CLINICAL REPORTS Octyl-2-cyanoacrylate Tissue Glue (Dermabond) Versus Monocryl Sutures in Lip Ciosure

Paul H.M. Spauwen, M.D., Ph.D., Wendy A.A. de Laat, M.D., Ed H.M. Hartman, M.D., Ph.D.

6 x 0

Objective: To assess the value of octyl-2-cyanoacrylate tissue glue in lip closure versus Monocryl stitches. Design: Closure of a cleft lip can be done using transcutaneous Monocryl 6 X 0 sutures or using octyl-2-cyanoacrylate tissue glue (Dermabond). In 15 consecutive patients, the cleft lip was closed with Monocryl 6 x 0 and in another 15 consecutive patients, Dermabond was applied. Outcome parameters were complications, satisfaction of the parents with the cosmetic result, and the cosmetic result as judged by professionals. Satisfaction of the parents was assessed using a questionnaire and a visual analog scale. The cosmetic result as judged by professionals was measured by rating standardized pictures according to a visual analog scale. Setting: A tertiary referral center for children with craniofacial anomalies. Results: Complications were equal in both patient groups ( p = .273). Satisfaction of the parents, as well as the professionals, with the cosmetic result did not show significant differences between the Monocryl 6 x 0 and the Dermabond groups ( p = .922 and .983, respectively). However, parents were significantly more positive about the cosmetic result than the professionals were ( p = .000). Condusion: The results of lip closure using Dermabond tissue glue equal the cosmetic results of lip closure using transcutaneous Monocryl 6 x 0 sutures. KEY WORDS: lip closure, sutures, tissue adhesive

In lip closure for cleft lip. stitch marks should be avoided, as Millard (1980) has stated. Modem resorbable suture materials such as Monocryl 6 X 0 facilitate uneventful wound healing following cleft lip repair. Recently, several types of tissue glues have been introduced in clinical practice as skin adhesives. Enbucrilate (Hi.sto-acryl; Braun Melsungen. Germany). N-butyl-cyano-acrylate (Indermil: Tyco Healthcare. Mansfield. MA), and octyl-2-cyanoacrylate (Dermabond; Ethicon Inc., Somerville. NJ) promise even better results (i.e.. less visible scars). To assess wound healing and the aspect of scars in patients with cleft lip, we performed a prospective investigation.

PATIENTS AND M E T H O D S

Dr. Spauwen is Professor ot" Plastic Surgery, Radboud University Medical Center, Nijmegen. the Netherlands- Dr. de Laaf Is Resident in Plastic Surgery, Radboud University Mediual Center, Nijmegen. the Netherlands, Dr, Hartman is Plastic Surgeon, Radboud University Medical Cenler. Nijmegen, the Netherlands. Submitted August 2(H).'i; Accepted December 2005. Address correspondence to: Profe,ssor P.H.M. Spauwen. M.D.. Pb.D., 895. Department of Plastic Surgery, Radboud University Medical Center, Reinier Postlaan 4, PO. 9101. 6300 HB Nijmegen. tbe Netberlands. E-mail p.spauwen@plchir.umcn.nl.

In 15 consecutive patients with unilateral or bilateral cleft lip (and palate), Monocryl 6 X 0 was used as the standard method for lip closure, as had been done during the last few years. Four key sutures were placed, after which two or three transcutaneous sutures were applied. These were left alone for spontaneous resorption. In the next 15 consecutive patients, four key sutures and one or two intradermal sutures were applied at the midlevel of the lip (Monocryl 6 X 0). At the epidermal level, the skin itself was adapted using Dermabond. All operations in both series of patients were performed by two skilled plastic surgeons applying the Millard II technique for unilateral cases and the Manchester type of closure for bilateral cases. The age at lip ciosure was 5.3 to 6.4 months. During the follow-up period, two checkpoints for evaluating wound healing and the aspect of scars were defined: 8 weeks and 1.8 to 2.7 years postoperatively. Outcome parameters after 8 weeks were infection or suture granuloma and redness and/ or hypertrophy of the scar. Long-term outcome parameters were complications, satisfaction of the parents as assessed by
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Cleft Paliite-Cratiiofacial Journal. September 2006. Vol. 43 No. 5

TABLE 2 Complications of Wound Healing 8 Weeks Postoperatively Monocrvl 6x0

Sulure granuloma Red scar Hypertrophic scar Good lip Significance (x' test) .05 < p <

Dermahimd

Questionnaires for assessing satisfaction were directed tu overall satisfaction with the aspect of the lip and the nose according to a 100-mm visual analog seale {VAS). Significance was chosen at the p < .05 level (Mann-Whitney test). Photographs were trimmed to the nasolabial region and were shown to a panel of professionals twice with an interval of 6 days (Fig. I). Scoring was based upon a VAS that addressed the cosmetic result. Signihcance was chosen at the p < .05 level (Mann-Whitney test). Interrater and intrarater reliability were determined aiso (one-way analysis of variance). The conduct of this experiment followed ethical guidelines outlined in the Declaration of Helsinki.
RKSULTS

F K ; U R K 1 Thrci- examples of visuai anaioj; scale (VAS) ratings by a team of prnfessional-s. A,Bbad (VAS = 2|; C,l>itKiderati' (VAS = 5); K.Kgood (VAS = 80t.

In Table 1 the characteristics of both patient groups show a relatively equal distribution in unilateral and bilateral clefts, whereas there was quite a difference in gender distribution in the Dermabond and Monocryl 6 X 0 groups. Both surgeons were involved equally in the surgical treatment of [he patients. In the Monocryl 6 X 0 group, one suture granuloma was seen, as well as six red scars and four scars showing hypertrophy 8 weeks postoperatively. Uneventful healing was seen in five lips. In the Dermabond group, no suture granulomas were seen. There were three red scars, three hypertrophic scars. and nine cases of uneventful healing. Wound breakdown did not occur in either group. The results for the Dermabond group showed a tendency toward better wound healing as compared with the Monocryl 6 X 0 group (chi-square test: 0.05 < p < .1; Table 2). In the long-term, the incidence of complications did not show significant differences between groups of patients (chisquare test: p = .273; Table 3). Overall cosmetic results as judged by the parents were equal for both groups of patients (Mann-Whitney test: p = .922). The cosmetic result estimated by professionals showed no differences for both patient groups (Mann-Whitney test: p = .983; Table 4). Comparison of the
TABLE 3 Complications of Wound Healing 2.2 Years (Range = 1.8 to 2.7 Years) Postoperatively

a questionnaire, and assessment of the aesthetic result by a panel of five plastic surgeons and registrars in plastic surgery who judged photographs of the palients. Comphcations were related to suture granuloma (arising from the transeutaneous or intradermal sutures) and redness andAtr hypertrophy of the scar. Significance was calculated according to a chi-square test.

TABLE 1 Characleristits of the Patient Groups

6x0 Number of paiienis Male/fcmalc ratio Unilateral cleft lip Unilateral cleft lip and palate Bilateral clefl lip and palate Lip closure surgeon A Lip closure surgeon H \5 U):5 Derinahoiui

4 5
7 S

15 6:9 6 6 3 7
S

MoniHryt 6X0 Suture granuloma Redness/hypertrophy Good lip Overall complications 3 3 9 d

tiernuihond 2 6 7 S

p Vuliw i)(- lest) 0.624 0.232 0.267 0.273

Spauwen et al.. DF.RMABOND VERSUS MONOCRYL SIJTURKS IN LIP CLOSURE

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TABLE 4 Cosmetic Results as Estimated by the Parents and Professionals According to a Visual Analogue Scale

Monocryl 6X0 Parents Professionals 80.87 (SD 17.68) 64.90 (SD 11.58)

tiennuhand 81,33 (SD 13.20) 65.12 (SD 13.281

p Value (Miinn-Whitiie\> 0.922 0.983

(Greene and Koch, 1999; Ong and Jacobsen, 2002). Incidental wound dehiscence also has been reported (Trott, 1997). Apart from a slight tendency in favor of Dermabond for better wound healing 8 weeks postoperatively, our end results do not reveal a positive effect of application of Dermabond. Because the cost of this type of tissue glue is relatively high compared to Monocryl 6 X 0, we switched again to sutures placed intradermally as much as possible.
RKFKRENCES

Opinions of the parents and the opinions of the professionals reveals that the parent.s judged significantly more positively than the profes.sionals did (Mann-Whitney test: p = .000). Interrater reliability of the (tbservers was high in the first cycle (p = .145), but weaker during the second cycle (/> = .000). Intrarater reliability was high for three observers (/; ^ .78.*i/ .862/.620), but weak for two t>bservers {p - .000/.015).

DISCUSSION

Dermabond appears to be a sufficient tissue glue for wound edge adaptation in the cleft lip. It has the highest tensile strength of glues available today (Bruns and Worthington, 2000). Some authors mention better healing of wounds using Dermabond 1 year after blepharoplasty (Toriumi and O'Grady, 1998). A shorter operation time has been suggested (Quinn and Maw, 1997; Bruns et al.. 1998; Abenovoli, 2001; Magee and Ajkay, 2003). but not all authors support this statement

Abenovoli FM. Using Dermabond. Pla.st Reainsir Surg. 2001; 108:269. Bruns TB. Robinson BS, Smilh RJ. Kile DL. Davis TP. Sulliviin KM. Quinn JV. A new tissue adhesive tor laceration repair in children../ I'ediatr. 1998; 132:1067-1070. Bruns TB. Worthinj;Ion JM. Using tissue adhesive for wound repair: y practical guide to Dermabond. Am Fam Physician. 2(K)O;61;1383-1388. Greene D. Koch RJ. Efficacy of iK:lyl-2-cyanoacrylale tissue glue in biepharoplasty. A prospective controlled study of wound healing characteristics. Arch Fucial Plu.si Siu-i;. 1999:1:292-296. Ong CC. Jacobsen AS. Comparing; wound closure using tissue glue versus subciiticuiar sulure for pediatric surgical incisions: a prospeciive randomized irial- PediutrSiirg tnt. 2(HI2; 18:553-555. Magec WP Ajkay N. Use of octyl-2-i.7anoacrylate in cleft lip repair. Ann Plast Surg. 2(X)3:5O:I-,S. Ahslraci. Millard RD. Clefi Crafi: The Evolution of hs Surgery. Boston: Little. Brown; 1980. Quinn JV. Maw J. Octyl-cyano-acrylaie lissue adhesive versus suture in wound repair in a contaminated wound model. Surgery. 1997; 12:62-79. Toriumi DM, O'Grady K. Use of oetyl-2-cyanoacrylate for skin closure in facial plastic surgery. Ptu.\l Reconstr Surg. I998;I02:2209-2219. Troti AT. Cyano-acrylate tissue adhesives. An advance in wound care. JAMA. 1997;277:l559-b60.