Introduction
Modern surgeons face a persistent challenge: balancing speed, cosmetic outcomes, patient comfort, and cost-effectiveness in wound closure decisions. Surgical adhesives have emerged as a compelling alternative to traditional sutures and staples, but selecting the right closure method requires understanding their specific strengths and limitations.
Tissue adhesives reduce closure time by approximately 22.78 minutes compared to traditional sutures in laparoscopic procedures, directly addressing OR efficiency demands.
However, wound dehiscence risk increases significantly with adhesives (RR 3.35) in high-tension areas. This trade-off requires careful patient and wound assessment when choosing closure methods.
This article explores the science behind surgical adhesives, their diverse applications, and practical guidance for choosing the right wound closure method for specific clinical scenarios.
TLDR:
- Surgical adhesives offer painless, rapid closure for low-tension wounds with excellent cosmetic outcomes
- Multiple adhesive types exist: cyanoacrylates for topical use, fibrin sealants for hemostasis, and PEG polymers for internal sealing
- Adhesives are 7X faster than sutures but carry higher dehiscence risk in high-tension areas
- Advanced closure systems combine adhesive speed with improved wound strength
- Proper patient selection based on wound characteristics determines optimal closure method success
What Are Surgical Skin Adhesives?
Surgical skin adhesives are medical-grade compounds specifically engineered to seal wounds and bring together (approximate) tissue edges. Unlike consumer-grade adhesives, these products undergo rigorous testing to meet biocompatibility standards and FDA approval requirements.
Medical-Grade vs. Consumer Products
The FDA classifies topical tissue adhesives as Class II devices, requiring 510(k) premarket notification and adherence to ISO 10993-1 biocompatibility standards.
Manufacturers must demonstrate safety through testing for cytotoxicity, sensitization, and irritation. Beyond biocompatibility, mechanical performance verification requires specific ASTM standards:
- ASTM F2255-05: Lap-Shear by Tension Loading
- ASTM F2458-05: Wound Closure Strength
- ASTM F2256-05: T-Peel by Tension Loading
Primary Functions
Surgical adhesives provide three core functions in wound closure:
- Sealing tissue to prevent fluid leakage and create watertight barriers
- Controlling bleeding through hemostatic properties
- Approximating wound edges to facilitate optimal healing
Ideal Characteristics
Surgeons look for adhesives that demonstrate:
- Safe performance under various conditions (moisture, bleeding)
- Easy, intuitive application without specialized equipment
- Fast drying time
- Appropriate strength matching wound tension requirements
- Minimal inflammatory response
Topical vs. Internal Applications
Topical adhesives seal skin surfaces for external wound closure. They create a protective barrier over superficial lacerations or surgical incisions.
Internal sealants serve a different role during surgery. Surgeons use them for deep tissue or organ repair, providing hemostasis and sealing in cardiovascular, pulmonary, and neurological procedures.
Types of Surgical Adhesives and Their Applications
Cyanoacrylate-Based Adhesives
Cyanoacrylates work through anionic polymerization triggered by moisture or tissue anions. Upon contact with wound exudate or skin moisture, the liquid monomers transform into solid polymer chains.
Chemistry and Formulation Differences:
2-Octyl cyanoacrylate formulations (like Dermabond) offer superior performance compared to shorter-chain derivatives:
- Provides ~30% higher elongation capacity for greater flexibility
- Produces fewer formaldehyde by-products during degradation
- 3-4 times stronger than n-butyl cyanoacrylate
- Longer alkyl chains create more stable bonds over time
Clinical Applications:
Ideal for low-tension wounds including:
- Pediatric lacerations where needle-free application reduces anxiety
- Laparoscopic port-site closures
- Minimally invasive surgery incisions
- Cosmetic procedures requiring optimal aesthetic outcomes
Antimicrobial Properties:
2-Octyl cyanoacrylate demonstrates in vitro antimicrobial activity against Gram-positive bacteria like Staphylococcus aureus, providing an adjunctive infection barrier. However, effectiveness against Gram-negative bacteria such as Pseudomonas is limited.
Fibrin Sealants
Moving beyond synthetic adhesives, fibrin sealants mimic the final stage of the natural clotting cascade. These combine separately packaged fibrinogen and thrombin that form a clot when mixed.
Composition and Mechanism:
Derived from purified human or animal plasma, thrombin cleaves fibrinogen to form fibrin monomers that polymerize into stable clots. Fibrin sealants are the only FDA-approved material for use as hemostat, sealant, and adhesive.
Primary Uses:
- Hemostasis in liver and cardiovascular surgery
- Sealing colonic anastomoses
- Skin graft attachment
- Controlling bleeding where standard methods fail
Degradation Timeline:
Fibrin sealants are completely resorbed through fibrinolysis within 10-14 days, making them ideal for temporary sealing applications.
Collagen and Thrombin-Based Products
These flowable hemostatic agents combine bovine or porcine collagen with thrombin or human plasma components.
Mechanism:
The collagen provides a mechanical scaffold for fibrin clot formation, enhancing clot stability and delivering fibrinogen directly to the wound area. This assists natural coagulation and controls bleeding in challenging surgical situations.
Applications:
- Liver resection procedures
- Cardiovascular surgery
- Bleeding-prone areas where standard hemostatic techniques prove ineffective
Polyethylene Glycol (PEG) Polymers
PEG-based synthetic hydrogels form through cross-linking reactions, with some formulations requiring photoactivation while others mix two chemical components.
Performance Characteristics:
PEG sealants demonstrate burst pressures exceeding 150 mmHg, significantly outperforming fibrin sealants for watertight sealing applications.
Specialized Applications:
- Cranial and spinal dura repair
- Lung and thoracic procedures for sealing air leaks
- Vascular anastomoses requiring high-pressure resistance
Bioabsorption:
Resorption times vary by formulation—CoSeal absorbs in about 30 days, while DuraSeal may persist for 4-8 weeks.
Albumin-Glutaraldehyde Adhesives
Composed of bovine serum albumin cross-linked with glutaraldehyde, these adhesives create exceptionally strong bonds.
Bonding Characteristics:
Polymerization occurs rapidly (20-30 seconds) with full strength achieved in 2 minutes. Burst strength reaches ~300 mmHg, suitable for high-pressure vascular applications.
Reserved Uses:
Internal surgeries requiring high-pressure resistance:
- Pulmonary repair
- Aortic and large vessel repair
- Femoral and carotid artery procedures
Important Considerations:
These adhesives carry embolization risks if improperly applied, requiring strict adherence to application guidelines.
Bioabsorbable Mechanical Closure Systems
Beyond adhesives, emerging closure systems bridge the gap between chemical bonding and traditional mechanical closure. These combine bioabsorbable materials with mechanical fastening.
Technology Overview:
Systems like SubQ It! utilize bioabsorbable fasteners placed subcutaneously, eliminating external skin piercing. The fasteners are made from polylactic-co-glycolic acid (PLGA), maintaining 80% strength for 21 days before complete absorption.
Key Advantages:
- 7X faster than manual sutures (7 seconds per fastener vs. 42 seconds per stitch)
- No removal procedures required
- Superior cosmetic outcomes without "train track" scarring
- Reduced patient anxiety and discomfort
FDA-Cleared Applications:
Approved for abdominal, thoracic, gynecologic, orthopedic, and plastic/reconstructive surgery, with particular effectiveness in laparoscopic trocar closure.
How Surgical Skin Glue Works
Polymerization Process
The bonding process involves a rapid chemical reaction:
- Cyanoacrylate monomers (liquid form) contact wound moisture or tissue fluids
- Weak bases present in wound exudate trigger anionic polymerization
- Liquid monomers transform into solid polymer chains within seconds
- These chains bond tissue edges together, creating structural closure
Exothermic Reaction
The polymerization reaction releases heat as the adhesive bonds to tissue. Patients generally tolerate this warmth well, though excessive application can cause temporary discomfort.
2-Octyl cyanoacrylate formulations generate less heat than shorter-chain variants (such as butyl or ethyl), making them more comfortable for patients during application.
Antimicrobial Mechanism
The adhesive provides dual antimicrobial protection:
- Physical barrier: The polymerized film prevents bacteria from entering the wound
- Chemical disruption: Negatively charged cyanoacrylate molecules interact with positively charged bacterial capsules, destabilizing them
This dual mechanism works particularly effectively against Gram-positive organisms, reducing infection risk during the healing period.
Watertight Seal Formation
Properly applied adhesive forms a waterproof, protective film over the wound. This seal allows patients to shower within 24 hours post-procedure without compromising wound closure, improving both hygiene and patient satisfaction compared to traditional sutures or staples that require extended dry-time periods.
Benefits and Advantages of Surgical Adhesives
Application Speed
Meta-analyses show tissue adhesives reduce closure time by approximately 22.78 minutes (95% CI: -40.68 to -4.89) for laparoscopic port-site wounds. This translates to:
- Increased operating room efficiency
- Higher patient throughput
- Reduced anesthesia exposure time
- Lower overall procedural costs
These speed advantages help surgical teams optimize schedules and reduce patient time under anesthesia.
Cosmetic Outcomes
Short-term benefits (1 month or less): Adhesives yield superior cosmetic results due to absence of "train track" marks from sutures.
Long-term results (3-12 months): Cosmetic outcomes are generally comparable between adhesives and sutures when assessed using validated measurement scales.
The cosmetic advantage is particularly valuable for visible areas where scarring affects patient satisfaction.
Patient-Centered Advantages
- Painless application: No needle sticks or anesthesia injections
- No removal procedures: Eliminates follow-up visits
- Reduced pediatric distress: Needle-free application decreases fear
- Immediate water exposure: Waterproof barrier allows normal hygiene
Clinical Benefits
Surgical adhesives provide multiple clinical advantages:
- Antimicrobial barrier reduces infection risk through physical and antibacterial properties
- Minimal scarring from subcutaneous placement
- Reduced tissue trauma promotes faster recovery
- Consistent closure strength across the incision
Operational Efficiency
Beyond clinical outcomes, adhesives improve operational metrics:
- Eliminates follow-up appointments for bioabsorbable systems
- Reduces total treatment costs in outpatient settings
- Frees OR resources through shorter closure times
Note: While this section focuses on adhesive benefits, alternative closure systems like bioabsorbable staplers (such as SubQ It!) offer similar advantages—combining speed with subcutaneous placement for optimal cosmetic results without removal procedures.
Limitations and Considerations
Contraindications
Surgical adhesives should not be used in these situations:
- Infected, gangrenous, or decubitus wounds
- Known hypersensitivity to cyanoacrylate or formaldehyde
- Mucosal surfaces or mucocutaneous junctions (lips)
- Areas with dense natural hair
- Intravascular applications (thrombosis risk)
Mechanical Limitations
Beyond these anatomical restrictions, adhesives face inherent performance limitations. Adhesives possess significantly lower tensile strength than sutures, with wound strength potentially reaching only 10% of sutured wounds.
They are unsuitable for:
- High-tension areas (knuckles, knees, elbows)
- High-mobility joints without immobilization
- Deep or jagged wounds requiring internal support
Dehiscence Risk
Meta-analyses indicate significantly higher wound dehiscence risk with tissue adhesives compared to sutures (RR 3.35; 95% CI 1.53-7.33), particularly in high-tension areas. Proper patient selection is critical.
Application Restrictions
Successful adhesive application requires specific wound conditions:
- Moisture sensitivity: Should not be applied to wet wounds, as moisture prevents proper bonding
- Ointment incompatibility: Petroleum-based products weaken adhesive bonds and cause premature failure
- Fluid accumulation risk: The adhesive barrier may trap seromas or hematomas, requiring drainage
- Proper approximation required: Adhesives seal edges but don't pull them together—manual approximation must precede application
Potential Complications
While generally well-tolerated, tissue adhesives carry specific complication risks:
- Allergic reactions: Contact dermatitis occurs in approximately 0.3% of cases, requiring alternative closure methods
- Foreign body reactions: Adhesive entering the wound bed can trigger inflammation and delayed healing
- Thermal discomfort: The exothermic polymerization reaction may cause temporary heat sensation (typically mild)
- Tattooing: Improper application can cause permanent skin discoloration if adhesive penetrates dermis
Choosing the Right Wound Closure Method
Selecting the optimal closure technique requires balancing clinical requirements, patient factors, and economic considerations. Each method offers distinct advantages depending on wound characteristics and surgical context.
Decision Framework
When adhesives are preferable:
- Clean, linear, low-tension wounds
- Facial lacerations requiring optimal cosmetics
- Pediatric cases where needle-free application minimizes trauma
- Laparoscopic port-site closures
- Patients unable to return for suture removal
When sutures remain gold standard:
- High-tension areas over joints
- Deep wounds requiring layered closure
- Irregular edges needing precise approximation
- Contaminated wounds requiring delayed closure
- Maximum tensile strength requirements
Hybrid Approaches
Combining subcuticular sutures with topical adhesives optimizes outcomes by leveraging:
- Mechanical strength of sutures for tension relief
- Microbial barrier and patient comfort of adhesives
- Improved cosmetic outcomes compared to sutures alone
- Reduced pain and anxiety
Beyond traditional combinations, bioabsorbable stapling systems like SubQ It! bridge the gap between metal staples and adhesives, delivering stapler speed with superior cosmetics and eliminating removal visits.
Total Cost Comparison
| Method | Initial Cost | Procedure Time | Removal Required | Infection Risk | Best Use Case |
|---|---|---|---|---|---|
| Manual Sutures | Low | 9 minutes | Yes | Comparable | High-tension wounds, precise control needed |
| Metal Staples | Low | 4 minutes | Yes | 3X higher in orthopedic surgery | Speed priority, cosmetics secondary |
| Topical Adhesives | Moderate | 2-3 minutes | No | Comparable | Low-tension, superficial wounds |
| Bioabsorbable Systems | Moderate-High | 1-2 minutes | No | Lower | Speed with superior cosmetics, subcutaneous placement |
Cost-Effectiveness Analysis
While adhesives and bioabsorbable systems cost more per unit than sutures, total cost of ownership favors these advanced methods in outpatient settings:
- Reduced operative time (OR costs typically $30-60 per minute)
- Elimination of removal visit costs (staff time, facility usage, scheduling)
- Decreased complication management expenses
- Improved patient satisfaction reducing administrative burden
Frequently Asked Questions
What is the difference between surgical skin glue and regular super glue?
Surgical skin glue meets FDA biocompatibility standards (ISO 10993-1) and undergoes extensive safety testing. Consumer super glue contains shorter-chain cyanoacrylates that produce toxic formaldehyde by-products and should never be used on wounds.
How long does surgical skin glue take to dissolve or fall off?
Topical cyanoacrylate adhesives typically slough off naturally in 5-10 days as the skin heals. Internal fibrin sealants are resorbed in approximately 2 weeks, while bioabsorbable fasteners maintain 80% strength for 21 days before complete absorption.
Can surgical skin adhesives be used on all types of wounds?
No. Adhesives are contraindicated for infected wounds, high-tension areas, mucosal surfaces, and deep wounds requiring layered closure. They work best for clean, linear, low-tension superficial wounds where edges can be easily approximated before application.
Are there any risks or side effects associated with surgical skin glue?
Most patients experience only mild heat sensation during polymerization. Rare complications include allergic contact dermatitis (0.3% incidence), wound dehiscence in high-tension areas, and foreign body reactions. Proper application technique minimizes these risks.
How does the cost of surgical adhesives compare to sutures and staples?
Initial material costs are higher for adhesives, but total cost of ownership is lower in outpatient settings. Savings come from reduced OR time (22+ minutes saved per procedure) and elimination of removal visits. Metal staples have the highest total costs due to removal procedure expenses.
What are the advantages of bioabsorbable closure systems over traditional methods?
Bioabsorbable systems combine 7X faster application than sutures with improved scarring profiles, eliminating both the "train track" scarring of metal staples and removal procedures. Systems like SubQ It! reduce patient anxiety and healthcare costs while maintaining optimal wound healing.
