Sutureless surgery with Dermabond Topical Skin Adhesive (Ethicon) is slowly edging its way into oculoplastics. First approved for medical use in 1998, Dermabond (2-octyl cyanoacrylate) is being used in blepharoplasty, dacryocystorhinostomy (DCR) and other oculoplastic procedures. Surgeons who have incorporated the adhesive into their practices report good technical results and favorable responses from patients, who appear to like the idea of being “glued” instead of stitched.
The adhesive application technique is straightforward, requiring no formal instruction. But surgeons who use Dermabond point to a few pitfalls that newcomers to sutureless surgery should strive to avoid. The learning curve, though not especially steep, can be made smooth-er with the right tools and some advice from oculoplastic surgeons experienced in the technique.
Why Go Sutureless?
Charles B. Slonim, MD, affiliate professor of ophthalmology at the University of South Florida in Tampa, has been using Dermabond for about five years. He contends that the surgical results are good and that using glue instead of stitches saves time and money.
“I do like the results with Derma-bond, and it definitely saves me time,” he said. “If I have a blepharoplasty wound where I would put in about 10 stitches in a running fashion, I can easily deliver droplets of glue in less than a minute. At $60 a minute for OR time, that becomes a significant savings in the OR.”
Michael T. Yen, MD, assistant professor of ophthalmology at Baylor College of Medicine in Houston, believes that the per-vial cost of Dermabond is a limiting factor and that the popularity of sutureless surgery will increase if the product’s cost comes down. Nonetheless, he does use the tissue adhesive for certain types of surgery and is pleased with the results.
“I tend to use it only in areas where I think that cosmetically it’s going to have an impact—for example, DCR procedures in the medial canthal region,” he said. “That’s an area of the face that has a tendency to develop hypertrophic scars or noticeable complications from scarring. Using the Dermabond allows me to use fewer sutures or no sutures to close the wound. That minimizes the amount of inflammation in that area and ultimately leads to a better cosmetic result.”
Good results so far. Dr. Yen’s group reported their experience in using tissue adhesive for external DCRs last year in Ophthalmic Plastic and Reconstructive Surgery.¹ Over a 12-month period, the surgeons performed 21 DCR wound closures on 19 patients. They reported no complications from the adhesive application, excellent wound closure in all patients and no wound infections. One patient experienced wound dehiscence (which was treated with forceps debridement of the residual adhesive and reapplication of the tissue glue) and there was an instance of hypertrophic scar formation, which resolved with daily massage. In all patients, the incision closure was judged to be aesthetically equivalent to what would have been expected with an incision closed with sutures.
The sutureless surgery leaves no suture cysts or suture tracks, Dr. Slonim said. And once the adhesive has dried, the skin-to-skin bond is virtually impossible to pull apart with a moderate pull or tug.
The convenience factor. Both Drs. Slonim and Yen noted the convenience, for doctor and patient, of having no stitches to remove. The adhesive usually comes off on its own in seven to eight days, or it can be gently peeled off by the patient.
“Patients like the Dermabond. It’s bactericidal and puts a protective coverage on the wound,” Dr. Slonim said. “And the patient doesn’t have to go to the drugstore and buy a prescription antibiotic ointment.”
The other selling point is that the no-stitch surgery obviates patients’ fear of having their stitches removed. That point is particularly important in young patients. “I do use Dermabond in pediatric patients,” Dr. Yen said, “because to take stitches out, you have to go back to the operating room. There’s risk to the patient and the additional costs of the operating room. In these instances, the tissue adhesive may be more expensive than sutures, but in the global picture, it definitely reduces cost and is less traumatic for the patient.”
With a few tools, some preparation and careful attention to technique, Dr. Slonim believes that ophthalmic surgeons can easily master sutureless surgery.
The tools are simple: a tuberculin syringe, something to pour the Dermabond onto so that it can be drawn up with the syringe, a 27-gauge needle to draw up the adhesive and a 30-gauge needle to apply it.
Packaging with a purpose. Dermabond comes in a single-use crushable glass ampule encased in a plastic vial with a cottonlike applicator tip. Some surgeons mistakenly stick the needle through the vial and directly into the ampule to draw the adhesive out. “What people don’t realize is that there is an initiator in the cotton tip of the Dermabond, and the product needs to pass through this cotton tip,” Dr. Slonim explained. “Not only that, but if you crush the ampule inside, there are little shards of glass that could theoretically be drawn up into the syringe if the shards were small enough.” As a result, for safety and efficacy, the adhesive must be squeezed through the cotton tip applicator onto another surface before it is drawn into the syringe. For that, “I use the lid of a specimen jar,” Dr. Slonim said. “The lid has a little groove on the top, so the Dermabond collects in this little mini-trough and you can put the tip of the tuberculin needle in it and draw it up.”
From syringe to wound. Dr. Slonim then takes the syringe, needle pointing up, and draws back so that all the adhesive hits the rubber plunger. He then squeezes out nearly all the air, leaving about 1/10 cc of air in the syringe. At this point he exchanges the 27-gauge needle for the 30-gauge needle that he uses to apply the adhesive.
When the syringe is pointed downward, a tiny air bubble floats up and separates the Dermabond and the plunger. The cushion of air ensures that all of the Dermabond can be applied, with none left in the syringe. Dr. Slonim gently pushes until a micro-droplet of adhesive appears at the bore of the needle tip. He starts the adhesive application in the middle of the wound. “With gentle pressure on the plunger, you deliver one droplet of adhesive onto the wound,” Dr. Slonim explained. “The droplet ‘runs the wound’ along the seam. I usually use two, sometimes three layers of Dermabond, waiting about a minute between each layer.”
The glue sets in about 45 to 90 seconds and does not require fanning or blowing. The surgeon does have a grace period of about 20 to 30 seconds to wipe off any stray adhesive. It’s a good idea to keep several saline-soaked cotton-tipped swabs nearby to catch runaway droplets or to wipe away excess adhesive.
Ophthalmic surgeons who want to try tissue glue should keep several other precautions in mind. For instance, the skin edges of the wound must be ab-solutely dry and free of debris such as dried blood or microbicide before the adhesive is applied. The minute Dermabond hits anything moist, it polymerizes, sets up and will not work as intended. Moreover, any moisture between the wound edges will leave a small gap in the wound. When the adhesive is applied, it will fill in these gaps, preventing the wound edges from touching. Although small gaps may eventually granulate in, careful wound preparation can prevent the problem.
An extra subcutaneous stitch will help ensure that the wound edges touch without any tension. If subcutaneous stitches are not well approximated, Dr. Slonim noted, a skin edge can imbricate, potentially leaving a noticeable groove. The surgical assistant plays an integral role in successful adhesive application by pushing small gaps together or pulling excessive or rolled skin edges apart so that only the wound edges touch.
Wounds that are not flat require special attention because the adhesive will run downhill from the wound onto surrounding skin. Wetting the skin surrounding the wound will help prevent runaway adhesive because the glue polymerizes upon contact with the water. Similar care is required with the medial aspect of a lid crease wound to keep the adhesive from running into the medial canthus.
Learn before you leap. “There definitely is a learning curve to preparing the tissue before you apply the adhesive and in applying the adhesive appropriately,” Dr. Yen added. “You can’t just slap it on and expect it to glue things together. If it isn’t done properly, you can get premature release of the tissues and gaping of the wound.”
These caveats aside, tissue adhesives appear to have few downsides and are expected to assume a greater role in oculoplastic surgery. “Dermabond and other adhesives are enticing,” Dr. Yen said. “They offer convenience benefits for the surgeon because you don’t have to spend a lot of time putting in sutures. They are convenient for patients because cosmetically they appear less noticeable, and the patient doesn’t have to come back for sutures to be removed.”
1 McKinley, S. H. and M. T. Yen. Ophthal Plast Reconstr Surg 2005;21:197–200.
Drs. Slonim and Yen have no related financial interests to disclose.