• 
• 

Three Part Question

In [children undergoing cleft lip repair] is [wound glue better than sutures] at [giving the best cosmetic result and reducing post operative distress]

Clinical Scenario

A 7 month old boy is undergoing primary repair of his cleft lip. Before the operation the parents were concerned about the cosmetic result from using sutures (cross hatching) and also the discomfort of removing them. You wonder whether the use of wound glue would be an acceptable alternative, given the high mobility of the area and need for accurate approximation of the wound.

Search Strategy

medline using the OVID interface 1966 to May week 2 2006
Also Pubmed
{cleft lip.mp or exp cleft lip} AND {fibrin tissue adhesive/ or exp Cyanoacrylates/ or exp Tissue Adhesives/ or wound glue.mp or Wound Healing/} limit to Humans and english language and yr="1902 to 2006" (in Medline).
(cleft lip) AND (cyanoacrylate) limit to English ( Pubmed)

Search Outcome

51 papers were found on the search. Of these, 49 were found to be irrelevant. The remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Magee WP Jr. Ajkay N. Githae B. Rosenblum RS. Jan 2003 USA	64 patients all had either unilateral, bilateral or midline cleft lips with or without cleft palate and with no regard to the size of cleft. Standard modified Millard technique was used to repair the lips in all cases.	Journal Article: retrospective descriptive trial	wound dehiscences	no wound dehiscences	Do not declare any conflicting interests. Retrospective descriptive trial. Do not explain patient selection. Unsatisfactory results determined by those requiring revision. Do not define how results assessed. No comparison with sutures except in the discussion.
			Allergic reactions	No allergic reactions
			Revision required	5 cases (7.8%) required revision. These required secondary nasal base repositioning. Three also required white line correction.
Cooper JM, Paige KT March 2006 USA	18 Adult and Paediatric patients between 1999 and 2003. 12 were primary cleft lip repairs and 6 were revisions.	Retrospective Review	Allergic Reactions	No allergic reactions	Retrospective review study. Small numbers. Do not compare with using sutures. Not looking solely at primary clefts in children.
			Infections	No Infections
			Dehiscences	No dehiscences
			Cosmetic outcome	17 of 18 had an "excellent" cosmetic outcome
			Complications	1 patient had minor flap necrosis

Comment(s)

There appears to be a definate lack of evidence of using wound glue in cleft lip surgery. There are no randomised controlled trials comparing sutures with wound glue. The first of two papers found gives an anecdotal account, does not describe assessment postoperatively and does not declare any interests. The second is also an anecdotal account and uses very small numbers looking both at revision and primary cleft lip repairs. The benefits of using wound glue as far as postoperative wound care and not needing to remove sutures are obvious. Application is not an issue as these patients are anaesthetised at the time. The unknown problem is whether they give superior cosmetic result compared with sutures in cleft lip surgery. This is particularly important in this group given that the result of surgery can have a profound effect on the patients future life and happiness and also that of their families.

Clinical Bottom Line

Further research is required to support the definitive use of wound glue in this group of patients.

References

1. Magee WP Jr. Ajkay N. Githae B. Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair Annals of Plastic Surgery 50(1):1-5, 2003 Jan
2. Cooper JM, Paige KT Primary and Revision Cleft Lip Repairs Using Octyl-2-Cyanoacrylate Journal of Craniofacial Surgery March 2006; 17(2) 340-343