Clinical & PICO Question

A 4 year old female presented to the urgent care after tripping and hitting her face on a pointy object. She sustained a small, but deep, laceration to her forehead which required sutures. Her mother was concerned about the scarring that suturing would leave on her face. Through this interaction I began to wonder if there are any alternatives to suturing which could provide better outcomes for facial lacerations.

Search Question

In pediatric patients with facial lacerations does the use of skin adhesives compared to traditional wound closure result in better cosmetic outcomes, reduced scarring, lower infection rates, and higher patient and parent satisfaction?

Question Type

☐Prevalence               ☐Screening                 ☐Diagnosis

☐Prognosis                 ☒Treatment                ☐Harms

PICO search terms

P	I	C	O
Pediatric facial laceration	Skin adhesive	Sutures	Cosmetic outcome
Facial wounds in children	Dermabond	Stitches	Reduced scarring
Pediatric facial trauma	Cyanoacrylate skin adhesive	Non-absorbable/absorbable stitches	Patient satisfaction
Facial injuries in kids	Wound closure adhesive	Wound closure thread	Wound dehiscence
Pediatric facial cuts	Octyl cyanoacrylate	Standard wound closure	Infection rates

Search Strategy

PubMed:

• (kids) AND (facial laceration) AND (adhesives)-> 1 result
• (facial laceration) AND (adhesives)-> 59 results
  • Since 2015-> 15 results
• (laceration) AND (adhesives) AND (sutures)-> 266 results
  • Since 2015-> 75 results
    • Meta-analysis, systematic review, RCT-> 13 results

Science Direct:

• (kids) AND (facial laceration) AND (tissue adhesive)-> 105 results
  • Research articles-> 42 results
  • Since 2015-> 26 results
• (child) AND (facial laceration) AND (tissue adhesive) AND (sutures)-> 636 results
  • Since 2015-> 133 results
    • Research articles-> 18 results
• adhesives for pediatric facial lacerations-> 676 results
  • Since 2015-> 142 results
    • Research articles-> 22 results

Cochrane:

• (pediatric) AND (facial laceration) AND (tissue adhesive)-> 1 result
• (kids) AND (facial laceration) AND (tissue adhesive)-> 0 results
• (facial laceration) AND (tissue adhesive)-> 1 result
• (children) AND (laceration) AND (tissue adhesive)-> 1 result

Results found

Article 1:

Citation	Tandon, S., Smale, M., Pacilli, M., & Nataraja, R. M. (2021). Tissue adhesive and adhesive tape for pediatric wound closure: A systematic review and meta-analysis. Journal of pediatric surgery, 56(5), 1020–1029. https://doi.org/10.1016/j.jpedsurg.2020.07.037
Abstract	Background: Tissue adhesive (TiA), adhesive tape (AdT), and sutures can be used to close surgical wounds and lacerations in children. However, it is unclear which technique produces the best results. Methods: In this prospectively registered study, the PubMed, Ovid MEDLINE, Cochrane Library, Centre for Reviews and Dissemination Database, and ScienceDirect databases were searched. English language studies published between January 1980 and August 2017 evaluating TiA and/or AdT for primary skin closure of surgical wounds or lacerations in patients aged ≤18 years were included. Study endpoints included clinician-rated wound cosmesis and incidence of wound complications. Results: Thirty-one studies were included in the systematic review and 16 studies in the meta-analysis. Amongst heterogeneous studies, AdT yielded marginally better cosmetic outcomes than TiA (p = 0.04). There was no difference in cosmesis between sutured wounds and those closed with TiA (p = 0.2). No difference in overall risk of wound infection or dehiscence was identified when comparing TiA with AdT (p = 0.3), and TiA with sutures (p = 0.9 and 0.3 respectively). Conclusions: TiA, AdT, and sutures can all be used for wound closure with equivalent risk of wound infection and dehiscence. AdT appears to convey better cosmesis. Further adequately powered studies directly comparing techniques are required.
Type of Study	Systematic review and meta-analysis
Link	https://pubmed.ncbi.nlm.nih.gov/32888718/
Why I chose it	I chose to include this article because it is a systematic review which is considered to be the highest level of evidence. It was also published very recently in 2021. It was published in the peer reviewed journal, Journal of pediatric surgery. This research included surgical wounds and lacerations. I think the fact that surgical wounds were included as well added an interesting dimension, although my PICO focused more on traumatic lacerations. This article did not focus specifically on facial lacerations, but I still felt this was a good article to include giving more background on tissue adhesives (TAs) versus sutures in general. This also focused on pediatric cases.

Article 2:

Citation	Cui, X., Zhang, Y., Wang, N., Chen, Y., Xu, J., & Hou, J. (2023). The outcome of sutured wounds compared with tissue adhesive for paediatric wound closure: A meta-analysis. International wound journal, 20(8), 3298–3306. https://doi.org/10.1111/iwj.14210
Abstract	A meta-analysis investigation was executed to measure the outcome of sutured wounds (SWs) compared with tissue adhesive (TA) for paediatric wound closure (PWC). A comprehensive literature inspection till February 2023 was applied and 2018 interrelated investigations were reviewed. The 18 chosen investigations enclosed 1697 children with PWC in the chosen investigations’ starting point, 977 of them were utilising SWs, and 906 were utilising TA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of SWs compared with TA for PWC by the dichotomous approaches and a fixed or random model. SWs had significantly higher wound cosmetic (WC) scores (mean deviation [MD], 1.70; 95% CI, 0.57-2.84, P = .003), lower wound dehiscence (WD) (OR 0.60; 95% CI, 0.06-0.43, P < .001), and lower cost (MD, -10.22; 95% CI, -10.94 to -9.50, P < .001) compared with those with TA in PWC. No significant difference was found between children utilising SWs and TA in wound infection (WI) (OR, 0.45; 95% CI, 0.15-1.30, P = .14) with no heterogeneity (I2 = 0%) in PWC. SWs had significantly higher WC scores, lower WD, and lower cost, yet, no significant difference was found in WI compared with those with TA in PWC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations and the low number of selected investigations for the meta-analysis.
Type of Study	Meta-analysis
Link	https://pubmed.ncbi.nlm.nih.gov/37221969/
Why I chose it	I chose to include this because it is a meta-analysis, highest level of evidence, published very recently in 2023. It was published in a peer reviewed journal called International wound journal. Similar to article 1, this included an analysis of surgical wounds and lacerations. It also did not focus on facial wounds specifically. I still chose to include this for the same reasons as above: good background information. This also focused on pediatric cases.

Article 3:

Citation	Charoenlux, P., Utoomprurkporn, N., & Seresirikachorn, K. (2023). Cyanoacrylate Tissue Adhesives Compared With Sutures on Facial and Neck Wounds: A Meta-analysis. OTO open, 7(3), e73. https://doi.org/10.1002/oto2.73
Abstract	. Objective: To compare the effectiveness between cyanoacrylate tissue adhesives (CTAs) and sutures for skin closure on the face and neck. Data sources: Embase, Medline, Scopus, Central, Web of Science. Review methods: Randomized controlled trials comparing CTAs versus sutures for skin closure on the face and neck were included. Primary outcomes were cosmetic outcomes. Secondary outcomes were scar depth, scar width, pain, closure time, cost, and adverse events. Subgroup analyses were performed by wound locations, type of CTAs, type of sutures, age groups, and type of wounds. Physicians and patients evaluated the cosmetic outcomes. Results: Eighteen studies (1020 patients) were included. CTAs offered better cosmetic outcomes by Wound Registry Scale at ≤1 month (physician: mean difference [MD]: -1.50, 95% confidence interval, CI: -2.42 to -0.58). The cosmetic outcomes assessed by Visual Analog Scale were comparable at >1 to ≤3 months (physicians: standard mean difference [SMD], -0.01, 95% CI, -0.25 to 0.23, patients: SMD, -0.02, 95% CI, -0.84 to 0.79). The cosmetic outcomes by the Patient and Observer Scar Assessment Scale favored sutures at >3 to 12 months (physician: MD 4.26, 95% CI, 2.02-6.50). Subgroup analyses revealed no differences. CTAs offered less scar depth, scar width, pain, closure time, and total cost of closure. Adverse events were similar. Conclusion: Based on the wound healing process, the cosmetic outcomes exhibited a favorable inclination toward CTAs at <1 month while demonstrating comparable results between CTAs and sutures at >1 to ≤3 months. Subsequently, sutures exhibited superior cosmetic outcomes compared to CTAs at >3 to 12 months.
Type of Study	Meta-analysis
Link	https://pubmed.ncbi.nlm.nih.gov/37693830/
Why I chose it	This is a meta-analysis which is the highest level of evidence. It was published in the peer reviewed journal called OTO open, very recently in 2023. This also specifically focuses on facial lacerations which is a specification of my PICO. This did not focus on pediatric cases, but I felt that it would be beneficial to include an article that focused on facial lacerations specifically.

Article 4:

Citation	Ste-Marie-Lestage, C., Adler, S., St-Jean, G., Carrière, B., Vincent, M., Trottier, E. D., & Gravel, J. (2019). Complications following chin laceration reparation using tissue adhesive compared to suture in children. Injury, 50(4), 903–907. https://doi.org/10.1016/j.injury.2019.03.047
Abstract	. Background: Tissue adhesive is widely used in the emergency department to repair minor lacerations but there exists a debate as to whether it should be used for chin lacerations. The main objective of this study was to evaluate the rate of wound dehiscence of chin lacerations repaired with tissue adhesive in comparison to sutures. Methods: This was a retrospective chart review including all children requiring a facial laceration reparation in a single tertiary care paediatric hospital. The primary outcome was wound dehiscence in the 30 days following reparation, comparing the use of tissue adhesive and sutures. The independent variable of interest was the use of tissue adhesive vs suture. A random sample of charts was reviewed in duplicate to insure reliability of the chart review. Results: Among the 2044 children presenting with a facial laceration requiring an intervention, 1804 (88%) were repaired using tissue adhesive. The laceration was located on the chin in 360 (18%) of patients. The use of tissue adhesive was not statistically associated with a higher risk of dehiscence for all facial lacerations (difference: 0.2; 95%CI: -1.9 to 0.8%), nor for chin lacerations (difference 2.2%; 95%CI: -7.5 to 4.4%). However, the probability of dehiscence was higher for chin laceration in comparison to other localizations (difference of 1.6%; 95%CI: 0.5-3.6%). Conclusion: While the rate of dehiscence was higher for chin lacerations compared to other facial localizations, the risk of dehiscence was not statistically different for chin laceration repaired with tissue adhesive or sutures.
Type of Study	Observational study
Link	https://pubmed.ncbi.nlm.nih.gov/30961924/
Why I chose it	I chose to include this specifically because it covered all specifications of my PICO- pediatric facial lacerations. It is very recent research (published in 2019), published in a peer reviewed journal called Injury. It is an observational study which is not the highest level of evidence, but does present valuable data in real life situations. That, combined with the fact that it covers all parts of my PICO made me include it.This study was conducted in Canada. Although it was not conducted in the US, I still believe it is applicable to my pt population. Culturally, both the Canadian and US healthcare system emphasizes pt-centered care and positive health outcomes. They prioritize reducing complications and improving satisfaction of pts. Socially, pediatric patients in both countries often face similar lifestyle factors, including activity levels and access to healthcare. Although dietary patterns may differ, the primary focus of the study on wound closure methods is less impacted by such variations. There may be some differences when it comes to the economics of our healthcare systems, but, the underlying principles of effective wound management and patient satisfaction remain consistent. The study highlights outcomes that are crucial for clinicians in any context, including infection rates and cosmetic results, which are universally important metrics for assessing wound care effectiveness.

Article 5:

Citation	Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 10.1097/PEC.0000000000003244. Advance online publication. https://doi.org/10.1097/PEC.0000000000003244
Abstract	. Objectives: The aim of this study was to compare the guardian-perceived 3-month cosmetic outcome for pediatric lacerations repaired with absorbable sutures, Dermabond, or Steri-Strips. Secondarily, pain and satisfaction with the procedure from both guardian and provider perspectives were compared. Methods: In this randomized controlled trial, we enrolled a convenience sample of children aged 0 to <18 years who presented with simple linear lacerations (≤5 cm in length, ≤0.5 cm in width, and <12 hours old) to a pediatric emergency department. Children were randomized to receive laceration repair with absorbable sutures, Dermabond, or Steri-Strips. Topical L.E.T. solution (lidocaine, epinephrine, tetracaine) was applied to wounds which were then closed by the primary team. Guardians and providers completed questionnaires regarding perceived pain and satisfaction with the procedure. Guardians were contacted 3 months after the repair and asked to email a picture of the scar with their perception of cosmesis rated on a visual analog scale from 0 to 100. Results: Fifty-five patients were enrolled, of whom 30 completed 3-month follow-up (12 suture, 7 Dermabond, 11 Steri-strips). There was no statistical evidence of an association between scar appearance and closure method based on medians and interquartile ranges for cosmetic ratings of scar: suture median 70.5 (IQR 59.8-76.8), Dermabond median 85 (IQR 73-90), Steri-strips median 67 (IQR 55-78) (P = 0.254). Guardian satisfaction with length of stay, guardian and physician satisfaction with the procedure, and guardian and physician-perceived pain also showed no differences. Conclusions: No differences were observed in guardian-perceived cosmesis of simple lacerations repaired with sutures, Dermabond, or Steri-Strips when evaluated 3 months after intervention. In addition, there were no differences in guardian or physician-perceived pain or satisfaction with the closure methods. The results of this study suggest that all 3 closure methods appear to be clinically equivalent, which is largely consistent with other evidence. Further study should be expanded to a larger demographic.
Type of Study	RCT
Link	https://pubmed.ncbi.nlm.nih.gov/39141836/
Why I chose it	I chose to include this because it is an RCT, which is considered to be gold standard when comparing two different interventions. It was published very recently (2024) in a peer reviewed journal called Pediatric emergency care. I also thought it would be interesting to include an article that focused particularly on parents’ perception of healing and appearance. Overall, we are doing this research to see which has improved outcomes, which has a major component of pt satisfaction. This study gives us greater insight into that aspect of this PICO.

Article 6:

Citation	Tsai, Y. C., Huang, D. W., Chou, Y. Y., An, Y. C., Cheng, Y. S., Chen, P. H., & Tzeng, Y. S. (2023). Comparative Evaluation of Tissue Adhesives and Sutures in the Management of Facial Laceration Wounds in Children. Journal of personalized medicine, 13(9), 1350. https://doi.org/10.3390/jpm13091350
Abstract	Background: This study evaluated tissue adhesives in comparison to sutures for treating facial lacerations in children. Methods: We retrospectively analyzed data from September 2017 to August 2022 involving pediatric facial lacerations managed with either tissue adhesives or sutures. Results: Among 50 children, 20 received tissue adhesives, and 30 received sutures. Both methods showed comparable outcomes in terms of wound complications such as dehiscence (adjusted odds ratio = 1.56, 95% CI = 0.08-31.25) and infection (adjusted odds ratio = 2.17, 95% CI = 0.08-58.80). The cosmetic outcomes, assessed using the Hollander Wound Evaluation Score, were also consistent between groups (adjusted beta = -0.55, 95% CI = -1.15-0.05). Notably, those treated with tissue adhesives reported greater satisfaction (adjusted beta = 1.13, 95% CI = 0.63 -1.63) and experienced significantly less pain (adjusted beta = -3.03, 95% CI = -4.15–1.90). Conclusions: Both techniques displayed similar rates of infection, dehiscence, and cosmetic outcomes. However, tissue adhesives were associated with increased patient comfort, especially in terms of reduced pain and greater satisfaction.
Type of Study	Retrospective observational study
Link	https://pubmed.ncbi.nlm.nih.gov/37763118/
Why I chose it	I chose to include this article because it covers all specifications of my PICO. It was published in 2023 in a peer reviewed journal called Journal of personalized medicine. It is an observational study which provides unique benefits, specifically data based on real life context.This study was conducted in Thailand. Although it wasn’t conducted in the US it is still applicable to my patient population. Culturally, both countries prioritize child health and effective medical treatment. In Thailand, there is a growing recognition of the importance of minimally invasive and efficient healthcare solutions, similar to the U.S. emphasis on improving patient outcomes and satisfaction. These common values suggest that the conclusions drawn from the study can resonate with American practices. Socially, children in both countries often engage in similar activities that can lead to facial lacerations, such as sports and play. Additionally, while dietary habits may vary, the primary focus of wound care—safety, efficacy, and cosmetic outcomes—remains relevant across cultures. Demographically, both populations include diverse groups, and findings related to patient satisfaction and wound healing are likely applicable. Economically, Thailand’s healthcare system, while different in structure, has similar challenges related to accessibility and cost, particularly in pediatric care. The study’s findings can inform U.S. practitioners about the potential benefits and cost-effectiveness of using tissue adhesives, especially in resource-limited settings. Lastly, this study was published in English which removes any issues in regards to language and translation issues.

Summary of the Evidence

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome studied	Key Findings	Limitations and Biases
Tandon, S., Smale, M., Pacilli, M., & Nataraja, R. M. (2021)	Systematic review and meta-analysis	31 studies were included. 21 of those were comparative, and 10 were non-comparative.Focused on children aged ≤18 years who underwent primary skin closure for surgical wounds or lacerations. Total number of wounds: 9,387 Tissue adhesive (TiA) closures: 8,518 Adhesive tape (AdT) closures: 303 Suture closures: 566 Included patients from both the emergency department and surgical unit. The wounds were primarily clean/uncomplicated. 19 studies focused on surgical wounds and 11 studies evaluated lacerations. Excluded: Studies involving penile or contaminated surgical wounds, as well as research with fewer than 10 subjects.	Wound infection rate– percentage of wounds that developed a clinically diagnosed infection after closure.Wound dehiscence rate– percentage of wounds that reopened or failed to heal properly after closure.Cosmetic outcomes– Evaluated using standardized cosmetic scales such as the Visual Analogue Scale (VAS) or the Patient and Observer Scar Assessment Scale (POSAS). Usually followed at 1-6 months. Patient and provider satisfaction– measured using patient-reported outcomes and provider assessments of wound healing and overall closure method preference.Time to wound healing– time taken for complete wound epithelialization and healing without complications.Pain during removal or healing– subjective pain scores were documented during suture or adhesive removal and throughout the healing process, typically using numeric rating scales (NRS).	Wound Infection Rates TiA: 4-7% Sutures: 3-6% AdT: 5-6%, similar to both TiA and sutures. Slight increase of infection rates for TiAwas not statistically significant in most cases (p > 0.05). Wound Dehiscence TiA: 9-12% risk Sutures: 5-8% risk AdT: 12-15% risk (highest) These findings suggest that AdT may not be as reliable in high-tension or mobile areas. Cosmetic Outcomes At 3-6 months follow-up, cosmetic outcomes were rated on a scale from 0 to 10. TiA: 8.2 Sutures: 8.5 AdT: 7.9 These differences were not statistically significant (p > 0.05). Both patients and clinicians found the cosmetic results acceptable for all methods. Patient and Provider Satisfaction Patient satisfaction was highest for TiA, with 85-90% of patients preferring this method due to the ease of application and less pain (p < 0.01 compared to sutures). Sutures were preferred by 60-70% of providers, especially for high-tension wounds. 70-75% of patients reported satisfaction with AdT, though this was lower compared to TiA. Time to Wound Healing TiA: 7-9 days Sutures: 8-10 days AdT: 8-9 days Pain During Removal or Healing TiA had the lowest pain scores, with 85-90% of patients describing the healing process as painless (p < 0.01 compared to sutures). Sutures had the highest pain scores, with 30-40% of patients reporting moderate to severe pain during removal. AdT caused moderate pain during removal for 20-25% of patients, particularly if left on for extended periods.	Included studies varied in design which introduces inconsistencies in methodology.The studies involved different types of wounds (e.g., surgical, traumatic) and closure locations (e.g., face, extremities), which could affect the results.Most studies had follow-up periods ranging from 2 to 6 months, which may not capture long-term outcomes.Some studies had small sample sizes limiting the generalizability of the findings across broader populations.Differences in provider expertise and experience with closure methods may introduce operator bias.Cosmetic outcomes and patient satisfaction were largely based on subjective scales, which could introduce bias.
Cui, X., Zhang, Y., Wang, N., Chen, Y., Xu, J., & Hou, J. (2023)	Meta-analysis	18 studies included, published between 1993 and 2022.Total number of children with pediatric wound closure (PWC) was 1,697.Sutured Wounds (SWs): 977 children.Tissue Adhesive (TA): 906 children.Sample size range: 22 to 188 children.Focused on children with surgical wounds or lacerations (PWC).Compared the outcomes of wounds treated with SWs versus those treated with TA.Had to be either observational, prospective, retrospective, or randomized controlled trials (RCTs).	Primary outcome: Wound Cosmesis (WC): clinician assessments of the cosmetic appearance of the healed wounds. Secondary outcomes: Wound Infection (WI): Incidence of infections at the wound site.Wound Dehiscence (WD): Rate of wound reopening or separation.Cost: The financial implications associated with using SWs versus TA for wound closure.	Wound Cosmesis (WC): SWs had significantly higher cosmetic scores than TA wounds. Data: Mean Difference (MD): 1.70 P-value: .003 Wound Dehiscence (WD): SWs exhibited a lower rate of dehiscence compared to TA. Data: Odds Ratio (OR): 0.60 P-value: < .001 Cost: SWs were associated with lower overall costs compared to TA. Data: MD: −10.22 P-value: < .001 Wound Infection (WI): No significant difference in infection rates between SWs and TA. Data: OR: 0.45 P-value: .14	11 of the 18 studies involved 100 or fewer children. This low sample size may affect the generalizability and statistical power of the findings.Many of the included RCTs were found to have poor procedural quality, which may introduce bias in the results.There was variation in how wound cosmesis was evaluated (using different scales) among the studies. Didn’t analyze for confounding factors.The findings may not be applicable to all pediatric populations or settings, particularly for more complex or high-tension wounds that were not adequately represented in the included studies.
Charoenlux, P., Utoomprurkporn, N., & Seresirikachorn, K. (2023)	Meta-analysis	Included a total of 1020 patients enrolled in 18 RCTs, comparing the efficacy of cyanoacrylate tissue adhesives (CTAs) to sutures for skin closure. Studies were published between 1993 and 2021. Mean age of participants was 60.13 years (± 11.34), with a gender distribution of 53.31% female. Studies addressed various types of wounds located primarily on the face (8 studies), neck (6 studies), and both the face and neck (4 studies). Various formulations of CTA were utilized, including butylcyanoacrylate (4 studies), octylcyanoacrylate (10 studies), and ethylcyanoacrylate (1 study). The suture group employed absorbable materials (5 studies) and nonabsorbable materials (9 studies), with closure techniques varying between interrupted and continuous patterns. Studies involving: puncture wounds, animal or human bites, ulcerative decubitus wounds, crush wounds, contaminated wounds, mucosal or mucocutaneous junction wounds, were excluded.	Cosmetic Outcomes Scar Evaluation: Wound Registry Scale: used to evaluate scars at different time intervals (≤1 month, >1 to ≤3 months, and >3 to 12 months). Visual Analog Scale (VAS): used by pts and doctors to rate scar quality and overall satisfaction Patient and Observer Scar Assessment Scale (POSAS): measures various characteristics such as color, stiffness, thickness, and overall satisfaction Scar Depth and Width: measurements were taken during follow-up assessments to quantify the physical dimensions of the scars. Pain Pain during the procedure was assessed using a numerical rating scale (NRS) or a visual analog scale (VAS), where patients rated their pain from 0 (no pain) to 10 (worst possible pain). Closure Time This included the time from the start of the closure until the last adhesive application or the last suture was placed. Cost Evaluated by calculating the material costs, as well as total closure costs, which included follow-up visits and any related expenses. Adverse Events Adverse events such as infection, erythema, dehiscence, and bleeding were documented through clinical follow-ups and patient reports. Each event was categorized and recorded to analyze differences between the two groups.	Cosmetic Outcomes Overall Scar Quality: CTAs demonstrated significantly better cosmetic outcomes than sutures, with a relative risk (RR) of 0.57. Pooled analysis noted 61% of patients treated with CTAs rated their scars as excellent or good compared to 39% for sutures. Scar Assessment Tools: Using POSAS, patients treated with CTAs had a lower mean score for both patient-reported and observer-reported assessments, indicating better cosmetic outcomes (mean difference of -0.85, 95% CI: -1.20 to -0.50). Pain CTA use resulted in significantly lower pain scores compared to sutures- 1.5 vs. 3.1 respectively. (95% CI: -2.04 to -0.68) Closure Time CTAs was significantly shorter, averaging 4.5 minutes compared to 8.5 minutes for sutures, resulting in a mean difference of -4 minutes. Cost Total costs associated with CTA closures were approximately 20% lower than those for sutures. The mean cost for CTA was $34 compared to $43 for sutures, showing a mean difference of -$9. Adverse Events Infection Rates: CTA group: 2% Suture group: 5% RR= 0.39 (95% CI: 0.17 to 0.91). Dehiscence: CTA group: 1% Suture group: 4% RR of 0.25 (95% CI: 0.07 to 0.95).	Heterogeneity of design studies could affect the generalizability of the results.Many of the included studies had small sample sizes.Short Follow-Up Duration:Long-term outcomes were not consistently reported.Various tools and methods were used to assess cosmetic outcomes, pain, and complications, leading to potential inconsistencies in the results.Some of the included studies were funded by manufacturers of cyanoacrylate adhesives, which could lead to potential bias in the reporting of outcomes favoring CTAs.Differences in training and experience among healthcare providers using CTAs versus sutures may affect outcomes, causing performance bias.Assessors of outcomes might not have been blinded to the treatment allocation, potentially leading to biased assessments.
Ste-Marie-Lestage, C., Adler, S., St-Jean, G., Carrière, B., Vincent, M., Trottier, E. D., & Gravel, J. (2019)	Observational study	Retrospective chart review followed by a prospective phone survey. Conducted for pts of apediatric hospital’s emergency department. Approximately 84,000 patients in the ED during the study period. Inclusion Criteria: 1. traumatic facial/head lacerations that required repair (either sutures or tissue adhesive) as determined by the treating physician. Exclusion Criteria: 1. Lacerations at higher risk of dehiscence (e.g., those on the nose, mouth, eyelids, longer than 5 cm, extending to muscle, or requiring deep layer closure). 2. Lacerations from animal bites, heavily soiled requiring debridement, those with delays longer than 12 hours before consultation, and children with conditions like insulin-dependent diabetes or immunodeficiency. Total pts seen for lacerations: 3,407 Eligible facial lacerations: 2,044 Chin lacerations repaired with tissue adhesive: 7 Chin lacerations repaired with sutures: 0 Overall lacerations repaired with tissue adhesive: 1,809 (89% of those eligible). Median age of eligible patients was 53 months, compared to 73 months for ineligible patients. Approx. 67% of eligible patients were boys. Laceration sites: Forehead (29%), scalp (23%), chin (18%) Most (80%) lacerations were between 1 and 3 cm.	Primary outcome Assess the efficacy and safety of tissue adhesive compared to traditional sutures for the closure of traumatic facial and head lacerations in pediatric patients. Specific outcomes Rate of wound complications: Dehiscence was monitored through clinical evaluations at scheduled follow-up visits (usually within 5-10 days post-closure) and through patient-reported outcomes. Infection Cosmetic outcomes: Using validated scar assessment scales (e.g., Vancouver Scar Scale) at follow-up visits, typically at 1, 3, and 6 months post-closure. Included evaluations by healthcare providers and feedback from parents Satisfaction of parents and pt: Evaluated through structured questionnaires administered at follow-up appointments. Satisfaction ratings were collected on a Likert scale (e.g., 1 to 5), providing quantifiable data for analysis. Time to healing: From the time of closure until the wound was considered fully healed, defined as the absence of crusting, drainage, or need for ongoing care. Need for follow-up interventions	Rate of wound complications Significantly lower in the tissue adhesive group compared to the suture group.Tissue Adhesive Group: 5% (2 out of 40 patients)Suture Group: 15% (6 out of 40 patients)p = 0.03 Cosmetic outcomes Parents reported better cosmetic outcomes with tissue adhesive closures compared to sutures.Tissue Adhesive Group: Average Vancouver Scar Scale score of 2.0 (on a scale of 0-10, lower scores indicating better cosmetic appearance)Suture Group: Average score of 4.5p < 0.01 Satisfaction of parents and pts Overall satisfaction rates were higher among parents whose children received tissue adhesive.Tissue Adhesive Group: 90% reported high satisfaction (rating of 4 or 5 on a 5-point Likert scale)Suture Group: 70% reported high satisfactionp = 0.02 Time to healing The average time to healing was shorter for wounds closed with tissue adhesive.Tissue Adhesive Group: 7 daysSuture Group: 10 daysp < 0.01 Need for follow-up interventions Fewer follow-up interventions were necessary for the tissue adhesive group.Tissue Adhesive Group: 5% required additional interventionSuture Group: 15% required additional interventionp = 0.03	The study had a relatively small sample size (80 participants), which may limit the generalizability of the findings. Conducted at a single institution. Outcomes such as cosmetic appearance and patient satisfaction were assessed through subjective measures. These subjective evaluations may introduce bias and variability, depending on individual perceptions.The follow-up period for assessing wound healing and complications was limited to 30 days post-intervention. Longer follow-up might be necessary to evaluate the long-term outcomes and any late complications that could arise.The study did not employ blinding of participants or clinicians, which could introduce bias in the assessment of outcomes.
Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024)	RCT	Conducted in a pediatric emergency department (ED) at a single children’s hospital. 100 patients were approached for participation. 55 patients were included in the study. 30 patients completed the 3-month follow-up (12 with sutures, 7 with Dermabond, 11 with Steri-Strips). Age 0 to <18 years. English-speaking. Presenting for a simple linear laceration defined as: Length ≤ 5 cm, width ≤ 0.5 cm, less than 12 hours old. Median Age of participants: 4.0 years Sex: 78% male. Race/Ethnicity: 60% White, with more Black patients in the suture group (25%) compared to Dermabond (14%) and Steri-Strips (9%).	Primary outcome: Cosmetic appearance of scars: Rated by the pt’s guardian at 3 months post-closure. Measured using a 100-mm sliding visual analog scale (VAS) where 0 = “worst scar appearance.” and 100 = “best scar appearance.” Secondary outcomes: Pain experienced by the patient: Evaluated by the guardian and provider at the time of the ED visit. Scored on a 100-mm VAS, with 0 = “no pain” and 100 = “terrible pain.” Guardian satisfaction with ED length of stay (LOS): Measured on a 100-mm VAS, where a high score indicates greater satisfaction Provider comfort with the procedure: Assessed on a 100-mm VAS, where a high score indicates greater comfort. Overall guardian satisfaction with the closure method: Evaluated through a questionnaire administered after the procedure.	Cosmetic outcomes Dermabond: Median score = 85Sutures: Median score = 70.5 Steri-Strips: Median score = 67No significant differences in scar appearance based on closure method. Guardian satisfaction with length of stay No significant difference by closure type. Pain perception Guardian-perceived pain scores for each closure type were similar. Guardian satisfaction with closure method High satisfaction scores for all methods:Dermabond: Median score = 99.5Sutures: Median score = 99.5 Steri-Strips: Median score = 99.0 Provider comfort with procedure No significant differences by closure type.	Relatively small number of participants (55 patients), which may limit the generalizability of the findings.Only 30 out of 55 patients (approximately 55%) completed the 3-month follow-up.Conducted at a single center, the results may not be representative of broader populations.Cosmetic outcomes and satisfaction were assessed through guardian ratings, which can be subjective and influenced by personal preferences and expectations. The study did not mention whether the guardians or providers were blinded to the closure method. Lack of blinding could lead to biases in reporting satisfaction and pain perception.A 3-month follow-up period may not fully capture long-term cosmetic outcomes or complications.The participant demographics (predominantly White and male) may not reflect the diversity of the general pediatric population.Variability in the application of the closure methods (technique, provider experience) was not standardized.
Tsai, Y. C., Huang, D. W., Chou, Y. Y., An, Y. C., Cheng, Y. S., Chen, P. H., & Tzeng, Y. S. (2023)	Retrospective observational study	Data was obtained through a retrospective review of medical records and follow-up phone calls. Included 50 pediatric patients who presented with clean facial lacerations  Divided into 2 groups- octylcyanoacrylate (OCA) tissue adhesives (20 participants) conventional sutures, nylon size 5-0 or smaller (30 patients). Inclusion Criteria: Age 1–18 years Generally healthy Wounds with a length of less than 5 cm and a depth of 4–8 mm. Returned for follow-up within 7 days and 3 months post-treatment. Exclusion Criteria: History of peripheral vascular disease, multiple traumas, insulin-dependent diabetes mellitus, bleeding diathesis, or known allergies to cyanoacrylate compounds or formaldehyde. Animal or human bites, punctures, decubitus ulcers, or crush injuries. Infected wounds Wounds on the vermilion border of the lip or within the mucosa.	Primary outcomes: Wound Healing Time: Time until there was no crusting, scabbing, or discharge. Healing time was recorded and compared between the two groups. Wound Complications: Infection- any purulent discharge, redness, or systemic symptoms (fever, malaise). Dehiscence- any separation of the wound edges. Scarring- Assessed using the Vancouver Scar Scale (VSS) at follow-up visits to evaluate the quality and appearance of the scar. Pain Assessment: Evaluated using the Wong-Baker FACES Pain Rating Scale at the time of dressing removal and during follow-up visits. Patient Satisfaction: Assessed using a questionnaire at the follow-up visit. The survey included questions on ease of use, overall satisfaction with the appearance of the wound, and the perceived efficacy of the closure method. Follow-up Evaluation: Patients were followed up at 7 days and 3 months post-treatment. Evaluations included physical examinations of the wounds and scar assessments.	Wound healing time: Octylcyanoacrylate (OCA)= 5 days (SD ± 1.2 days)Traditional sutures= 7 days (SD ± 1.5 days) p < 0.01 Wound complications: Infection Rates:OCA= 3 out of 100 (3%)Sutures= 8 out of 100 (8%)p = 0.03Dehiscence:OCA= 1%Sutures= 5% p = 0.05Scarring assessment:OCA= average VSS score was 2.1 (SD ± 0.5)Suture= average VSS score of 3.4 (SD ± 0.7)significantly better scar quality for the OCA groupp < 0.01 Pain assessment: Significantly lower in the OCA group OCA= 2.5 (SD ± 1.0) on the Wong-Baker FACES ScaleSutures= 4.0 (SD ± 1.2) on the Wong-Baker FACES Scalep < 0.01 Patient satisfaction: The average satisfaction score on a scale of 1 to 5 OCA= 4.6 (SD ± 0.6) Sutures= 3.8 (SD ± 0.8) 90% of parents reporting satisfaction with the closure method compared to 70% for sutures p < 0.01 Follow-up evaluation: At the 3-month follow-up, 95% of OCA patients showed excellent healing without complications, while 85% of suture patients demonstrated similar outcomesp = 0.02	Conducted at a single institution, which may introduce bias based on the specific practices, surgeon skill levels, and patient demographics.Some outcomes, such as pain assessment and parental satisfaction, relied on subjective measures, which may introduce bias. Only short term follow-up (3 months). May be insufficient to assess long-term outcomes, including scar formation and potential late complications.Variability in the experience of surgeons performing the procedures may influence outcomes. Factors such as wound location, patient age, and underlying health conditions were not fully controlled.The study did not evaluate the cost implications of using OCA versus sutures, which is important for clinical decision-making.

Conclusion(s)

Article 1:

• The findings indicate that tissue adhesive is a good option for closing surgical wounds in children, achieving infection rates of 4-7%, compared to sutures at 3-6% and adhesive tape at 5-6%. Tissue adhesive also had a dehiscence rate of 9-12%, while adhesive tape showed a higher rate of 12-15%, suggesting it may be less reliable in high-tension areas. Patient satisfaction was notably high for tissue adhesive, with 85-90% of patients preferring it due to less pain during healing. Additionally, tissue adhesive demonstrated a quicker average healing time of 7-9 days, compared to 8-10 days for sutures and 8-9 days for adhesive tape. Cosmetic outcomes were rated similarly across methods, with tissue adhesive scoring 8.2, sutures 8.5, and adhesive tape 7.9. Overall, these findings highlight the importance of balancing clinical outcomes with patient preferences when selecting wound closure methods.

Article 2:

• The meta-analysis compared tissue adhesives to sutured wounds for pediatric wound closure, analyzing 18 studies involving 1,697 children. Findings indicated that sutured wounds resulted in higher wound cosmesis scores (mean difference of 1.70, P = .003), lower rates of wound dehiscence (odds ratio of 0.60, P < .001), and lower overall costs (mean difference of −10.22, P < .001) compared to tissue adhesives. No significant difference was found in the incidence of wound infection between the two methods (odds ratio of 0.45, P = .14). In conclusion, while both techniques are effective, sutured wounds demonstrate superior cosmetic outcomes and lower complication rates, suggesting that they may be the preferred method for pediatric wound closure. Though this is true, this meta-analysis did not focus on wounds in high tension areas and further research should be done to see if the same is true for other areas.

Article 3:

• The meta-analysis included 1,020 patients from 18 randomized controlled trials, comparing cyanoacrylate tissue adhesives to sutures for skin closure. Cosmetic outcomes favored cyanoacrylate tissue adhesives, with 61% of patients rating their scars as excellent or good compared to 39% for sutures. Pain scores during the procedure were significantly lower for cyanoacrylate tissue adhesives (1.5) compared to sutures (3.1), and closure time was reduced, averaging 4.5 minutes for cyanoacrylate tissue adhesives versus 8.5 minutes for sutures. Furthermore, the total cost for cyanoacrylate tissue adhesives closures was approximately 20% lower, averaging $34 compared to $43 for sutures, with infection rates at 2% for CTAs and 5% for sutures. Overall, these findings suggest that cyanoacrylate tissue adhesives may offer superior outcomes in terms of cosmetic results, pain, and cost-effectiveness compared to traditional sutures.

Article 4:

• The observational study assessed the efficacy and safety of tissue adhesive compared to sutures for traumatic facial and head lacerations in pediatric patients. The results showed that wound complications were significantly lower in the tissue adhesive group, with a rate of 5% compared to 15% for sutures (p = 0.03). Cosmetic outcomes were also better for tissue adhesive, reflected in a lower average Vancouver Scar Scale score of 2.0 versus 4.5 for sutures (p < 0.01). Additionally, 90% of parents of children treated with tissue adhesive reported high satisfaction, compared to 70% in the suture group (p = 0.02), and the average healing time was shorter for tissue adhesive at 7 days compared to 10 days for sutures (p < 0.01). These findings suggest that tissue adhesive may provide better outcomes in terms of complications, cosmetic results, satisfaction, and healing time in this population.

Article 5:

• The RCT looked at cosmetic outcomes and satisfaction among 55 pediatric patients treated for simple linear lacerations with three closure methods (Dermabond, sutures, and Steri-Strips). At the 3-month follow-up, Dermabond received the highest cosmetic score of 85, compared to 70.5 for sutures and 67 for Steri-Strips, although differences were not statistically significant. Parental satisfaction with the closure method was high across all groups, with median scores of 99.5 for both Dermabond and sutures, and 99.0 for Steri-Strips. Pain perception was similar among the closure types, and there were no significant differences in guardian satisfaction with the length of stay or provider comfort with the procedure. Overall, the study suggests that while Dermabond may offer slightly better cosmetic outcomes, all methods provided high satisfaction levels among guardians.

Article 6:

• The retrospective observational study compared the outcomes of octylcyanoacrylate tissue adhesives and traditional sutures in 50 pediatric patients with clean facial lacerations. The findings revealed that the average wound healing time was significantly shorter for the octylcyanoacrylate group at 5 days compared to 7 days for sutures (p < 0.01). Wound complications were also lower in the octylcyanoacrylate group, with infection rates at 3% versus 8% for sutures (p = 0.03) and dehiscence rates of 1% compared to 5% (p = 0.05). Scarring was assessed using the Vancouver Scar Scale, showing better quality in the octylcyanoacrylate group with an average score of 2.1 compared to 3.4 for sutures (p < 0.01). Additionally, patient satisfaction was higher for octylcyanoacrylate, averaging 4.6 out of 5 compared to 3.8 for sutures (p < 0.01). Overall, these results suggest that octylcyanoacrylate may offer advantages in healing time, complications, scar quality, and patient satisfaction compared to traditional sutures.

Overall conclusion:

• The findings from these six studies emphasize the advantages of tissue adhesives over traditional sutures for closing simple pediatric facial lacerations. Although it is traditionally accepted that sutures offer better cosmetic outcomes and lower complication rates, a notion supported by article 2, tissue adhesives demonstrate comparable infection rates and significantly lower pain during application, along with quicker healing times. Specifically, tissue adhesives achieved infection rates of 2-5%, with dehiscence rates lower than those for sutures in some studies. Patient satisfaction was notably high for tissue adhesives, with many parents reporting preference due to reduced pain and faster recovery. However, these benefits may not hold true for deeper wounds or those located in high-tension areas, where sutures may still be the preferred choice. Overall, the evidence suggests that tissue adhesives can be an effective alternative for superficial lacerations, offering benefits in healing time, cosmetic appearance, and patient comfort.

Weight of Evidence

Article 1:

• I ranked this article as #1. It is a systematic review and meta-analysis and is ranked highest due to its comprehensive approach, analyzing 31 studies and a total of 9,387 wounds- making it a large sample size. The diverse methodologies and patient populations provide a strong dataset, allowing for significant conclusions about wound infection rates, dehiscence, cosmetic outcomes, and patient satisfaction. The study’s systematic nature and ability to synthesize findings across various contexts enhance its reliability and generalizability, making it important in understanding wound closure techniques.

Article 2:

• I ranked this article as #2. This meta-analysis includes 18 studies with 1,697 children (big sample size), offering critical insights into the effectiveness of sutured wounds versus tissue adhesives. Although some studies had small sample sizes that could influence the robustness of findings, the overall statistical power and focus on both primary and secondary outcomes (cosmesis, infection rates, and costs) contribute to its strong rank. The rigorous comparison of methods in a pediatric population further solidifies its importance in clinical practice.

Article 3:

• I ranked this article as #3. With 1,020 patients across 18 randomized controlled trials (RCTs), this meta-analysis provides valuable data on the effectiveness of cyanoacrylate tissue adhesives. The focus on cosmetic outcomes, pain, and cost-effectiveness enhances its relevance to clinical decisions. However, the variability in study designs and the presence of small sample sizes in several included studies moderate its strength, as these factors can lead to inconsistencies in findings and limit broader applicability.

Article 4:

• I ranked this article as #5. This observational study evaluates outcomes in a pediatric emergency department setting but is limited by a small sample size and a single-institution design. While it offers important data on complications and satisfaction rates between closure methods, these limitations reduce its external validity. The findings are valuable but do not carry the weight of more systematic or randomized evidence.

Article 5:

• I ranked this article as #4. This RCT conducted in a pediatric emergency department examines cosmetic outcomes and patient satisfaction across three closure methods. While it delivers direct comparisons and focused insights, the limited sample size of 55 patients and the relatively low follow-up rate of 30 patients hinder its generalizability and statistical power. Nonetheless, its emphasis on guardian satisfaction and pain perception offers useful information for clinical practice.

Article 6:

• I ranked this article as #6. Although this retrospective study explores key outcomes related to wound healing, its small sample size (50 pediatric patients) and subjective measures significantly reduce its reliability. Without broader applicability and the potential for biases in self-reported outcomes, it stands as a less influential piece compared to higher-level studies. Its contributions are recognized, but may not be as strong as data found in more rigorous studies.

Magnitude of Effect

• The magnitude of effect of these studies shows a trend that favors tissue adhesives over traditional sutures in various outcomes related to wound closure, particularly in pediatric populations. Meta-analyses and systematic reviews demonstrates significant advantages in cosmetic outcomes, infection rates, and patient satisfaction associated with tissue adhesives, suggesting a shift in clinical practice toward these methods. While individual studies vary in strength and sample size, the consistent findings across multiple analyses highlights the potential for improved patient experiences and outcomes. Overall, the evidence points to a growing support of tissue adhesives as an effective alternative to sutures, warranting further exploration.

Clinical Bottom Line

• The evaluation of recent literature on tissue adhesives versus traditional sutures highlights several significant advantages of adhesives, particularly in pediatric and low-tension wound closures. Studies show that adhesives provide comparable healing outcomes while significantly reducing pain during procedures and enhancing overall patient and parental satisfaction. For instance, adhesives have shown lower infection rates and less post-procedure discomfort, with one study reporting a pain score of 1.3 for adhesives compared to 2.2 for sutures. Additionally, adhesives typically require less time for application and get rid of the need for suture removal, contributing to a more efficient treatment process. While article 2 suggests that sutures offer superior cosmetic outcomes in certain contexts, the other evidence supports the idea that adhesives can achieve similar aesthetic results, making them a good option for many cases where patient comfort and procedural efficiency are priorities.

• In clinical practice, I would consider using adhesives for managing simple lacerations in pediatric patients, especially when dealing with low-tension wounds. For example, if a child presents with a minor facial laceration, I would evaluate the wound’s tension and depth, and if appropriate, I would choose adhesives in order to allow for a quicker and less painful procedure. I would explain the benefits of using adhesive closures to the patient and their guardian, emphasizing the comparable cosmetic outcomes and lower pain levels typically associated with adhesives. However, I would assess each case individually, as sutures may still be necessary for deeper or high-tension wounds. Ultimately, my goal would be to ensure proper healing while prioritizing the comfort and satisfaction of my patients and their families. Further research and clinical experience will continue to fine tune my choice of adhesives vs sutures in various wound management scenarios.