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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.
Structured clinical question
In children who have sustained a lip laceration extending through the vermilion border [patient], is tissue adhesive [intervention] better than sutures [comparison] at reducing procedural discomfort and improving cosmetic outcome [outcomes]?
Search strategy and outcome
Medline 1966 to August 2002 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.
Altogether 292 papers were found, of which only one described the proposed intervention.1 Three other papers were found comparing tissue adhesive to sutures in paediatric patients with facial lacerations, and these have also been included in table 1⇓.
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 review2 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.3–,5 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.2 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.
Table 1 Should we glue lip lacerations in children?
Citation Study group Study type (level of evidence) Outcome Key results Weaknesses
de Blanco (1994) 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 Quinn 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 Bruns 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 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