The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2001 The American Laryngological,
Rhinological and Otological Society, Inc.
Aesthetic Comparison of Wound Closure
Techniques in a Porcine Model
Nathan M. Tritle, MD; Jeffrey R. Haller, MD; Steven D. Gray, MD
Objective: To compare various commonly used
closure techniques and their esthetic results. Also to
look for differences in cost, time, and ease of use
among the methods. Design: A prospective compari-
son in a porcine skin model with a blinded assessment
of outcomes. Methods: Thirty 6-cm, full-thickness skin
incisions were made on the back of two domestic
white swine. Undermining was accomplished, and
buried simple, interrupted, absorbable, braided
(Polysorb, US Surgical) subdermal sutures were
placed in a uniform fashion in each wound. The skin
was then closed using one of the following five meth-
ods: running subcuticular 4-0 nylon, running subcu-
ticular 4-0 absorbable monofilament (Biosyn, US Sur-
gical), tissue glue (Dermabond, Ethicon), adhesive
tape, or running subcuticular nylon with intradermal
injection of hyaluronic acid. Nonabsorbable sutures
and tape were removed on postoperative day 7, and
photographs were taken at regular intervals during a
12-week healing period. Biopsies were taken from
wounds in each group at 2 weeks and 12 weeks for
histologic comparison. Independent observers evalu-
ated the photographs, and an independent histologist
evaluated the biopsies to look for differences in in-
flammation and scar formation. The surgeons who
performed the wound closure rated the ease of use
and amount of time required for each technique. Re-
sults: Adhesive tape closure was faster and easier to
perform. There were no significant differences among
the adhesive tape, nylon, or absorbable suture groups
regarding cosmetic appearance throughout the study
period. The tissue glue wounds had more of a ten-
dency to dehisce. Adhesive tape is less expensive than
the other methods when material costs and operating
room time are considered. Conclusion: Adhesive tape
closure of surgical wounds is cosmetically acceptable,
convenient, and saves both time and material costs.
We recommend it as an alternative for closure of neck
Presented at the Western Section meeting of the Triological Society,
January 7, 2001.
From the Division of Otolaryngology, University of Utah Medical
Center, Salt Lake City, Utah, U.S.A.
Funded and supported by the Division of Otolaryngology, University
of Utah Medical Center.
Editor’s Note: This Manuscript was accepted for publication July 24,
2001.
Send Correspondence to Jeffrey R. Haller, MD, Division of Otolar-
yngology, University of Utah Medical Center 3C120, Salt Lake City, UT
84132, U.S.A.
Laryngoscope 111: November 2001
incisions. Key Words: Neck incisions, adhesive tape,
tissue glue, subcuticular, cosmetic.
Laryngoscope, 111:1949 –1951, 2001
INTRODUCTION
A variety of methods of wound closure have been
used over the years. Different approaches have different
advantages.1 For cosmetic reasons, nylon closure proba-
bly remains the gold standard.1 However, this is not an
absorbable suture and obviously needs to be removed.
Absorbable sutures have been available for many years,
whereas rapidly absorbing sutures became available more
recently. Initial advantages of the rapidly absorbing su-
tures were less tissue reaction because of the nature of
resorption and not having to remove the sutures. More
recently, tissue glues (cyanoacrylates) have become com-
mercially available with the stated advantages of de-
creased foreign body reaction during the healing process
and, again, not requiring removal. Tissue glue requires
perfect approximation of the epidermis before its applica-
tion, because any glue which seeps between poorly coapted
skin edges will actually prevent the wound from closing.2,3
Additionally, tissue glues are more expensive than most
suture materials used for skin closure.
In our practice, we have customarily used nylon su-
ture for our neck wound closure. More recently, as an
alternative to tissue glues, we have approximated the
epidermis precisely with deep sutures and simply placed
adhesive tape over Mastisol to close the epidermis. We
have not previously found this reported in the head and
neck literature and, therefore, undertook an animal
study comparing adhesive tape closure with other avail-
able methods, including tissue glue, nylon, and absorb-
able monofilament suture. The domestic swine was chosen
as the animal model because of its similarity to human
skin regarding tissue morphology and wound healing
characteristics.4
METHODS
Two domestic white swine underwent incision and wound
closure under general anesthesia. Each pig had six groups of five
incisions placed on its back. Each incision was made with a No.
15-blade scalpel down to the paraspinous fascia and measured 6
cm in length placed transversely. All incisions were closed in
layers with buried subdermal 3-0 braided polyglactin (Polysorb,
Tritle et al.: Comparison of Wound Closure Methods
1949
US Surgical) for deep tissue approximation. The epidermis of
each of the five incisions was closed using one of the following
methods: running subcuticular 4-0 nylon, running subcuticular
4-0 absorbable monofilament (Biosyn, US Surgical), tissue glue
(Dermabond, Ethicon), adhesive tape (1/2⬙ Proxi-strips) over Mas-
tisol, or running subcuticular nylon with hyaluronic acid injec-
tion. Sutures were placed under loupe magnification. Tissue glue
was applied in three layers, as recommended on the package
insert, allowing each layer to dry before application of the next.
Adhesive tape was placed over Mastisol, which had been allowed
to dry to a tacky consistency. Hyaluronic acid 0.5% solution was
injected in the amount of 0.2 mL intradermally at the time of
wound closure and on postoperative day 11.
The pigs were housed in the animal facility and fed pig feed
ad libitum. On postoperative day 7, nylon sutures were removed
and any remaining adhesive tapes were removed before taking
photographs. The tissue glue was allowed to slough off, which
took 10 days to 2 weeks. Each group of incisions was photo-
graphed using an SLR camera with a macrolens weekly for 6
weeks, then biweekly for another 6 weeks.
Six-millimeter punch biopsies were taken from randomly
selected incisions in each category at 2 weeks and 12 weeks to
compare histologic evidence of inflammation and scar formation.
The tissue obtained at biopsy was stained with hematoxylin and
eosin and trichrome and was evaluated by a trained histologist.
Photographs were evaluated by blinded independent observers.
Six wound closures in each category were timed excluding the
subdermal closure, which was performed identically in all
wounds.
RESULTS
On postoperative day 7, at the time of suture or tape
removal, all incisions closed with sutures were uniformly
intact with moderate crusting and erythema. The taped
incisions showed less erythema and crusting with excel-
lent wound approximation. Only one incision in the tape
group showed any amount of dehiscence. Interestingly,
the tissue glue group had several incisions that were
slightly dehiscent. At 1 week, the impression of the inde-
pendent observers was that the wounds did not differ
significantly except for the dehiscent wounds in the tissue
glue group. There was no mention of asymmetric ery-
thema, swelling, or skin coaptation.
At 2 weeks, all nylon sutured wounds remained in-
tact. At this point, the incisions closed with absorbable
running subcuticular suture were showing some increased
erythema and slight wound elevation, but all wounds re-
mained completely intact. The dehiscent tissue glue
wounds remained essentially unchanged and the tape clo-
sures remained completely intact. Of note at this point, it
was obvious that the tape closure wounds epithelialized
sooner because there was less crusting along the epithelial
edges.
On approximately postoperative day 14, one of the
pigs developed a cutaneous dermatophytic fungal infec-
tion and began local systemic treatment as directed by the
laboratory veterinarian. This infection took 3 weeks to
resolve and caused two groups of incisions to be excluded
from evaluation during this time.
At 3 weeks, there continued to be only slight differ-
ences between the tissue glue wounds and the other
groups. Of note, the incisions injected with hyaluronic acid
after wound closure exhibited no visible difference at any
Laryngoscope 111: November 2001
1950
time during the study when compared with the non-
injected wounds. By 6 weeks of healing, all wounds ap-
peared to be uniformly healed except the small areas of
dehiscence in the wounds closed with tissue glue. The
independent observers confirmed that the wounds had no
significant differences except small areas of persistent
scab and wound widening where wound dehiscence had
occurred. We continued to follow the wounds for another 6
weeks, totaling 12 weeks postoperative follow-up, and
there were no significant differences from this point for-
ward. It was the impression of the independent observers
that the wounds had all reached a steady state at 6 weeks.
Evaluation of the biopsy specimens revealed no sig-
nificant difference among the closure methods regarding
scar formation or incision width at 2 weeks and 12 weeks.
There was a moderate amount of inflammatory infiltrate
in all wounds at 2 weeks. This was resolved by 12 weeks
and again did not differ among the groups.
The average time for placement of running subcutic-
ular nylon suture in the 6-cm wounds was 3 minutes 23
seconds. As expected, this was similar to the average time
for running subcuticular suture, 2 minutes 45 seconds.
Application of three layers of tissue glue required an av-
erage of 60 seconds, whereas placement of adhesive tapes
over Mastisol took only an average of 26 seconds.
When asked about the handling properties of each
material and overall convenience of application, the three
surgeons involved in the study agreed that adhesive tape
was, by far, the easiest to use. They also noted that the
tissue glue often required a second surgeon to retain the
epidermis in alignment during application of the first
layer. The two suture varieties used did not seem to differ
in their handling properties.
DISCUSSION
Because many types of wound closures continue to
exist, the perfect wound closure remains unknown. Con-
siderations include cosmetics and cost and convenience for
the patient and physician. Removing the sutures on a
specific day may be inconvenient. Nylon sutures remain
the gold standard for optimal cosmetic result. However,
the differences may be subtle from other methods of clo-
sure. Most of these differences have only been experienced
early on in wound healing, with long-term results being
similar. Monofilament absorbable sutures offer an alter-
native to nylon suture with certain advantages, but may
still result in a significant early inflammatory response,
which is perceived by the patient as cosmetically displeas-
ing. In an attempt to decrease time of closure and achieve
optimal cosmetic results, tissue glues have been devel-
oped. If any glue gets between the skin edges, it will
prevent epithelialization across the wound and cause a
suboptimal result. Advantages of tissue glues include ease
of application, decreased time of closure, and decreased
foreign body reaction within the wound.
We think an excellent alternative to tissue glue
would be to use adhesive tape. Using adhesive tape for
epithelial closure is quick and less expensive. Our pig
study revealed excellent cosmetic results and minimal
dehiscence of wounds with the use of subcutaneous su-
tures for close approximation of the epidermis and the
Tritle et al.: Comparison of Wound Closure Methods
placement of adhesive tapes over Mastisol. Adhesive tape
also appears to act as a semi-occlusive dressing, which
may have contributed to the early epithelialization of the
wounds in this study.
Previous authors have compared tensile strength in
wounds using the variety of closures that we have studied,
and they found similar strength in all cases.1 In this study,
dehiscence occurred frequently in wounds closed with tissue
glue. This may be the result of the fact that any glue between
the skin edges prevents healing in that area.
The difference in cost among the different methods of
closure is significant, resulting from both material costs
and the time in the operating room (approximately $16.75
per minute at our institution) required for wound closure.
Packages of the suture used in this study cost between $2
and $5 each, but the increased time required to place
suture in the operating room make this an expensive
alternative. For material costs alone, adhesive tape after
deep tissue closure is far and away the least expensive
($0.18 per package plus $1.45 for Mastisol). The most
expensive material is tissue glue ($23.28 per vial). The
time required to place adhesive tape and tissue glue is
similar; however, both of these procedures are signifi-
cantly shorter than placing subcuticular suture. This
made the adhesive tape method less expensive than all of
the other methods.
Hyaluronic acid has been shown to decrease scar
formation5 and was used in the study to see if we could
identify any improvement in the scar formation in our pig
model. No advantage in cosmesis was noted in this study.
Histologic studies were performed on the incisions, and
there was no difference seen between the incisions that
were treated with hyaluronic acid and the other incisions.
CONCLUSION
We have adopted this approach for wound closure in
our practice over the last 2o years. We find the closures to
Laryngoscope 111: November 2001
be quick, the wound well protected, and the patients are
pleased with the convenience of not having a specific day
to return for suture removal. Deep (subdermal) closure is
critical to the use of adhesive tape placement. Most im-
portantly, we have had no wound dehiscence in over 100
patients and have been extremely pleased with our cos-
metic results. The epithelial edges must be able to be
approximated precisely and without tension, or we will
elect to place a cutaneous or subcuticular suture.
We simply present this as an alternative in wound
closure. Similar techniques have been reported previously
in the literature for closure of other surgical wounds6,7;
however, it has not been presented for use in head and
neck surgery. While new materials are often beneficial in
advancing medical care, we think advantages need to be
compared with other approaches and cost needs to be
entered into the equation.
BIBLIOGRAPHY
1. Reiter D. Methods and materials for wound management.
Otolaryngol Head Neck Surg 1994;110:550 –556.
2. Toriumi DM, O’Grady K. Surgical tissue adhesives in
otolaryngology– head and neck surgery. Otolaryngol Clin
North Am 1994;27:203–209.
3. Maw JL, Quinn JV, Wells GA, et al. A prospective comparison
of octylcyanoacrylate tissue adhesive and suture for the
closure of head and neck incisions. J Otolaryngol 1997;26:
26 –30.
4. Roth JH, Windle BH. Staple versus closure of skin incisions
in a pig model. Can J Surg 1988;31:19 –20.
5. Burd DA, Greco RM, Regauer S, Longaker MT, Siebert JW,
Garg HG. Hyaluronic and wound healing: a new prospec-
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6. Rubio PA. Use of adhesive tape for primary closure of surgical
skin wounds. Int Surg 1990;75:189 –190.
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Dermatol Surg Oncol 1990;16:721–723.
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1951