Introduction
Wrong closure technology choices lead to preventable complications. Surgeons face dehiscence, infection, and poor cosmetic outcomes when they mismatch product capabilities with surgical requirements.
According to market projections, the surgical closure market is growing at approximately 10% annually through 2032, driven by demands for faster surgical workflows. This growth reflects adoption of both adhesive technologies (cyanoacrylate, fibrin sealants) and mechanical closure systems (bioabsorbable staplers).
Selecting the right solution determines whether you achieve:
- Rapid closure with waterproof barriers
- Superior cosmetic outcomes without train-track scarring
- Reduced infection risk through proper wound approximation
- Cost-effective closure without removal procedures
Understanding selection criteria and avoiding common pitfalls prevents complications and optimizes both clinical and financial outcomes.
TLDR
- Surgical skin adhesives bond wound edges chemically without mechanical closure devices
- Main types include cyanoacrylates, fibrin sealants, and synthetic polymer alternatives
- Selection depends on wound tension, location, vascularity, speed needs, and cosmetic goals
- Proper selection reduces complications, eliminates removal visits, and improves patient comfort
- Understanding contraindications prevents adhesive failure and wound dehiscence
What Are Surgical Skin Adhesives?
Surgical skin adhesives are liquid or gel formulations that create chemical bonds to hold wound edges together during healing. Unlike sutures that mechanically bring tissue together through thread tension or staples that clamp skin edges, adhesives polymerize on contact with skin moisture to form a protective barrier film.
Different closure methods work through distinct mechanisms:
- Sutures bring tissue together through tied knots
- Staples compress tissue between metal points
- Bioabsorbable fasteners (like SubQ It!) create subcutaneous closures without piercing external skin
- Adhesives form molecular bonds with the stratum corneum
The chemical bonding approach eliminates removal procedures and provides an immediate waterproof barrier.
Core Types of Surgical Skin Adhesives
Understanding each adhesive type helps match the right product to your surgical context.
Cyanoacrylate-Based Adhesives
2-octyl cyanoacrylate represents the most widely adopted topical surgical adhesive. The liquid monomer polymerizes within seconds upon contact with anionic substances (water, blood) on the skin surface.
| Characteristic | Details |
|---|---|
| Mechanism | Exothermic polymerization forming flexible polymer chains |
| Strength | Longer side chains create stronger, less brittle bonds than earlier butyl formulations |
| Barrier function | Maintains 99% barrier against surgical site infection organisms for at least 72 hours |
| Best applications | Low-tension closures, facial lacerations, laparoscopic port sites |
| Limitations | Not suitable for high-tension areas, mucous membranes, or wounds requiring deep support without subcutaneous sutures |
Fibrin Sealants
These biological adhesives mimic the final stage of the coagulation cascade by combining human fibrinogen and thrombin to form fibrin clots. Common applications include:
- Hemostasis during surgery
- Internal tissue sealing
- Adjunct to sutures in vascular procedures
Absorption timeline: The fibrin matrix biodegrades and resorbs within 10-14 days. Tensile strength is lower than cyanoacrylates, making fibrin sealants better suited for internal applications rather than primary skin closure under tension.
Other Adhesive Technologies
PEG polymers (CoSeal, DuraSeal) serve specialized roles in dural repair and lung sealing but swell significantly (50-400%) post-polymerization, making them unsuitable for skin closure.
Albumin-glutaraldehyde (BioGlue) creates strong cross-linked bonds for internal vascular repair but carries toxicity concerns for superficial application.
Selection depends on surgical context, with topical cyanoacrylates dominating skin closure applications.
Benefits of Surgical Skin Adhesives
Adhesives offer several clinical advantages when properly matched to wound characteristics:
Closure-time efficiency: Prospective trials show median closure of 2.5 minutes for adhesives versus 6 minutes for sutures in laparoscopic port sites, translating to over $100 saved in OR time per case.
Patient comfort: Visual analog pain scores were 7.2 mm for adhesive versus 18.0 mm for sutures in laceration trials, with no removal visit required.
Microbial barrier: The waterproof film allows immediate showering while protecting against bacterial penetration.
Comparable cosmetic outcomes: Long-term scar appearance at 6-12 months matches meticulous suturing when adhesives are properly applied.
What to Consider When Choosing the Best Surgical Skin Adhesive
Optimal adhesive selection requires matching product characteristics to wound mechanics, tissue biology, and procedural goals. The following criteria connect technical specifications to measurable outcomes.
Wound Characteristics and Location
Tension assessment is the single most critical factor. Low-tension areas (face, abdomen) tolerate adhesive-only closure, while high-tension sites (joints, back) risk wound reopening without support.
Subcutaneous sutures provide essential support in these situations:
- Wounds >3 cm in length
- Lacerations on torso or extremities
- Any closure where skin edges don't naturally approximate
- Areas subject to dynamic movement
Deep dermal sutures relieve all tension before adhesive application, preventing the adhesive from bearing mechanical loads it cannot sustain.
Anatomical contraindications:
- Mucosal surfaces (lips, oral cavity)
- Hair-bearing scalp (interferes with adhesion)
- High-moisture areas (groin, axillae)
- Contaminated or infected wounds
Tissue Type and Vascularity
Moisture compromises bonding strength. Biomechanical testing confirms cyanoacrylates require dry surfaces for optimal adhesion, making complete hemostasis non-negotiable.
Different specialties prioritize different performance factors:
- Plastic surgery: Preferred for facial closures due to excellent short-term cosmesis
- Orthopedics: Often combined with deep sutures; waterproof barrier may reduce infection risk
- Pediatrics: Eliminates needle anxiety but requires parent education to prevent picking
Closure Speed and Workflow Efficiency
Comparative closure times:
| Method | Laparoscopic Ports | Arthroscopy Portals |
|---|---|---|
| Adhesive | 2.5 minutes | 1.5 min/cm |
| Sutures | 6.0 minutes | 4.0 min/cm |
| Staples | N/A | 0.5 min/cm |
At OR costs at approximately $30/minute, saving 3.5 minutes per case translates to over $100 in direct cost reduction. One analysis calculated mean savings of $303 per laparoscopic patient using adhesive versus sutures.
Learning curve: Surgical teams require training on proper application technique, including wound preparation, layering, and drying protocols.
Cosmetic Outcome Requirements
Long-term equivalence: Meta-analysis of 18 RCTs found comparable scar scores at 6-12 months between adhesives and sutures, though adhesives showed better cosmesis at <1 month.
Staple comparison: Metal staples create "train track" scarring from visible puncture marks. Adhesives avoid this pattern entirely. Newer bioabsorbable subcuticular closure systems combine stapler speed with superior cosmetic outcomes by placing fasteners beneath the skin surface, eliminating both external puncture marks and removal procedures.
Application technique matters: Meticulous edge approximation and proper layering determine final scar quality as much as product selection.
Patient Factors and Post-Operative Care
Patient characteristics and compliance directly affect closure success:
- Pediatric: Eliminates removal trauma but requires preventing film picking
- Skin sensitivity: Test for allergic reactions in sensitive patients
- Activity level: High-mobility patients may require immobilization or deep support
- Compliance: Patients must follow showering restrictions (no soaking, scrubbing, or swimming)
Post-operative protocols: The adhesive acts as its own waterproof dressing, eliminating bandage needs. Patients may shower immediately but must avoid submersion until the film sloughs off in 5-10 days.
Common Pitfalls When Using Surgical Adhesives
Even with proper adhesive selection, application errors compromise outcomes and increase complication rates. Understanding these pitfalls helps surgical teams avoid preventable complications.
Improper Wound Preparation
Critical preparation steps:
- Remove all debris and devitalized tissue through thorough debridement
- Achieve complete hemostasis—blood interferes with polymerization
- Dry the surface completely—moisture accelerates polymerization too quickly
- Place dermal sutures first to eliminate all tension before applying adhesive
Application on wet or bleeding surfaces leads to weak bonding, premature sloughing, and dehiscence risk.
Beyond preparation, selecting appropriate wound types is equally critical for successful adhesive closure.
Using Adhesive on Inappropriate Wound Types
Contraindications checklist:
- Active infection or gangrene
- Animal bites or puncture wounds
- Contaminated wounds
- High-tension areas without immobilization
- Mucous membranes
- Dense hair-bearing regions
- Decubitus ulcers
Misuse in high-tension settings without deep support is the primary cause of adhesive failure and wound separation.
Application Technique Errors
Common mistakes:
- Forcing adhesive into the wound, which acts as a foreign body and inhibits healing
- Applying one thick layer instead of 2-3 thin coats
- Releasing wound edges before polymerization completes (requires 90 seconds to 2.5 minutes)
- Creating excessive heat through thick applications (causes patient discomfort)
Proper technique: Approximate wound edges manually, apply thin layers to the surface only, allow full polymerization, then release.
How SubQ It! Can Help
SubQ It! Bioabsorbable Skin Closure System addresses the core limitations of both traditional adhesives and metal staples through a subcutaneous fastening approach.
Unlike surface adhesives that require manual edge holding and have limited tension tolerance, SubQ It! delivers mechanical fastening strength with automated deployment.
The system places bioabsorbable fasteners subcutaneously (under the skin) using retractable needles. The external skin is never pierced, which eliminates the "train track" scarring that metal staples create.
Key advantages:
- Each fastener deploys in 7 seconds versus 42 seconds for a subcuticular stitch—7X faster than manual sutures
- Subcutaneous placement minimizes visible scarring compared to surface staples
- Eliminates removal procedures: The body absorbs bioabsorbable PLGA fasteners after healing, removing all costs and patient visits associated with staple removal
- FDA-cleared for multiple specialties: Approved for abdominal, thoracic, gynecologic, orthopedic, and plastic/reconstructive surgery
- ISO 13485 certified: Manufactured under certified quality management systems
The system delivers both the speed surgeons need and the cosmetic results patients expect. It offers a practical alternative when traditional adhesives lack tension support and metal staples create unacceptable scarring.
Conclusion
Selecting the right surgical skin adhesive requires matching product characteristics to wound tension, tissue type, anatomical location, and patient factors. The optimal choice is not the most popular or newest product, but the one that aligns with your specific surgical context and desired outcomes.
Consider these closure method strengths:
- Cyanoacrylate adhesives: Excel in low-tension closures where speed and waterproof barriers matter
- Fibrin sealants: Serve specialized hemostasis roles
- Bioabsorbable subcutaneous systems: Provide speed with superior cosmesis for incisions where surface penetration should be avoided (e.g., SubQ It!)
As new technologies emerge, review your closure method selection periodically. Innovations continue to improve the balance between efficiency, safety, and patient satisfaction.
Frequently Asked Questions
What kind of glue do they use for surgery?
Surgeons primarily use 2-octyl cyanoacrylate-based adhesives (Dermabond, LiquiBand) for topical skin closure, which polymerize on contact with skin moisture. Fibrin sealants (Tisseel) provide internal hemostasis. Selection depends on wound type, tissue tension, and application location.
Can you use Dermabond while pregnant?
Topical cyanoacrylate adhesives like Dermabond are generally considered safe during pregnancy as they form a surface barrier without systemic absorption. Use only when clearly needed and consult your treating physician, as adequate controlled studies in pregnant women are lacking.
What is the difference between surgical glue and sutures?
Surgical glue creates chemical bonds on the skin surface through polymerization, while sutures mechanically approximate tissue through tied thread. Glue applies faster (2.5 vs 6 minutes), requires no removal, and provides immediate waterproof barriers. Sutures offer superior strength for high-tension closures and deep tissue approximation.
How long does surgical skin adhesive last?
Most cyanoacrylate adhesives spontaneously slough off in 5-10 days as the epidermis regenerates. Patients should not remove the film prematurely, as it maintains a protective barrier while healing continues beneath.
What are the contraindications for surgical adhesives?
Contraindications include contaminated wounds, animal/puncture bites, mucous membranes (lips, mouth), high-moisture areas (groin), dense hair-bearing regions (scalp), and high-tension closures without support sutures. Active infection and areas requiring deep closure are also contraindicated.
Are bioabsorbable skin closures better than metal staples?
Bioabsorbable closures eliminate train track scarring and removal discomfort while providing comparable tensile strength. Systems like SubQ It! combine stapler speed with superior cosmetic outcomes, absorbing naturally without removal visits or associated costs. Selection depends on wound characteristics, incision length, and surgeon preference.
