By John Jesitus; Reviewed by Hayes B. Gladstone, MD
The watertight, bactericidal, and aesthetically advantageous properties of surgical glues have made them popular in dermatologic surgery and beyond. However, a reported association between cyanoacrylate, the chemical cornerstone of these products, and contact dermatitis (CD) in some patients has attracted attention, including a suggestion that dermatologic surgeons perhaps should forgo surgical glues.
In a series of 102 consecutive breast-reconstruction patients treated with surgical glues in 2018, Nigro et al. report that 14 patients (of 100 evaluated) developed CD.1 Four of them exhibited reactions at the time of their nipple delay procedure, 2 weeks before their mastectomies and first-stage reconstruction. All reactions were confirmed with scratch testing. The study was published in January 2020 in Plastic and Reconstructive Surgery.
Mechanistically, write authors Nigro et al., degradation products of cyanoacrylate glues, such as formaldehyde and cyanoacetate, can induce inflammation and/or reactions, particularly in areas of thin skin or open wounds. Study patients who reported prior surgical-glue exposure were slightly more likely to develop CD than were those without prior exposure. However, this trend did not reach statistical significance (P = 0.0732). Because the 14% incidence rate exceeds the 7% rate found by a prior retrospective case review of surgical glue used mainly in the abdominal area,2 Nigro et al. suggest that surgeons reconsider cyanoacrylate glues altogether.
However, experts have told The Dermatology Digest that when surgical glues are used appropriately, these products remain a safe, effective element of the therapeutic armamentarium.
Two surgeons’ experiences
“In dermatologic surgery,” said Hayes B. Gladstone, MD, “cyanoacrylate glue plays a significant role in pediatric cutaneous wounds and reconstruction after Mohs surgery and certain aesthetic procedures such as facelifts. It is not painful, more time-efficient than sutures, may be bacteriostatic, and may improve cosmetic results in certain patients.” Dr. Gladstone is a dermatologist and Mohs surgeon and President and Founder of the Gladstone Clinic in San Ramon, California.
Rod J. Rohrich, MD, FACS, said that Nigro et al.’s 14% CD rate is higher than he has seen reported or in his clinical experience, but the study is well done and published in the top plastic surgery journal. He is a Clinical Professor of Plastic Surgery at Baylor College of Medicine, past Chair/Distinguished Teaching Professor of Plastic Surgery at the University of Texas Southwestern, and founding partner of the Dallas Plastic Surgery Institute.
“I use Dermabond (2-octyl cyanoacrylate, Ethicon) on almost every body and breast contouring surgery because it avoids the need for skin sutures,” said Dr. Rohrich. In well over 1000 such procedures, he said, only 1 or 2 patients developed CD.
Dr. Gladstone occasionally uses surgical glue for skin grafts and rarely for facelift closures. Even a 7% CD rate appears high, he said, as the reported overall complication rate for Mohs surgery is 1.64%.3 A few of his patients have developed minor irritation after exposure to surgical glue, he said, but none have developed CD.
Dr. Gladstone added that any type of chemical can cause skin irritation or an immune reaction and inflammation. Significant inflammation often inhibits wound healing and may raise the risk of local infection, hinder healing, and create prolonged scar erythema. “That’s why Nigro et al. bring this up—not just because it’s causing a rash,” he said. However, these authors report no delayed healing in their series.
Similarly, Nakagawa et al. note in a September 2018 Plastic and Reconstructive Surgery—Global Open publication that some patients treated with surgical glues can experience severe allergic reactions that may require systemic steroids.2 Drs. Rohrich and Gladstone said that such reactions are uncommon. And if addressed immediately with antihistamines or steroids, said Dr. Rohrich, they do not affect healing.
“Though there is definitely a risk for contact dermatitis when using cyanoacrylate glue,” Dr. Gladstone said, “the study by Nigro et al. is very narrow since it only examines breast reconstruction patients.” The breast may be an especially sensitive area because it involves more easily irritated skin, lower vascularity compared to the face, and post-surgical maceration, he explained. Moreover, breast reconstruction itself is a complex, often multi-stage procedure that disrupts various skin layers and can provoke significant inflammation.
Figure 1. Progression of rash in patient (33-year-old woman after bilateral reduction mammoplasty). (A) Patient at initial follow-up on postoperative day (POD) 6 with bilateral swelling, blisters, and erythema. (B) Patient at POD 11 after 5 days of steroid taper. Steroid taper was subsequently terminated due to gastrointestinal intolerance. Rash had spread bilaterally since initial presentation. (C) Resolution of rash at POD 19.7
Additionally, Dr. Gladstone disagreed with Nigro et al.’s inference that because affected patients reacted to both Dermabond and LiquiBand (Advanced Medical Solutions Ltd.), their findings apply to all cyanoacrylate glues.1 At best, said Dr. Gladstone, the findings may be generalizable to breast reconstruction.
Safe usage
Drs. Gladstone and Rohrich said that the Nigro et al. publication will not significantly alter their clinical approaches. Safe use of surgical glue starts with a thorough patient history. “If there’s any history of allergies to glues or cyanoacrylate,” said Dr. Rohrich, “I don’t use it.” In closing surgical wounds, he added, cyanoacrylate glues currently available in the United States should go no deeper than the dermis.
Dr. Gladstone said, “I usually ask patients if they have allergies in general. If someone has asthma, allergies, and a history of atopic dermatitis, then I most likely would abstain from using surgical glue.”
He may begin asking patients specifically about reactions to cyanoacrylate glues such as those used with false nails and eyelashes.
Essentially, said Dr. Gladstone, Nigro and colleagues drew an overreaching conclusion from a very narrowly focused study. Yet drawing firm conclusions about surgical glues remains difficult because evidence consists largely of small case series. Larger prospective, randomized studies are needed, Dr. Gladstone said, but unlikely to occur.
Pragmatically, he added, most dermatologic surgeons still use sutures because they are comfortable with them. Along with increasing operative time, sutures may provoke infections, and most sutures require subsequent removal. Comparatively, he said, surgical glue represents an advance—no matter how imperfect—as surgeons continue seeking better ways to close acute cutaneous wounds.
“In my experience,” Dr. Rohrich added, “the benefits of surgical glue outweigh the risks.”
Meanwhile, use of fibrin glues is increasing. Composed mainly of fibrinogen and thrombin, these adhesives are less likely than cyanoacrylates to provoke CD, said Dr. Gladstone. Additional approaches under study include light-activated nanosutures, laser-assisted tissue welding, and animal-inspired biomimetic adhesives.4-6 “That’s where we’re headed,” he said. “It will be a totally new paradigm. For many patients, surgical glue is at least is a step in the right direction.”
Use of deep-tissue glues for indications such as facelifts and abdominal surgeries is clearly on the horizon, said Dr. Rohrich, who added that several formulations are available in Europe. “It’s very appealing that you would be able to close a wound and get it to heal without having a drain.” However, he said, these products will require extensive FDA trials, and formulations available to date have proven less promising than cyanoacrylate-based glues.
REFERENCES
1. Nigro LC, Parkerson J, Nunley J, et al. Should we stick with surgical glues? the incidence of dermatitis after 2-octyl cyanoacrylate exposure in 102 consecutive breast cases. Plast Reconstr Surg. 2020;145(1):32-37.
2. Nakagawa S, Uda H, Sarukawa S, et al. Contact dermatitis caused by Dermabond Advanced use. Plast Reconstr Surg Glob Open. 2018;6(9):e1841.
3. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol. 2003;139(2):143-152.
4. Ge L, Chen S. Recent advances in tissue adhesives for clinical medicine. Polymers (Basel). 2020;12(4):939-961.
5. Bhagat V, Becker ML. Degradable adhesives for surgery and tissue engineering. Biomacromolecules. 2017;18(10):3009-3039.
6. Ghosh D, Urie R, Chang A, et al. Light-activated tissue-integrating sutures as surgical nanodevices. Adv Healthc Mater. 2019;8(14):e1900084.
7. Knackstedt RW, et al. Rash with DERMABOND PRINEO skin closure system use in bilateral reduction mammoplasty: a case series. Case Rep Med. 2015:Article ID 642595. https://doi.org/10.1155/2015/642595
DISCLOSURES
Dr. Gladstone reports no relevant financial interests. Dr. Rohrich is editor-in-chief of Plastic and Reconstructive Surgery. He reports no other relevant financial interests.