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Three Part Question

In [children who have sustained a lip laceration extending through the vermillion border] is [tissue adhesive better than sutures] at [reducing pain during procedural discomfort and improving cosmetic outcome]?

Clinical Scenario

A 7 year old boy presents to the Emergency Department having fallen in the playground, sustaining a laceration to his bottom lip which crosses the vermilion border. You know that the potential uses of tissue adhesive in the paediatric population are increasing, and wonder if it may be used in these circumstances instead of the traditional method of formal suturing.

Search Strategy

Medline 1966-08/02 using the Ovid interface.
(exp lacerations OR exp wounds, nonpenetrating OR exp facial injuries OR laceration$.mp OR exp wounds and injuries OR wound$.mp) AND (exp lip OR lip$.mp OR vermilion$.mp) AND (exp fibrin tissue adhesive OR exp tissue adhesives OR tissue adhesive$.mp OR $cyanoacrylate$.mp OR exp cyanoacrylates OR wound glue$.mp OR histoacryl.mp OR exp wound healing OR exp suture techniques) Limit to human AND English

Search Outcome

Altogether 292 papers were found, of which only 1 described the proposed intervention. Three other papers were found comparing tissue adhesive to sutures in paediatric patients with facial lacerations, and these have also been included in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Quinn JV et al, 1993,	81 paediatric patients with clean facial lacerations, randomised to glue or sutures	PRCT (level 1b)	Cosmetic score at 3 months, procedural pain, time taken for procedure	No difference in cosmesis, glue faster and less painful than sutures	Lip lacerations excluded
de Blanco LP, 1994, Argentina	A 10 year old boy and a 46 year old woman, both with lip lacerations	Case report (level 4)	Cosmesis at 18 days and 1 year	Wound closed with only slight scar	Simple case report, no comparison with standard, one of the patients adult
Bruns TB et al, 1996,	61 paediatric patients with facial and scalp lacerations, randomised to glue or sutures	PRCT (level 1b)	Cosmetic score at 2 months, procedural pain (perceived by parents), time taken for procedure	No difference in cosmetic outcome, glue faster and less painful than sutures. Parents more likely to recommend glue to others	Lip lacerations excluded
Barnett P et al, 1998,	163 paediatric patients with non-ragged lacerations, randomised to glue or sutures	PRCT (level 1b)	Cosmetic score at 3 and 12 months, procedural pain (perceived by parents, doctors, nurses, and children), time taken for procedure	Glue faster and less painful than sutures (scored by all except the child). No difference in cosmesis at 3 or 12 months	Lacerations to all body parts included except eyes and mucous membranes

Comment(s)

Traditional teaching has been that in lacerations involving the lip, the vermilion border must be accurately approximated with a suture to ensure that healing occurs without a step. A recent systematic review (5) has outlined the benefits of using tissue adhesive as an alternative method of wound closure to sutures, and three studies have specifically looked at a comparison between tissue adhesive and sutures in paediatric facial lacerations (1, 3-4). These all compared tissue adhesive to sutures, and gave comparable cosmetic results with less time taken for the procedure and less pain for the child with tissue adhesive. However, lacerations of the lip were excluded from these trials. Although it is tempting to extrapolate these findings to other specific areas of wound management such as closure of lip lacerations, problems associated with this location could be anticipated, such as the child biting or licking off the glue. It should be borne in mind that there is a small but statistically significant increased rate of dehiscence with tissue adhesives compared to sutures (5). There is only one published case report supporting tissue adhesive as a method of closure in these lacerations.

Clinical Bottom Line

Pending further studies looking specifically at this problem, local advice should be followed.

References

1. Quinn JV, Drzewiecki A, Li MM, et al. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med 1993;22:1130–5.
2. de Blanco LP. Lip suture with isobutyl cyanoacrylate. Endod Dent Traumatol 1994;10:15–18.
3. Bruns TB, Simon HK, McLario DJ, et al. Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics 1996;98(4 pt 1):673–5.
4. Barnett P, Jarman FC, Goodge J, et al. Randomised trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric lacerations. J Paediatr Child Health 1998;34:548–50.
5. Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database of Systematic Reviews 2002(3):CD003326.