This study included only those patients who had a classical preauricular fistulectomy (no incision and drainage) and those patients who could receive follow-up for at least 3 months.

   The advantages and disadvantages of the tissue adhesive, including the additional cost, were explained to the patients preoperatively. The adhesive was used only for those patients who gave written permission. Those who permitted its usage were called the adhesive-sutured group, and the others were referred to as the 5-0 nylon-sutured group.

   Surgical preauricular fistulectomy techniques. Adult patients underwent the operation under local infiltrative anesthesia as outpatients; children were given general endotracheal anesthesia and were admitted for 2–3 days. Preauricular fistulectomy was performed as follows: to prevent incomplete removal, the sinus tracts were dissected meticulously; a probe was used in all cases to define the sinus tracts. The portion of auricular cartilage attached to the sinus tract was usually removed. All cystic structures and fibrous tissues within the superficial temporal vessels, temporalis fascia, and conchal cartilage, were removed completely. A silastic drain was usually inserted to minimize any dead space during wound closure. For all patients, a subcutaneous re-approximation was made with an interrupted 4-0 Vicryl suture (Ethicon Inc, Somerville, NJ).

   Surgical skin closure techniques. For the patients whose skin was closed with a 5-0 nylon suture, the epidermal approximation was made in an interrupted simple or vertical matrix. The silastic drain, which was usually about 3 mm x 20 mm, was inserted through the surgically incised wound. In the time between operation (for outpatients) or discharge (for inpatients) and suture removal, it was recommended that the patients change the dressing on a daily basis in addition to keeping the wound dry.

   For the patients whose skin was approximated with the tissue adhesive, a small opening was made for a silastic drain before the subcutaneous suture. A #11 bladed knife made this opening from the most-dependent portion of the surgical wound to the orifice of external auditory canal away from the auricular cartilage; this portion was very thin and facilitated insertion of a silastic drain. After the silastic drain was inserted and a subcutaneous suture was made with a 4-0 Vicryl suture, the skin was cleaned with saline- and alcohol-soaked gauze where the tissue adhesive was applied. It was applied over the skin incision in multiple thin layers (Figure 1). A 10- to 20-second delay between applications was required to allow the previous layer to dry. A 1- to 2-mm gap between the applicator tip and the skin surface was maintained to create surface tension during application. After it dried, a compression dressing was applied. The silastic drain was left in the wound for 1–2 days, and thereafter was removed along with the compression dressing. Inpatients were discharged without a wound dressing on the day when the compression dressing and a silastic drain were removed. The only coverage consisted of a cotton ball placed on the cavum concha, which was enough to cover the drain-inserted site. Immediately after discharge, the patients were allowed to wash their face and hair, or to shower/bathe.

   Evaluations. Postoperative photographs of all patients were taken at least 1 month after the operation. One otologist assessed unidentified photographs and was blinded to the type of wound closure received (the tissue adhesive versus 5-0 nylon suture).