They explained that their young children often contaminated the dressing, that it was too stressful to change the dressing or to remove sutures of scared/anxious children, and that it was too difficult to shower, bathe, or to wash hair with a gauze dressing. Five male patients complained that their busy work life did not allow enough time to visit the hospital for frequent dressing change. Two female office workers who met with business clients frequently felt an overwhelming sense of shame by the display of the gauze dressing.

   Complications. There were no cases of contact dermatitis. Wound complication was noted in 4 tissue adhesive-sutured patients. Wound dehiscence developed in 2 patients, but was healed by conservative dressing without complication. In 2 patients, a stitch abscess was noted. The tissue adhesive coat over the abscess was removed, skin approximation was widened, and the abscess was evacuated. The stitch abscess and dehiscence were healed without complication. Wound complication developed in 2 cases in the 5-0 nylon-sutured group; seroma and resultant wound dehiscence in 2 cases were healed by seroma evacuation and skin re-suture. Wound complication rates did not differ between groups (P = 0.941).

Discussion

   Cyanoacrylate adhesives were first synthesized in 1949, and first used clinically 10 years later. These liquid monomers polymerize via an exothermic reaction when exposed to a fluid or basic medium, and thereby form a strong bond when applied to skin.^1,5–8

   Cyanoacrylate derivatives differ according to the length of their carbon chain and initial formulations used short-side-chain alkyl groups, such as ethyl or methyl groups. The main disadvantage of cyanoacrylates is that they degrade into the histotoxic byproducts, such as cyanoacetate and formaldehyde. These toxic byproducts can induce an acute and chronic inflammatory response in the surrounding tissues, potentially compromising wound healing. Since shorter carbon chain cyanoacrylate derivatives have a more rapid degradation time and release larger quantities of toxic byproducts to surrounding tissues, these cyanoacrylates have not been used clinically.^1,7,8 Subsequently, longer-chain derivatives, such as butyl and octyl, have been developed and degrade more slowly, causing less local toxicity and decreased inflammation. In 1970, butyl-2-cyanoacrylate (Histoacryl®, Braun, Melsungen, Germany) was developed, which had negligible toxicity and a good tissue seal. For a number of years, butyl-2-cyanoacrylate had been used for wound closure, but less strength and flexibility have limited its use.^1,5–7

   Octyl-2-cyanoacrylate is an 8-carbon alkyl derivative that has a breaking strength 3 to 4 times that of butyl-2-cyanoacrylate.^1,5 The US Food and Drug Administration (FDA) approved the use of octyl-2-cyanoacrylate for superficial skin closure in 1998.¹ The tissue adhesive is maintained in the liquid state by an acidic stabilizer, preventing premature polymerization. Upon application, partially ionized water molecules on the skin surface neutralize the stabilizer, thereby allowing polymerization to occur, usually within 10 seconds. Its breaking strength approximates that of a 5.0 monofilament nylon suture, while its plasticizers form flexible bonds. The flexibility of octyl-2-cyanoacrylate allows for nonlinear incisions, and contributes to a decrease in the tension exerted on the skin from movement. It may be used in combination with intradermal or subcutaneous sutures, but not as a substitute. For this reason, it has been used in a wide variety of clinical settings including laparoscopic surgery, orthopedics, plastic surgery, ophthalmology, otorhinolaryngology, and vascular surgery.