Use of 2-Octyl-Cyanoacrylate Skin Adhesive (Dermabond) for Wound Closure following Reduction Mammaplasty: A Prospective, Randomized Intervention Study:

Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: A randomized evaluator-blinded split-wound comparative effectiveness trial

BACKGROUND

Dermatologic surgeons are increasingly using surgical adhesives in their practice. Studies comparing sutured wounds to those that utilize a combination of suturing and skin adhesive have not been previously conducted.

OBJECTIVE

To compare the cosmetic outcome and patient wound care satisfaction of an intermediate suture closure with an intermediate suture closure followed by the application of 2-octyl cyanoacrylate (2-OCA).

METHODS

Fifty patients were enrolled in a randomized, evaluator-blinded, split-scar study. Following intermediate sutured closure of a surgical defect, one side of the wound was randomized to receive an additional application of 2-OCA. After 3 months, the scar was assessed using the POSAS tool and patients reported wound care preferences.

RESULTS

As the primary outcome measure, the mean sum of observer POSAS was 12.80 for sutured closure alone versus 12.40 for sutured closures followed by 2-OCA (P = .49).

LIMITATIONS

Single-center study of a relatively homogenous population.

CONCLUSION

Although there were no significant differences in scar cosmesis, both patients and observers tended to prefer the side with an additional application of 2-OCA in most POSAS components, in overall opinion, and in patient wound care satisfaction. Dermatologic surgeons may add this to their practice without sacrificing scar outcomes or patient satisfaction.

Breakthrough treatments for accelerated wound healing

Skin injuries across the body continue to disrupt everyday life for millions of patients and result in prolonged hospital stays, infection, and death. Advances in wound healing devices have improved clinical practice but have mainly focused on treating macroscale healing versus underlying microscale pathophysiology. Consensus is lacking on optimal treatment strategies using a spectrum of wound healing products, which has motivated the design of new therapies. We summarize advances in the development of novel drug, biologic products, and biomaterial therapies for wound healing for marketed therapies and those in clinical trials. We also share perspectives for successful and accelerated translation of novel integrated therapies for wound healing.

Patient and Clinician Reported Outcomes of the Inframammary Incision "Short Scar Technique" in Primary Breast Augmentation

Background

Breast augmentation is a common aesthetic surgery procedure and surgeons are constantly trying to develop techniques that help improve patients' outcome. One of the most important aspects is achieving a favorable scar. The "traditional" breast augmentation scar is in the inframammary fold (IMF), whereas trans-axillary and trans-umbilical approaches have been described as an attempt to move the "location" of the scar and make it less noticeable. Nonetheless, relatively little attention has been paid to improving the IMF scar, which remains the most commonly used scar for silicone implants.

Objectives

The authors have previously described a technique that uses an insertion sleeve and custom-made retractors to allow implant insertion through a shorter IMF scar. However, at the time, the authors did not evaluate the quality of the scar and patient satisfaction. In this manuscript, the authors describe patient and clinician-reported outcomes for this short scar technique.

Methods

All consecutive female patients, undergoing primary aesthetic breast augmentation with symmetric implants were included in this review.

Results

Three different scar-assessment scales demonstrated good results at 1-year postop, as well as the good correlation between patient-reported and clinician-observed scores. BREAST-Q subscale for overall satisfaction also demonstrated good overall patient satisfaction.

Conclusions

Besides providing an added aesthetic value to the result of breast augmentation, a shorter scar may also appeal to patients who are concerned about the size and quality of postoperative scars and like to search for "before and after" pictures prior to scheduling consultations.

Level of Evidence 4

Novel In Vitro Study to Assess Microbial Barrier Properties of Polyurethane-Based Tissue Adhesives in Comparison to the Gold Standard Dermabond®

Tissue adhesives as a physical barrier to microorganism penetration provide an alternative method with many advantages for wound closure in surgical settings compared to the clinical standard. This raises the need of developing and conducting in vitro methods that are sensitive and reproducible to assess their microbial barrier properties. In this study, three different polyurethane-based tissue adhesives with different physicochemical properties were evaluated in comparison to Dermabond® as a clinical gold standard for topical wound closure. Here, physicochemical properties varied in lactide concentration, viscosity, processing, and the full polymerization time. To evaluate the microbial barrier function, a 5 μl aliquot of E. coli Lux inoculum containing at least 1 × 109 CFU/ml was applied to the surface of each test adhesive and sterile filter paper as the control that was placed on an agar plate and incubated at 37°C. Plates were observed for bacterial growth (morphology), the adhesion of the adhesive/filter paper, and bioluminescence after 24, 48, and 72 hours. The data presented in this in vitro model indicated that polyurethane-based tissue adhesives with lactide concentration ≥ 5% provided a suitable barrier against microbial penetration with 95% confidence of 99% efficacy for 72 h along with Dermabond®. Interestingly, the here described method was able to discriminate between the different physicochemical properties showing a better microbial barrier function with increasing lactide concentration of the adhesive. Overall, the results of this study showed the noninferiority between Dermabond® and the two abovementioned polyurethane-based tissue adhesives.

Effect of tissue adhesives in repairing perineal trauma during childbirth: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To investigate the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth.

BACKGROUND

Due to the high incidence and severe consequences of perineal trauma during childbirth, tissue adhesives are recommended as an alternative to conventional sutures to repair perineal trauma. Although many original studies have explored the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth, these studies have differed in participants, interventions and outcomes. Therefore, the effect of tissue adhesives on wound healing and pain relief in perineal trauma during childbirth is inconclusive.

DESIGN

A systematic review and meta-analysis based on PRISMA 2020.

METHODS

A systematic and comprehensive literature search was conducted. Eight electronic databases, three clinical trial registers, and grey literature were searched from inception to 28th April 2021 and reference lists were also retrieved. Randomised controlled trials (RCTs) involving women with first- or second-degree perineal lacerations or women who underwent episiotomy were included. The intervention was the use of tissue adhesives alone or in combination with sutures. For the outcome indicators of perineal wound healing and pain relief, subgroup analyses based on the extent of perineal trauma and measurement time points were conducted, respectively.

RESULTS

A total of 14 RCTs involving 2264 participants were included in this research. The results indicated that for first-degree lacerations, the incidence of wound complications was significantly higher in the tissue adhesives group. In contrast, for episiotomy, the effect of the combination of tissue adhesives and sutures was comparable to that of sutures exclusively. The pooled results revealed that tissue adhesives exerted a positive effect on relieving immediate and short-term perineal pain, but no significant difference was found in the effect of long-term pain relief. Moreover, this review also supported the effect of tissue adhesives in shortening intraoperative repair time and improving clinician-maternal satisfaction.

CONCLUSIONS

The existing evidence illustrates that tissue adhesives effectively promote perineal wound healing and relieve immediate and short-term pain. However, for first-degree lacerations, the increased occurrence of wound complications must be prudently considered when applying tissue adhesives alone, whereas, for episiotomy, the combination of tissue adhesives and sutures may be a promising repair alternative. Future studies are encouraged to adopt long-term effect, adverse effect, and cost-effect analysis as important outcome indicators to comprehensively validate the applicability and generalisability of tissue adhesives.

RELEVANCE TO CLINICAL PRACTICE

For first-degree perineal lacerations, we do not recommend using tissue adhesives alone to repair the wound, given the increased wound complications. While for episiotomy, the combination of tissue adhesives and sutures may be a promising alternative to the use of sutures exclusively. Additionally, the adverse effect and long-term effect of using tissue adhesives alone to repair perineal trauma should be further clarified.

A Prospective, Randomized and Controlled Study on Tissue Adhesive for Skin Incision in Total Knee Arthroplasty

Background

The study focusing on the tissue adhesive in total knee arthroplasty (TKA) was rare. This study aimed to evaluate the clinical outcomes and economic costs of tissue adhesive when acting as the adjunct to standard incision closure in TKA.

Patients and Methods

From September 2019 to November 2019, we prospectively enrolled the consecutive patients who underwent simultaneous bilateral TKA in our institute. The allocation using the tissue adhesive was done after the subcuticular suture in right knee first and another method was applied in the left knee automatically. The patients’ demographics, length of stay (LOS), times of dressing changes and incision-related cost, range of motion (ROM), incision-related complications and incision evaluation scores were recorded.

Results

Thirty-two patients were enrolled in this study and followed at two months after surgery. In the knees of tissue adhesive, the times of dressing change and patient scar assessment scores (PSAS) were significantly less than those standard skin closure (p=0.000; p=0.003). Although there were no significant differences of the delayed discharge, incision-related cost, ROM, incision-related complications and Vancouver scar score (VSS) between two groups, 65.6% (21/32) patients preferred the tissue adhesive and only 15.6% (5/32) patients preferred the standard incision closure.

Conclusion

Tissue adhesive could effectively reduce postoperative wound drainage and improve patients’ satisfaction rate with no difference in medical costs and ROM in TKA. The application of tissue adhesive and subcuticular sutures might be one safe and convenient method of skin closure in TKA.

Chinese Clinical Trial Registry

ChiCTR1900025730; Registered 6 September 2019.

Subcuticular sutures for skin closure in non-obstetric surgery

BACKGROUND

Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications.

OBJECTIVES

To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery.

SEARCH METHODS

In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers.

AUTHORS' CONCLUSIONS

There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.

Patient and Physician Assessment of Surgical Scars: A Systematic Review

Importance

Surgical scarring affects patients by distracting the gaze of onlookers, disrupting social interactions, and impairing psychosocial health. Patient and physician agreement regarding ideal scar characteristics is important in developing congruent expectations after surgery.

Objective

To summarize published studies assessing patient and physician ratings of surgical scars, rates of patient and physician agreement in scar assessment, and elements of cutaneous scar assessment that differ between patients and physicians.

Evidence Review

A literature search of Ovid/Medline, PubMed, and EMBASE was conducted from January 1, 1972, to August 1, 2015. Prospective studies comparing scars from different surgical techniques using at least 1 physician-reported and patient-reported scar measure were included. Strength of studies was graded according to the Oxford Centre for Evidence-Based Medicine guidelines.

Findings

The review identified 29 studies comprising 4485 patients. Of the 29 included studies, 20 (69%) were randomized clinical trials (RCTs), 5 (17%) were prospective, nonrandomized studies, and 4 (14%) were descriptive studies. Disagreement between patients and physician evaluation of scars occurred in 28% (8 of 29) studies, with only patients rating scar difference in 75% (6 of 8) of these cases. Patients were more likely to value scar depth while physicians were more likely to value scar pigmentation and relief.

Conclusions and Relevance

Methodologically rigorous studies that include clinician- and patient-reported scar outcomes are uncommon. Studies that incorporate subjective and objective scar grading reveal disagreement between patients and clinicians. Of the incision and wound closure techniques assessed, few affected patient- and clinician-reported outcomes, but the evidence remains weak and future studies are recommended.

Clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape

PURPOSE

To compare clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). We hypothesized that cesarean deliveries with skin closure through 2OPMT may be associated with a lower rate of wound complications and infections as compared with skin closure through SSWWD; we also hypothesized that, accordingly, 2OPMT may be associated with lower hospital length of stay (LOS), hospital costs, and all-cause readmissions as compared with SSWWD.

METHODS

Retrospective, observational study using a research database derived from administrative records routinely contributed by hundreds of hospitals in the USA. We queried the database for patients aged 18-49 years who had an in-hospital low transverse cesarean delivery between 1 January, 2012 and 31 March, 2017. Using records of medical supplies used during deliveries, we identified deliveries for which skin closure was performed by either SSWWD (SSWWD group) or 2OPMT (2OPMT group). Our primary study outcome was a composite endpoint of infection/wound complication diagnosis during the hospital stays in which the deliveries were performed. Our secondary outcomes included: length of stay (LOS) and total hospital costs for the hospital stays in which the deliveries were performed, and all-cause readmissions (30/60/90 days post discharge) to the same hospital in which the delivery was performed. We compared outcomes between propensity-score matched groups using regressions accounting for hospital-level clustering and non-Gaussian empirical outcome distributions.

RESULTS

Each group comprised 2133 patients (4266 total patients; mean age = 30.3 years [SD = 4.6]). Compared with the SSWWD group, the 2OPMT group had statistically significant lower rates of complications (infection, 0.7 versus 1.6%, p = .011; wound complication, 0.6 versus 1.3%, p = .036; composite, 0.9 versus 2.0%, p = .002), shorter LOS (mean = 3.5 days [SD = 1.6] versus 3.7 days [SD = 1.8], p = .007), and lower total hospital costs (mean = $8879 [SD = $3157] versus $9313 [SD = $3311], p = .025). Between-group differences for 30/60/90-day all-cause readmissions were statistically insignificant.

CONCLUSIONS

This large observational study is the first of its kind and provides evidence that cesarean delivery skin closure with 2OPMT is associated with lower rates of in-hospital infection and wound complications, lower LOS, lower total hospital costs as compared with SSWWD.

Incisões cirúrgicas mamárias tratadas com 2-octilcianoacrilato versus sutura intradérmica com fio de nylon: ensaio clínico randomizado

RESUMO Objetivo: avaliar o perfil de segurança e os resultados estéticos do 2-octilcianoacrilato versus sutura intradérmica com fio de nylon em cirurgias mamárias. Métodos: ensaio clínico randomizado, aberto, que avaliou a ocorrência de complicações, como deiscência, hematoma, infecção e reações alérgicas após o uso do 2-octilcianoacrilato ou do fio de nylon. Também foi analisado o tamanho das incisões, o tempo de fechamento da pele e o tempo cirúrgico total. O resultado estético foi avaliado após 40 e 180 dias da cirurgia, por meio da largura média da ferida operatória e por avaliação subjetiva conceitual (ótimo, bom, razoável ou ruim). Resultados: foram incluídas 79 pacientes, sendo 37 no grupo 2-octilcianoacrilato e 42 no grupo de sutura com fio de nylon. O estudo foi interrompido antes do término do recrutamento dos pacientes pela ocorrência de maior número de deiscências no grupo do adesivo (OR: 11,42; IC95%: 1,36-96,02; p=0,007). Em relação às demais complicações analisadas, ao tempo cirúrgico e ao resultado estético no pós-operatório, não se observaram diferenças significativas entre os grupos. A média do tamanho da ferida operatória foi maior no grupo do adesivo em relação ao grupo da sutura, mas não houve correlação entre o tamanho da ferida e o maior número de deiscências. Conclusão: o 2-octilcianoacrilato apresentou maior risco de deiscência em relação à sutura intradérmica, com resultados estéticos equivalentes.

Comparison of 2-Octyl Cyanoacrylate Topical Skin Adhesive and Simple Interrupted Nylon Sutures for Wound Closure in Ankle Fracture Surgery

BACKGROUND

Multiple options are available for closure of incisions in ankle fracture surgery. The aim of our study was to compare postoperative outcomes between conventional simple interrupted nylon sutures and 2-octyl cyanoacrylate as a topical skin adhesive to close the incision after ankle fracture surgery.

METHODS

We retrospectively reviewed the records of 367 consecutive patients (174 simple interrupted nylon suture patients and 193 topical skin adhesive patients) who underwent operative treatment for ankle fracture between 2010 and 2015. Development of wound complications, operative time, Olerud-Molander Ankle Score (OMAS), and patient satisfaction with the wound were compared. The demographics between the 2 groups were not different.

RESULTS

There were no differences in complication rates ( P = .861), OMAS at 3 months or 12 months following surgery ( P = .897 and .646, respectively) between the 2 types of wound closure. Operative time was 9 minutes shorter when topical skin adhesive was used compared to nylon sutures ( P = .003). Patient satisfaction with their wound was significantly higher in the topical skin adhesive group than the nylon skin suture group ( P = .012).

CONCLUSIONS

The use of 2-octyl cyanoacrylate topical skin adhesive for wound closure following ankle fracture surgery was effective, safe, and showed higher patient satisfaction compared to simple interrupted nylon sutures. Although caution should be taken because of the insufficient statistical power of complications, this method was an additional safe option for wound closure in ankle fracture surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Bioadhesives for internal medical applications: A review

Bioadhesives such as tissue adhesives, hemostatic agents, and tissue sealants have gained increasing popularity in different areas of clinical operations during the last three decades. Bioadhesives can be categorized into internal and external ones according to their application conditions. External bioadhesives are generally applied in topical medications such as wound closure and epidermal grafting. Internal bioadhesives are mainly used in intracorporal conditions with direct contact to internal environment including tissues, organs and body fluids, such as chronic organ leak repair and bleeding complication reduction. This review focuses on internal bioadhesives that, in contrast with external bioadhesives, emphasize much more on biocompatibility and adhesive ability to wet surfaces rather than on gluing time and intensity. The crosslinking mechanisms of present internal bioadhesives can be generally classified as follows: 1) chemical conjugation between reactive groups; 2) free radical polymerization by light or redox initiation; 3) biological or biochemical coupling with specificity; and 4) biomimetic adhesion inspired from natural phenomena. In this review, bioadhesive products of each class are summarized and discussed by comparing their designs, features, and applications as well as their prospects for future development.

STATEMENT OF SIGNIFICANCE

Despite the emergence of numerous novel bioadhesive formulations in recent years, thus far, the classification of internal and external bioadhesives has not been well defined and universally acknowledged. Many of the formulations have been proposed for treatment of several diseases even though they are not applicable for such conditions. This is because of the lack of a systematic standard or evaluation protocol during the development of a new adhesive product. In this review, the definition of internal and external bioadhesives is given for the first time, and with a focus on internal bioadhesives, the criteria of an ideal internal bioadhesive are adequately discussed; this is followed by the review of recently developed internal bioadhesives based on different gluing mechanisms.

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

METHODS

A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

RESULTS

High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

CONCLUSION

Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A 1-Year Follow-Up of Post-operative Scars After the Use of a 1210-nm Laser-Assisted Skin Healing (LASH) Technology: A Randomized Controlled Trial

BACKGROUND

Laser therapies are used prophylactically for excessive scar formation. The Laser-Assisted Skin Healing treatment induces a controlled heat stress that promotes tissue regeneration. This comparative trial is the first to evaluate the performance of a new automated 1210-nm laser system, compatible with all Fitzpatrick scale phototypes.

METHODS

Forty women undergoing bilateral breast reduction were enrolled in this double-blinded randomized controlled trial. The horizontal sutured incision of one breast was treated with the portable 1210-nm laser while in the operating theatre. The other breast was used as the study control. Objective measurements, subjective clinical assessments and safety evaluation were carried out over 1 year by both clinicians and patients.

RESULTS

Six weeks following surgery, better overall appearance and modified OSAS scores were reported for the laser-treated scars when compared to the control group (p = 0.024 and p = 0.079). This supports an early effect of the laser treatment during the inflammatory stage of the healing process. After a post-treatment period of 6 months, there continued to be a strong tendency in favour of the laser treatment based on the subjective scores and corroborated by the objective improvement of the treated scar volume (p = 0.038). At 1 year, the laser-treated scars continued to improve compared to the control ones in terms of volume (p = 0.004), surface (p = 0.017) and roughness (p = 0.002), and these comparatively better results were strengthened with the blind expression of patients' preference for their laser-treated scar (p = 0.025).

CONCLUSIONS

This new 1210-nm laser treatment, used as a single session performed immediately after surgery, provides significant objective and subjective improvements in scar appearance. These data can be useful when preparing patients to undergo their surgical procedure.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of a new skin closure device in surgical incisions associated with breast procedures

BACKGROUND

A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner. To determine its clinical utility in breast procedures, a prospective clinical investigation was undertaken to demonstrate equivalence of a new adhesive (PRINEO™ Skin Closure System) to intradermal sutures in wound closure.

METHODS

The investigation comprised 79 patients who underwent elective surgery for bilateral breast procedures. Each breast incision was randomized to wound closure with the PRINEO™ Skin Closure System or intradermal sutures (used in accordance with standard local practice). Postoperative evaluations took place at 24 hours, 7 days, 12-25 days, 90 days, 6 months, and 12 months. Data were collected on the continuous approximation of the skin edges, the time required to close the include final skin layer, the evaluation of incision healing, and cosmesis outcomes. Safety evaluations were related to the incidence and extent of local acute inflammatory reactions, clinical infection, skin blistering, and adverse events.

RESULTS

PRINEO™ Skin Closure System was found to be equivalent to intradermal sutures for the continuous approximation of wounds associated with breast procedures. The upper limit of the one-sided 95% confidence interval for difference in proportions was less than the predetermined 12%, at 5.9%. The mean time to closure for the PRINEO™ Skin Closure System was 2.56 minutes, which was 13.66 minutes faster than that for intradermal sutures (16.22 minutes, P < 0.0001). Time savings may be less if 2 operators close simultaneously. On the other hand, because the device can be applied by 1 operator, the assistant's time may be freed up to attend to other tasks. Both treatments had similar incision healing and cosmetic outcomes. No quantitative or qualitative differences of clinical significance were evident between the treatment groups for local acute inflammatory reactions, clinical infection, or skin blistering. The number of serious adverse events was low, although the number of adverse events was higher, with 54/79 patients experiencing at least 1 adverse event.

CONCLUSION

PRINEO™ Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions associated with breast procedures, with regard to safety and effectiveness. It was also 6.3 times faster than intradermal sutures for wound closure.

The mammalian blastema: regeneration at our fingertips

In the mouse, digit tip regeneration progresses through a series of discrete stages that include inflammation, histolysis, epidermal closure, blastema formation, and redifferentiation. Recent studies reveal how each regenerative stage influences subsequent stages to establish a blastema that directs the successful regeneration of a complex mammalian structure. The focus of this review is on early events of healing and how an amputation wound transitions into a functional blastema. The stepwise formation of a mammalian blastema is proposed to provide a model for how specific targeted treatments can enhance regenerative performance in humans.

Epidermal closure regulates histolysis during mammalian (Mus) digit regeneration

Mammalian digit regeneration progresses through consistent stages: histolysis, inflammation, epidermal closure, blastema formation, and finally redifferentiation. What we do not yet know is how each stage can affect others. Questions of stage timing, tissue interactions, and microenvironmental states are becoming increasingly important as we look toward solutions for whole limb regeneration. This study focuses on the timing of epidermal closure which, in mammals, is delayed compared to more regenerative animals like the axolotl. We use a standard wound closure device, Dermabond (2-octyl cyanoacrylate), to induce earlier epidermal closure, and we evaluate the effect of fast epidermal closure on histolysis, blastema formation, and redifferentiation. We find that fast epidermal closure is reliant upon a hypoxic microenvironment. Additionally, early epidermal closure eliminates the histolysis stage and results in a regenerate that more closely replicates the amputated structure. We show that tools like Dermabond and oxygen are able to independently influence the various stages of regeneration enabling us to uncouple histolysis, wound closure, and other regenerative events. With this study, we start to understand how each stage of mammalian digit regeneration is controlled.

A comparison of 2-octyl cyanoacrylate with nylon for wound closure of knee arthroscopy portals

OBJECTIVE

To compare the cosmetic results, complications and patient satisfaction of 2-octyl cyanoacrylate (Dermabond, Ethicon Inc. Somerville, NJ, USA), a liquid bonding agent, with 3-0 nylon sutures (Ethilon, Ethicon Inc) skin closure in two groups of patients undergoing elective knee arthroscopy at 6 weeks.

METHOD

The retrospective clinical audit recruited patients undergoing knee surgery for the first time between October 2010 and August 2011. The patients were either treated with the liquid bonding agent or nylon sutures. The patients in the bonding agent group were allowed to shower as normal on postoperative day one, while patients in the suture group kept their wounds dry for 2 weeks.

RESULTS

Between the two groups (40 patients per group) there was no difference in the cosmetic outcome (p=0.285), patient satisfaction (p=0.29), pain scores (p=0.44) or wound complication rate (p<0.05). Patient satisfaction was high in both groups. Furthermore, 83.75% of all patients indicated they would prefer the liquid bonding closure over nylon sutures if undergoing the same procedure in the future as they could shower the next day and avoid suture removal.

CONCLUSION

2-octyl cyanoacrylate is safe to use in the short term in knee arthroscopy providing comparable results to nylon suture closure. Allowing patients to shower the next day appears to cause no adverse effects.

DECLARATION OF INTEREST

The authors would like to state that they do not have any economic or social interest in any of the products used or mentioned. No grant or finance was received for this study, nor any input from other sources.

Diffuse Cutaneous Allergic Reaction to Dermabond

Wound closure with 2-octyl cyanoacrylate (Dermabond; Ethicon, Somerville, New Jersey USA) has recently increased in popularity across a wide spectrum of physicians ranging from surgeons to emergency medicine practitioners. Generally, very few complications are associated with Dermabond and are usually related to application techniques. Uncommonly, patients present with allergic reactions to the adhesive compounds; these allergies are often misdiagnosed as cellulitis or another infectious process, and are incorrectly treated. This report describes a rare case of a diffuse cutaneous allergic reaction to Dermabond following its use to close a surgical incision, its prompt identification, and treatment after presentation to an emergency department.

RicciJA, ParekhNN, DesaiNS. Diffuse cutaneous allergic reaction to Dermabond. Prehosp Disaster Med. 2014;29(5):1-3.

Use of 2-octyl cyanoacrylate together with a self-adhering mesh (Dermabond™ Prineo™) for skin closure following abdominoplasty: an open, prospective, controlled, randomized, clinical study

BACKGROUND

Abdominoplasty is one of the most commonly performed procedures in plastic surgery. The appearance of the scar is a major factor that contributes to the aesthetic outcome of the procedure and depends largely on the technique of wound closure. The new Prineo™ wound closure system was introduced to combine the effectiveness of 2-octyl cyanoacrylate (Dermabond™) together with a self-adhering mesh.

METHODS

Fifty-two women and eight men aged between 21 and 65 years who were scheduled for abdominoplasty were included in the study. The total operating times after abdominoplasty of the traditional wound closure technique and the Prineo™-type wound closure technique were compared. Furthermore, an analysis comparing the cost of the two methods was performed. Two weeks after surgery the wounds were examined and graded using the Hollander Cosmesis Scale. At the 6- and 12-month follow-ups, the aesthetic outcome of the abdominal scar was evaluated using the Vancouver Scar Scale. Twelve months after surgery, the patients were asked to answer their part of the Patient Scar Assessment Scale.

RESULTS

The mean total operating time for the new skin closure system was statistically significantly shorter than that of intradermal sutures. The mean price difference per patient was 104.27<euro> (134.79$) in favor of Prineo™. The Hollander Cosmesis Scale indicated a significantly more favorable overall result with Prineo™ at 2 weeks after surgery. The Vancouver Scar Scale demonstrated a better cosmetic outcome in favor of Prineo™ 6 and 12 months after surgery. The Patient Scar Assessment Scale scores 12 months after surgery indicated that the patients noted significantly less pain, thickness, and irregularity with Prineo™.

CONCLUSION

Based on our results, we conclude that Prineo™ is a safe and effective substitute for superficial skin closure, with good cosmetic results and no increase in wound complications. The use of Prineo™ decreases operative time and cost and enhances the patient's postoperative comfort.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Histological effects of occlusive dressing on healing of incisional skin wounds

Occlusive dressing is widely accepted and used to manage skin ulcers. However, with respect to its application to incisional wounds, most studies have been conducted about the clinical effects on incisional healing of surgical sites. Studies of the histological effects of occlusive dressing for incisional wounds have been few. The aim of this study was to clarify the histological effects of occlusive dressings on healing of incisional skin wounds. Rat dorsal skin was incised down to the panniculus and sutured immediately. Dressing types included 2-octyl cyanoacrylate and hydrocolloid materials as occlusive dressings and no-dressing as the open therapy. Histological examination and dermoscopic observation were performed 1, 2, 4 and 7 days after surgery. The findings from each dressing type were compared. In the open therapy group, the upper portion of the edge of incision was necrosed minimally and finally healed with wide scar formation. However, in the occlusive dressing groups, micronecrosis of the incision edge seen in the no-dressing group was not observed, healing was more rapid and the remaining scar was finer. Occlusive dressing can prevent micronecrosis of the incision edge, resulting in rapid and excellent healing. This study shows that the efficacy of and supports the use of occlusive dressing in incisional wound management.

Cyanoacrylate tissue adhesives - effective securement technique for intravascular catheters: in vitro testing of safety and feasibility

Partial or complete dislodgement of intravascular catheters remains a significant problem in hospitals despite current securement methods. Cyanoacrylate tissue adhesives (TA) are used to close skin wounds as an alternative to sutures. These adhesives have high mechanical strength and can remain in situ for several days. This study investigated in vitro use of TAs in securing intravascular catheters (IVC). We compared two adhesives for interaction with IVC material, comparing skin glues with current securement methods in terms of their ability to prevent IVC dislodgement and inhibit microbial growth. Two TAs (Dermabond, Ethicon Inc. and Histoacryl, B. Braun) and three removal agents (Remove™, paraffin and acetone) were tested for interaction with IVC material by use of tensile testing. TAs were also compared against two polyurethane (standard and bordered) dressings (Tegaderm™ 1624 and 1633, 3M Australia Pty Ltd) and an external stabilisation device (Statlock, Bard Medical, Covington) against control (unsecured IVCs) for ability to prevent pull-out of 16 G peripheral IVCs from newborn fresh porcine skin. Agar media containing pH-sensitive dye was used to assess antimicrobial properties of TAs and polyurethane dressings to inhibit growth of Staphylococcus aureus and Staphylococcus epidermidis. Neither TA weakened the IVCs (P >0.05). Of removal agents, only acetone was associated with a significant decrease in IVC strength (P <0.05). Both TAs and Statlock significantly increased the pull-out force (P <0.01). TA was quick and easy to apply to IVCs, with no irritation or skin damage noted on removal and no bacterial colony growth under either TA.

Effective wound closure with a new two-component wound closure device (Prineo™) in excisional body-contouring surgery: experience in over 200 procedures

BACKGROUND

In excisional body-contouring surgery the surgeon is often confronted with time-consuming closure of long wounds. Recently, a new combination of a self-adhering mesh together with a liquid 2-octyl cyanoacrylate adhesive (Prineo™; Ethicon, Inc., Somerville, NJ, USA) has been introduced to replace intracutaneous running suture.

METHODS

An observational study was undertaken to evaluate the efficacy of the new wound closure device in excisional body-contouring procedures between January 2008 and November 2010. Wound characteristics were recorded in a prospectively maintained database.

RESULTS

During the study period, 224 procedures in 180 patients were undertaken. Twenty-seven patients had two subsequent operations and four patients had three subsequent operations. Application of the new device was easy and safe and patient satisfaction with the results was generally high. However, intense local allergic reactions were seen in 4 patients (1.8%), which necessitated early removal and topical corticosteroid treatment.

CONCLUSIONS

Prineo™ enables the surgeon to perform a quick and smooth skin closure, especially in long incisions frequently encountered in excisional body-contouring surgery. The application is fast and easy if basic guidelines are respected. Operating time is saved by eliminating the need for time-consuming intracutaneous running sutures. Removal is easy and painless for the patient. However, there is a potential for local allergic adverse effects of which the surgeon must be aware.

Assessment of Scar Quality after Cleft Lip Closure

Objective

To assess scar quality after cleft lip repair.

Design

The linear scars of patients with cleft lip with or without cleft palate were evaluated in a prospective study using the Patient and Observer Scar Assessment Scale. Linear regression was performed to identify which scar characteristics were important according to patients and observer.

Setting

Regular outpatient follow-up visit with the cleft palate teams of two tertiary centers.

Patients

All consecutive patients were asked to participate in this study after informed consent, minimally 1 year postsurgery.

Main Outcome Measure

Scar characteristics influencing patient and observer opinion after cleft lip repair.

Results

A total of 86 patients with cleft lip with or without cleft palate were included, resulting in evaluation of 99 scars. Two scar characteristics, itching and pain, were seldom a concern for the patients. Linear regression showed that scars assessed longer after surgery had a better outcome.

Conclusion

Scar itching and pain did not seem to have an effect on patient opinion of the quality of the scar, and the majority of the patients were more satisfied with the outcome of their scar than the observer was.

State-of-the-Art Review: Hemostats, Sealants, and Adhesives II: Update As Well As How and When to Use the Components of the Surgical Toolbox

The goal of this submission is to describe how and when to best use hemostats, sealants, and adhesives as well as to compare their characteristics and to update the surgical toolbox with respect to any new products approved by the Food and Drug Administration (FDA) as of this date (November 2009). The materials will be presented in 3 major groups each containing specific categories: (1) hemostats; mechanical, active, flowable, and fibrin sealant, (2) sealants; fibrin sealant, polyethylene glycol polymer, and albumin and glutaraldehyde, (3) adhesives; cyanoacrylate, albumin and glutaraldehyde, and fibrin sealant. The categories will be used for comparisons based on safety, efficacy, usability, and cost. Recommendations with respect to how and when to best use these materials will be presented. A review of the recent literature is also provided with respect to the most recent uses of these materials in specific surgical specialties.