In this Part 2 of our 3-part podcast series on management of lacerations Dr. Haley Cochrane, Dr. Justin Morgenstern and Dr. Anton Helman explore the evidence around the various methods to repair skin lacerations in the Emergency Department. In it they discover 4 themes making concrete conclusions on this topic challenging: the lack of blinding in all the studies, the subjective outcomes measured in the studies, the interplay between the multiple steps of suture repair and the effect of the skill of the provider that may impact outcomes…
Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Anton Helman January, 2023
Cite this podcast as: Helman, A. Cochrane, H. Morgenstern, J. Journal Jam 22 Laceration Repair – Glue vs Strips vs Staples vs Sutures. Emergency Medicine Cases. January, 2023. https://emergencymedicinecases.com/laceration-repair-glue-strips-staples-sutures. Accessed February 15, 2025
Surgical skin glue for skin lacerations
2002 Cochrane review comparing skin glue to sutures
- 11 RCTs
- no differences in cosmesis
- advantages of skin glue: pain scores and time of laceration repair lower with glue; overall less expensive
- disadvantages of skin glue: skin glue more likely to have short term localized erythema and rate of dehiscence is 2% higher
Adding adhesive strips (“steri-strips”) to skin glue doubles the tensile strength as compared to using either alone.
Hair apposition technique for scalp lacerations
1 RCT – the HAT trial comparing hair apposition technique to sutures
- 189 patients with scalp lacerations 3-10 cms
- excluded patients requiring resuscitation, with arterial bleeds and with significant contamination
- hair apposition 5 mins vs sutures 15 mins
- hair apposition 2 vs 4 out of 10 pain score
- At 7 days 100% of the hair apposition group had adequate wound healing compared to 96% of the suture group.
- At 4 weeks all wounds were healed, but scars were bigger in the suture group
- When asked if they would want the same procedure in the future, 84% of the hair apposition group said “yes” compared to 10% of the suture group
It is unknown whether hair apposition technique has any advantage over simply applying skin glue to a scalp laceration.
Wound closure strips for skin lacerations
2021 systematic review comparing wound closure strips (“steri-strips”) to sutures and to skin glue
- included traumatic wounds in ED and patients in the operating room
- all studies were small, at high risk of bias
- infection and dehiscence equivalent in all three groups
- wound closure strips associated with better cosmesis in 1 small unblinded RCT
- wound closure strips generally faster and less painful compared to sutures
Surgical skin staples for skin lacerations
2020 meta-analysis of 42 low quality RCTs of operating room studies
- staples are generally faster than sutures
- cost is about equivalent
- no differences in cosmesis
- the overall adverse event rate is about double with staples
Absorbable vs non-absorbable sutures for skin lacerations
2007 meta-analysis of 7 small unblinded underpowered ED or operating room RCTs comparing absorbable to absorbable sutures for skin lacerations
- no overall statistical difference in cosmesis
- Odds Ratio (OR) for dehiscence 0.16 favouring absorbable sutures
- Odds Ratio (OR) for infections 0.42 favouring absorbable sutures
Sutures vs simple dressing
2002 RCT hand lacerations ≤2cm comparing sutures to simple dressing
- 3 months cosmesis, no difference
Take home points on laceration repair glue vs strips vs staples vs sutures
There is no convincing evidence that one method of laceration repair is much better than another. Factors to consider in deciding which material to use/method for laceration repair:
- location, depth and length of wound
- need for tensile strength (eg laceration over large joint)
- patient’s work/recreational activities, age
- patient pain associated with using a particular material
- convenience of aftercare
- efficiency, flow of ED
- cost
- exclusion criteria used in the studies
- patient preference
- physician experience
Next episode in this series…Journal Jam 23 Laceration Aftercare
References
Morgenstern, J. Lacerations: Does closure technique matter?, First10EM, November 28, 2022. Available at:
https://doi.org/10.51684/FIRS.128664
Morgenstern, J. Laceration evidence: absorbable sutures or not?, First10EM, December 5, 2022. Available at:
https://doi.org/10.51684/FIRS.128625
Bresnahan KA, Howell JM, Wizorek J. Comparison of tensile strength of cyanoacrylate tissue adhesive closure of lacerations versus suture closure. Ann Emerg Med. 1995 Nov;26(5):575-8.
Brown JL, Jehle D, Mayrose J, Schwartz L, Pugh J, O’Brien C. Skin tapes and tissue adhesive vs. either method alone for laceration repair in a porcine model. Am J Emerg Med. 2021 Jul;45:317-323.
Cochetti G, Abraha I, Randolph J, Montedori A, Boni A, Arezzo A, Mazza E, Rossi De Vermandois JA, Cirocchi R, Mearini E. Surgical wound closure by staples or sutures?: Systematic review. Medicine (Baltimore). 2020 Jun 19;99(25):e20573.
Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002;2002(3):CD003326.
Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004 Jul;22(4):254-7.
Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002 Sep;19(5):405-7.
Munns E, Kienstra AJ, Combs PD, Gabriele G, Wilkinson M. Cosmetic Outcomes of Simple Pediatric Facial Lacerations Repaired With Skin Adhesive Compared With Skin Adhesive With Underlying Adhesive Strips: A Randomized Controlled Trial. Pediatr Emerg Care. 2022 Oct 1;38(10):477-480.
Ong ME, Chan YH, Teo J, Saroja S, Yap S, Ang PH, Lim SH. Hair apposition technique for scalp laceration repair: a randomized controlled trial comparing physicians and nurses (HAT 2 study). Am J Emerg Med. 2008 May;26(4):433-8.
Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995 Jun;126(6):892-5. Otterness K, Thode HC Jr, Singer AJ. Methods of laceration closure in the ED: A national perspective. Am J Emerg Med. 2020 Jun;38(6):1058-1061.
Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. BMJ. 2002 Aug 10;325(7359):299.
Quinn J, Wells G, Sutcliffe T, Jarmuske M, Maw J, Stiell I, Johns P. Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome. Ann Emerg Med. 1998 Dec;32(6):645-9.
Romero P, Frongia G, Wingerter S, Holland-Cunz S. Prospective, randomized, controlled trial comparing a tissue adhesive (Dermabond™) with adhesive strips (Steri-Strips™) for the closure of laparoscopic trocar wounds in children. Eur J Pediatr Surg. 2011 May;21(3):159-62.
Sajid MS, Siddiqui MR, Khan MA, Baig MK. Meta-analysis of skin adhesives versus sutures in closure of laparoscopic port-site wounds. Surg Endosc. 2009 Jun;23(6):1191-7.
Singer AJ, Hollander JE, Valentine SM, Thode HC Jr, Henry MC. Association of training level and short-term cosmetic appearance of repaired lacerations. Acad Emerg Med. 1996 Apr;3(4):378-83.
Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ. 2010 Mar 16;340:c1199.
Tandon S, Smale M, Pacilli M, Nataraja RM. Tissue adhesive and adhesive tape for pediatric wound closure: A systematic review and meta-analysis. J Pediatr Surg. 2021 May;56(5):1020-1029.
Wong EM, Rainer TH, Ng YC, Chan MS, Lopez V. Cost-effectiveness of Dermabond versus sutures for lacerated wound closure: a randomised controlled trial. Hong Kong Med J. 2011 Dec;17 Suppl 6:4-8.
Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis. Pediatr Emerg Care. 2007 May;23(5):339-44.
Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004 Jul;22(4):254-7.
Karounis H, Gouin S, Eisman H, Chalut D, Pelletier H, Williams B. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004 Jul;11(7):730-5.
Luck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008 Mar;24(3):137-42.
Tejani C, Sivitz AB, Rosen MD, Nakanishi AK, Flood RG, Clott MA, Saccone PG, Luck RP. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med. 2014 Jun;21(6):637-43.
Great post. Seems I’ve been using too little glue for 20 years!
I had a question about absorbable sutures. What technique are you using? Interrupted ‘normal’ sutures that just have the advantage that they just dissolve and fall out or continuous subcuticular?
Amazing post. Greetings from Belgium! Great idea about the emailadress for feedback about woundhealing. Was wondering if you have rules/restrictions/ethical approval to run such a project. What about responsability/continuity of care in case of complications reported on this email?
I have the same question as Jo Tillett – Do you just use the absorbable suture as interrupted or are you making an attempt to bury the suture?