a range of material properties [37]. A way of research is directed toward modifying existing nondegradable polymers into biodegradable, photodegradable, or hydrolyzable polymers by chemical alteration or inclusion of additives (e.g., sensitizers and biopolymers) and developing methods to exploit native biodegradable polymers [2]. Besides directly biodegradable materials [poly(lactic acid), poly(caprolactone), poly(glycolic acid), and related polymers], hydrolyzable polymers (e.g., polyesters, polyanhydrides, and polycarbonates) and modified biopolymers (cellulose, starch) are of particular potential [2]. Currently, although multiple growth factors have been tested clinically, the only growth factor approved by the Food and Drug Administration for clinical use is recombinant human platelet-derived growth factor-BB. This growth factor was used in diabetic foot ulcers and culminated in three pivotal trials that involved more than 1000 patients, who demonstrated consistent 10% improvement over controls in the complete healing of ulcers [46]. Marketed as 0.01% Regranex gel (becaplermin), plateletderived growth factor is currently only approved for the indication of diabetic ulcers, although other studies are ongoing [22]. The variability in healing and the multiple factors that impair healing (ischemia, bacteria, aging, and suboptimal nutrition) undoubtedly explain much of the difficulty in demonstrating a therapeutic effect with growth factors [46]. Laser-assisted skin closure was shown to improve the wound healing process in male hairless rats when compared to control wounds closed with conventional suture techniques. Laser-assisted skin closure led to an acceleration and improvement of wound healing with earlier continuous epidermis and dermis and a thinner resulting scar [9]. Clinical application of biomaterials research will steadily increase in the future of wound closure procedures [50]. Because currently used biomaterials for wound closure display proinflammatory signs and foreign body reaction instead of sound biodegradation, new biodegradable polymers will emerge and change the field of currently widespread and wellaccepted biomaterials such as poly(glycolic acid) and poly(lactic acid). A promising field is nontoxic biodegradable peptide-based polyurethanes with carbohydrate-sidechains as soft extender [1,78]. They are superior to most existing polymers because of
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significant higher biocompatibility that allows cell growth of various types. They do not display noticeable foreign body reactions, antibody responses, inflammatory reactions, or necrosis of the surrounding tissue and permit covalent binding of substrates to be released as bioactive forms to the wound out of sutures, adhesives, and wound dressings. Currently, conventional nonbiodegrading polyurethanes are used extensively in biomedical applications [1,78]. Future advances in wound closure will involve the development of improved suture biomaterials and wound closure tapes, absorbable adhesives, and wound dressings [16]. Nontoxic absorbable materials will revolutionize wound care. Closure of wounds without the need for sutures will be a major advancement, an opportunity to improve care for patients, especially children, and reduce pain and anxiety caused by treatment [77].
References [1] Agarwal S, Gassner R, Piesco N, Ganta S. Tissue biodegradable urethanes for biomedical applications. In: Lewandrowski K-U, Trantolo DJ, Wise DL, Gresser DJ (editors). Tissue engineering and biodegradable equivalents: scientific and clinical applications. New York: Marcel Dekker; 2002. [2] Albertsson AC, Karlsson S. Degradable polymers for the future. Acta Polymer 1995;46:114 – 23. [3] Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317 – 20. [4] Barefoot J, Toriumi D, Thorn M, et al. Food and Drug Administration Physician Advisory Panel Presentation. Rockville, MD; January 31,1998. [5] Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med 1988;17:496 – 500. [6] Bodiwala GG, George TK. Surgical gloves during wound repair in the accident and emergency department. Lancet 1982;2:91 – 2. [7] Brickman KR, Lambert RW. Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med 1989;18:1122 – 5. [8] Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatr 1998;132:1067 – 70. [9] Capon A, Souil E, Gauthier B, et al. Laser assisted skin closure (LASC) by using a 815-nm diode-laser system accelerates and improves wound healing. Lasers Surg Med 2001;28:168 – 75. [10] Cardany CR, Rodeheaver G, Thacker J, et al. The crush injury: a high risk wound. J Am Coll Emerg Phys 1976;5:965 – 70.
[11] Clark RA. Fibrin sealant in wound repair: a systematic survey of the literature. Expert Opin Investig Drugs 2000;9:2371 – 92. [12] Cruse PJE, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973;107:206 – 9. [13] Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23:535 – 40. [14] Demling RH, DeSanti L. Management of partial thickness facial burns. Burns 1999;25:256 – 61. [15] Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990;19:704 – 8. [16] Edlich RF. Tissue adhesives. Ann Emerg Med 1998; 32:274 – 5. [17] Edlich RF. Tissues adhesives: revisited. Ann Emerg Med 1998;31:106 – 7. [18] Edlich RF, Thul J, Prusak M, et al. Studies in the management of the contaminated wound. VII. Am J Surg 1971;117:394 – 7. [19] Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous stasis ulcers and lack of clinical rejection with an allogenic cultured human skin equivalent: human skin equivalent investigators group. Arch Dermatol 1998;134:293 – 300. [20] Forrest RD. Early history of wound treatment. J R Soc Med 1982;75:198 – 205. [21] Gaboriau HP, Belafsky PC, Pahlavan N, et al. Closure of mucosal defects over exposed mandibular plates using fibrin glue. Arch Facial Plast Surg 1999;1:191 – 4. [22] Galiano RD, Zhao LL, Clemmons DR, et al. Interaction between the insulin-like growth factor family and the integrin receptor family in tissue repair processes: evidence in a rabbit ear dermal ulcer model. J Clin Invest 1996;98:2462 – 8. [23] Gross CW, Gallagher R, Schlosser RJ, et al. Autologous fibrin sealant reduces pain after tonsillectomy. Laryngoscope 2001;111:259 – 63. [24] Greene D, Koch RJ, Goode RL. Efficacy of octyl-2cyanoacrylate tissue glue in blepharoplasty: a prospective controlled study of wound-healing characteristics. Arch Facial Plast Surg 1999;1:292 – 6. [25] Haury B, Rodeheaver G, Vensko J, et al. Debridement: an essential component of traumatic wound care. Am J Surg 1978;135:238 – 42. [26] Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature 1963;200:377 – 8. [27] Hollander JE, Giarrusso E, Cassara G, et al. Comparison of staples and sutures for closure of scalp lacerations. Acad Emerg Med 1997;4:460 – 1. [28] Hollander JE, Richman PB, Werblud M, et al. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1988;31:73 – 7. [29] Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:356 – 67. [30] Hollander JE, Singer AJ, Valentine S, et al. Wound registry: development and validation. Ann Emerg Med 1995;25:675 – 85.
R. Gassner / Oral Maxillofacial Surg Clin N Am 14 (2002) 95–104 [31] Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: the influence of ultra-violet radiation of the operating rooms and various other factors. Ann Surg 1964;160:32 – 81. [32] Howell JM, Newsome J, Bresnahan K. Histologic effect of butyl-2-cyanoacrylate on skin lacerations. Acad Emerg Med 1996;3:426 – 7. [33] Hudson JW. Wound healing. Oral and Maxifollacial Surgery Clinics of North America 1996;8:457 – 599. [34] Kanegaye JT, Vance CW, Chan L, et al. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr 1997;130:808 – 13. [35] Krause RS, Moscatti R, Filice M, et al. The effect of injection speed on the pain of lidocaine infiltration. Acad Emerg Med 1997;4:1032 – 5. [36] Kung A. Evaluation of the undesirable side-effects of the surgical use of histoacryl glue with special regard to possible carcinogenicity. Basel, Switzerland: RCC Institute for Contract Research in Toxicology and Ecology, Project 064315; 1986. [37] Langer R. New methods of drug delivery. Science 1990;28:232 – 6. [38] Macsai X, Marian S. The management of corneal trauma: advances in the past twenty-five years. Cornea 2000;19:617 – 24. [39] Majno G. The healing hand: man and wound in the ancient world. Cambridge, MA: Harvard University Press; 1975. [40] Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconst Surg 2001;107:229 – 37. [41] Manstein CH. What’s wrong with Dermabond? Plast Reconst Surg 1999;104:1587 – 8. [42] Markovchick V. Suture materials and mechanical aftercare. Emerg Med Clin North Am 1992;10:673 – 88. [43] Maw JL, Quinn JV, Wells GA, et al. A prospective comparison of octylcyanoacrylate tissue adhesive and sutures for the closure of head and neck incisions. J Otolaryngol 1997;26:26 – 30. [44] McCaig LF. National hospital ambulatory medical care survey: 1992 emergency department summary. Vital Health Stat 1994;245:1 – 12. [45] Moscati R, Mayrose J, Fincher L, et al. Comparison of normal saline with tap water for wound irrigation. Am J Emerg Med 1998;16:379 – 81. [46] Mustoe TA, Han H. The effect of new technologies on plastic surgery. Arch Surg 1999;134:1178 – 83. [47] Noordiz JP, Foresman PA, Rodeheaver GT, et al. Tissue adhesive wound repair revisited. J Emerg Med 1994;12:645 – 9. [48] Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr 1995;126: 892 – 5. [49] Pirisi A. Cosmetically, tissue adhesives are as good as sutures for closing wounds. Lancet 1998;352:1834. [50] Pulapura S, Kohn J. Trends in the development of
[51] [52]
[53]
[54] [55]
[56]
[57]
[58]
[59]
[60]
[61] [62] [63]
[64]
[65]
[66]
[67]
[68]
103
bioresorbable polymers for medical applications. J Biomater Appl 1992;6:216 – 50. Quinn J. Tissue adhesives. Ann Emerg Med 1998; 32:274. Quinn JV, Maw JL, Ramotar K, et al. Octylcyanoacrylate tissue adhesive wound repair versus suture wound repair in a contaminated wound model. Surgery 1997; 122:69 – 72. Quinn JV, Osmond MH, Yurack JA, et al. N-2-butylcyanoacrylate: risk of bacterial contamination with an appraisal of its antimicrobial effects. J Emerg Med 1995;13:581 – 5. Quinn JV, Wells GA. An assessment of clinical wound evaluation scales. Acad Emerg Med 1998;5:583 – 6. Quinn J, Wells G, Sutcliffe T, et al. Randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997; 277:1527 – 30. Quinn JV, Wells GA, Sutcliffe T, et al. Tissue adhesive vs. suture wound repair at one year: randomized clinical trial correlating early, three-month, and one year cosmetic outcome. Ann Emerg Med 1998;32:645 – 9. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturing techniques. Semin Dermatol 1994; 13:20 – 6. Ritchie AJ, Rocke LG. Staples versus sutures in the closure of scalp wounds: a prospective, double-blind, randomized trial. Injury 1989;20:217 – 8. Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res 1973;14:426 – 30. Rodeheaver GT, Halverson JM, Edlich RF. Mechanical performance of wound closure tapes. Ann Emerg Med 1983;12:203 – 7. Rosen P, Barkin R. Emergency medicine. St. Louis: Mosby-Year Book; 1998. Rothnie NG, Taylor GW. Sutureless skin closure: a clinical trial. BMJ 1963;26:1027 – 30. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med 1998;31:36 – 40. Schauerhamer RA, Edlich RF, Panek P, et al. Studies in the management of the contaminated wound. VII. Susceptibility of surgical wounds to postoperative surface contamination. Am J Surg 1971;122:74 – 7. Simon HK, Zempsky WT, Bruns TB, et al. Lacerations against Langer’s lines: to glue or suture? J Emerg Med 1998;16:185 – 9. Singer AJ, Hollander JE, Quinn JV. Current concepts: evaluation and management of traumatic lacerations. N Engl J Med 1997;337:1142 – 8. Sonnleitner D, Huemer P, Sullivan DY. A simplified technique for producing platelet-rich plasma and platelet concentrate for intraoral bonegrafting techniques: a technical note. Int J Oral Maxillofac Implants 2000; 15:879 – 82. Start NJ, Armstrong AM, Robson WJ. The use of chromic catgut in the primary closure of scalp wounds in children. Arch Emerg Med 1989;6:216 – 9.
104
R. Gassner / Oral Maxillofacial Surg Clin N Am 14 (2002) 95–104
[69] Steele MT, Sainsbury CR, Robinson WA, et al. Prophylactic penicillin for intraoral wounds. Ann Emerg Med 1989;18:847 – 52. [70] Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1994 emergency department summary. Advance data from vital and health statistics. No. 275. Hyattsville, MD: National Center for Health Statistics; 1996. DHHS publication no. (PHS) 96-1250. [71] Swanson NA, Tromovitch TA. Suture materials, 1980s: properties, uses, and abuses. Int J Dermatol 1982;21: 373 – 8. [72] Toriumi DM, Raslam WF, Friedman M, et al. Variable histotoxicity of histoacryl when used in a subcutaneous site. Laryngoscope 1991;101:339 – 43. [73] Toriumi DM, Watson D. Cyanoacrylate tissue adhe-
[74] [75]
[76]
[77] [78]
sives for superficial skin closure. Cur Opin Otolaryng Head Neck Surg 1999;7:214. Wheeler WM. Ants: their structure and behavior. New York: Columbia University Press; 1960. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962;193:293 – 4. Yaron M, Halperin M, Huffer W, et al. Efficacy of tissue glue for laceration repair in an animal model. Acad Emerg Med 1995;2:259 – 63. Zempsky WT, Simon H. Tissue adhesives. Ann Emerg Med 1998;32:275. Zhang JY, Beckman EJ, Piesco NP, et al. A new peptide-based urethane polymer: synthesis, biodegradation, and potential to support cell growth in vitro. Biomaterials 2000;21:1247 – 58.