Foreign body reaction after usage of tissue adhesives for skin closure: a case report and review of the literature
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- Dragu, A., Unglaub, F., Schwarz, S. et al. Arch Orthop Trauma Surg (2009) 129: 167. doi:10.1007/s00402-008-0643-5
The usage of tissue adhesives such as 2-octyl cyanoacrylate is a standard tool for closure of superficial wounds of the body. The benefits using 2-octyl cyanoacrylate are well known and appreciated by surgeons world wide. Especially in superficial or small wounds in children where no surgical procedure is wanted this technique is commonly used. However, so far the risks and possible complications after using 2-octyl cyanoacrylate are not sufficiently published and discussed.
We report a case of foreign body reaction after 3 weeks in a 39-year-old female patient after usage of 2-octyl cyanoacrylate treating a superficial wound of the right wrist.
The use of 2-octyl cyanoacrylate for the closure of superficial and small wounds or lacerations is a simple, quick and comfortable method. However, there is clinical evidence that in some cases the use of this type of tissue adhesive may lead to foreign body reaction. We suggest that each patient who is treated by this type of wound closure technique should be mandatory informed on the potential risk of a foreign body reaction.
KeywordsTissue adhesives2-Octyl cyanoacrylate (Dermabond®)Foreign body reactionPostoperative complicationWound healing
The usage of tissue adhesives such as 2-octyl cyanoacrylate is an alternative to traditional sutures for repair of superficial and small wounds in all surgical fields [1–13]. The idea of using a sort of synthetic glue for the sutureless closure of a wound is more than 40 years old and not as often believed a modern idea and invention of biomedicine [14–17]. Since then a lot of research and studies have been performed on the effectiveness of 2-octyl cyanoacrylate [10, 11, 14, 18–21]. The tissue adhesive does not impair wound healing and may reduce the risk of wound infection. The potential benefits and advantages of 2-octyl cyanoacrylate are eminent: the ease of use, the rapid closure of wounds, less wound infections, the convenient, comfortable and painless procedure for the patient and the obviation of suture removal. Furthermore, the cosmetic outcomes have been published as to be equal to other wound closure techniques such as steri-strips or sutures [1, 6, 8]. However, little is known about the risks and complications of the use of 2-octyl cyanoacrylate. Literature data indicates cases of foreign body reactions due to other synthetic material [22–24], but offers little information about the risks and complications of 2-octyl cyanoacrylate [19, 25–27].
The idea of using a sort of synthetic glue for the sutureless closure of a wound is more than 40 years old. In 1965 Regensburger et al. published an article dealing with the principle of sutureless closure of wounds. The ideal method for closure of simple wounds remains controversial. The reason for this controversial discussion is because the ideal method has to meet the following criteria: painless, inexpensive, easy and quick to use, low learning curve, aesthetically appealing results [6, 28]. With the scientific progress and innovation on the field of tissue engineering and biomaterials, new possibilities of wound therapy and closure have been developed which meet many of these criteria [29–33]. The development of 2-octyl cyanoacrylate meets many of the above mentioned criteria, which led to the approval of 2-octyl cyanoacrylate by the FDA in 1998. Today a majority of surgeons use 2-octyl cyanoacrylate worldwide and frequently in small lacerations and for wound closure [2, 10–12, 14, 15, 34]. Not only the different surgical subspecialities are using 2-octyl cyanoacrylate, but also the indications have been extended as for example for skin graft fixation [7, 13, 35, 36]. In addition in clinical trials, infection rates have been relatively low with a reported maximum of 8% frequency [6, 13, 37, 38]. Therefore, there is no doubt that in general the use of 2-octyl cyanoacrylate is clinically justified.
Nevertheless, every medically used technique has its risks, complications and negative aspects. A review of the literature, however, gives little data of possible complications and risks after the use of 2-octyl cyanoacrylate. One negative aspect is clearly the high price of 2-octyl cyanoacrylate compared to suture material. More important for the patient clearly is the possibility of a foreign body reaction as a complication after the use of 2-octyl cyanoacrylate. Yamamoto et al. speculated that “tissue adhesive within the wound may result in a foreign body reaction and form a nidus for infection” . In 2001 Edmonson et al. presented a case report of a seven-year-old boy with progressive but unclear local swelling and pains, after the treatment of a laceration above his right eyebrow with 2-octyl cyanoacrylate . These authors could not prove their hypothesis of a foreign body reaction after the use of 2-octyl cyanoacrylate, as no histopathological analysis was done. But the description of his clinical findings are very similar to our findings presented in this case. We were able to prove a foreign body reaction with its typical clinical findings after the use of 2-octyl cyanoacrylate with the performed histopathological results. Our findings clearly prove that a foreign body reaction with its clinical symptoms such as tenderness of the skin and localised pain may be a possible complication after the use of 2-octyl cyanoacrylate in the treatment of lacerations or small wounds. Since in the same location at the palmar wrist crease ganglions are very frequent, as a differential diagnosis it seems advisable to surgically revise unclear swellings and tumour like findings after a timely connection with cyano-acrylate bonding of wounds.
The use of 2-octyl cyanoacrylate for the closure of superficial and small wounds or lacerations is a simple, quick and comfortable method. However, there is clinical evidence that in some cases the use of this type of tissue adhesive may lead to foreign body reaction. Therefore, we suggest that each patient who is treated by this type of wound closure technique should be mandatory informed on the potential risk of a foreign body reaction with typical clinical signs such as tenderness of the wound area, local pains and eventually a development of a tumour in the treated area. These clinical symptoms may lead to another necessary operation to remove the implemented material.