Introduction
As healthcare systems are demanding cost-containment and examining outcomes-based productivity, surgeons must also maximize their efforts, while balancing patient care and resource utilization. We have traditionally closed nasolabial flaps with non-absorbable suture. However, patients have increasingly asked about the “glue” closure they have seen on television and heard about from friends. Additionally, with stress for time and unpredictable patient compliance with wound care and return visits, adhesive closure has become an attractive alternative for both the patient and surgeon. Chemically developed by Ardis 1949 and reported as a surgical adhesive by Coover in 1959, cyanoacrylates have only recently increased in popularity for surgical wound closure. 2-octyl-cyanoacrylate, a commercially available surgical adhesive has FDA approval and has shown success in numerous studies looking at closure efficacy, level of comfort, ease of post-operative care and aesthetics. In this study, we report our experience in the use of a topical skin adhesive in nasolabial flaps.
Methods
Over a four year period from March 2000 to March 2003, we retrospectively examined patients undergoing nasolabial skin flap reconstruction by a single surgeon with multiple residents. Our medical records search included Current Procedural Terminology Codes 14060, 14061, and 14300 for both minor procedure room and operating room procedures based on patient anesthesia needs. Data analysis included patient age, sex, diagnosis, surgical closure technique, pathology, infection, and dehiscence rate. Additionally, patient factors such as smoking status, diabetes mellitus, intravenous drug use, HIV status, and use of steroids were examined. All patients received either traditional two-layer suture closure or single-layer subcuticular approximation with surgical adhesive closure externally. The surgical adhesive was applied with four thin-layer applications in 30-second intervals, as described in manufacturer instructions. All patients were scheduled for a one-week follow-up visit after the initial procedure.
Results
89 patients were identified through our chart analysis, with an average age of 51 years (range 2 to 91). There were 35 female and 54 male patients. 27 patients underwent surgical adhesive closures and 62 traditional suture closures. The procedures were performed mostly for cancer (58.4%), small wounds (27%) or burns (9%). Patient factors of smoking (38.2%), intravenous drug use (0%), diabetes mellitus (14.6%), positive HIV status (2%), and concomitant use of steroids (7.9%) showed no statistically significant correlation with patient outcome. Additionally, infection rate was similar for both the surgical adhesive (3.7%) and suture closure (3.6%) groups. However, dehiscence rate was lower in the surgical adhesive group (3.7%) versus the suture closure (5.5%) groups.
Conclusions
The advantages of surgical adhesive closure are multifold. We were able to achieve comparable results for skin closure between traditional two-layer suture closure and use of surgical adhesive. Previous studies have shown skin adhesives to facilitate faster skin closure, require less time for wound dressings, and reduction of exposure to needle-stick injuries. Additional advantages include less ischemia to the wound edges (a potential benefit in smokers), no need for suture removal, and no need for post-operative dressings. We found a significant difference in dehiscence rate, with surgical adhesive more beneficial than sutures. Although not specifically examined in this study, we feel that surgical adhesive also maximized efficiency while achieving expected results. Facilitating faster closure during the procedures and no need to remove sutures in the clinic allows the surgeon and residents to maximize their efforts and remain productive. As the cost of surgical adhesive continues to fall, the utility of surgical adhesives becomes even more advantageous. While future prospective study is needed, we feel that topical skin adhesives improve patient care and efficiency.