Boring Question | Are wound closure strips an acceptable alternative to tissue-adhesives?

Your next patient is a seven-year-old boy with a 3 cm linear laceration to his calf that he sustained sliding into second base during his little league baseball game. The patient was seen 3 months ago for a facial laceration that was repaired with sutures according to his mother. She reports he was very uncomfortable with the stitches last time, and would like to know “if there is some other way to do it without hurting him.” You walk over to the cart looking for the tissue-adhesive … but find that you have run out! What can you do?

Boring Question:

Are wound closure strips an acceptable alternative to tissue-adhesives?

Discussion:

In a study of pediatric Emergency Department patients receiving wound closure strips vs tissue adhesives, the two treatments were found to have equally acceptable cosmesis by parents and plastic surgeons(1). Adhesive strips are somewhat easier to apply, and based on the above case, this may be a legitimate concern when one considers issues around ED flow and staff requirements needed to assist with suturing toddlers and/or younger children.

Likewise, a review of 12 studies (2) showed no cosmetic difference or rate of infection between tissue adhesive, sutures, staples, or closure strips, though wound dehiscence was slightly higher for tissue adhesives (NNH – 25). wound closure strips were found to have a slight edge in patient satisfaction, closure time, and lower incidence of erythema. Additionally, this study (3) examined the economics behind tissue adhesives, wound closure strips, and sutures. Wound closure strips were found to have the lowest cost per laceration, cost per infected laceration, and cost per dehiscence of the three, with cosmetic outcomes equivalent in this study.

Conclusion:

You discuss the above findings with the patient’s mother, who is elated that her child does not need “a numbing shot” or “the glue.” You explain that for smaller lacerations in areas of low tensile strength, tissue-adhesive strips are an acceptable option. However, you further explain that on areas of the body that are under significant tensile strength such as an elbow or knee, sutures will still likely be required to ensure proper closure and prevent dehiscence.

Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002;19:(5)405-7. [pubmed]
Gkegkes ID, Mavros MN, Alexiou VG, Peppas G, Athanasiou S, Falagas ME. Adhesive strips for the closure of surgical incisional sites: a systematic review and meta-analysis. Surg Innov. 2012;19:(2)145-55. [pubmed]
Zempsky WT, Zehrer CL, Lyle CT, Hedbloom EC. Economic comparison of methods of wound closure: wound closure strips vs. sutures and wound adhesives. Int Wound J. 2005;2:(3)272-81. [pubmed]

Reviewing with the Staff

by Dr. Brian Lin, MD, FACEP of Kaiser Permanente, San Francisco, CA.
Dr. Lin (@bwlin720) is an Assistant Clinical Professor at UCSF. He is the guru behind www.lacerationrepair.com.

The placement of wound closure strips is an under-utilized practice, and the authors of this article do a nice job of driving this point home. Tape strips are cheap, cost-effective, and rapid for closure of minor lacerations under little tension. However, failure to use this technique regularly also creates one of its biggest pitfalls: a lack of understanding of the proper technique of application. This in turn may lead to its complications, which include premature strip sloughing, wound dehiscence, and skin shearing with traction blistering.

Key points to remember in the application of tissue adhesive tapes are as follows:

Select the wound properly. Tape doesn’t work as well on hair-bearing areas, mucosal surfaces, and areas that tend to sweat like the axilla or groin. It is tougher to apply to irregular wounds and won’t hold tension well on convex surfaces. Exudative and bleeding wound tend to cause tape dehiscence.

Handling the tape is best accomplished using a pair of toothed forceps–as opposed to your gloved fingers, which tend to cause the tape to get twisted and kinked.

Most importantly—for a wound with tension, be sure to pinch the wound edges together, then apply tape tension-free to both sides of the wound. This is preferred to applying the tape to one wound edge, then pulling the taped edge to the other side of the wound, which can lead to uneven distribution of shearing forces across the surface of the wound.

I encourage readers with less familiarity to review the placement technique at my website, with this particular post.

This post has been reviewed by Drs. B. Lin and T. Chan.