Can We Really Use Super Glue Instead of Suture?
The Real Scoop on the Use of Tissue Adhesive for Wound Closure
For several years there has been increasing interest in the midwife Super Glue
" types of adhesives for wound
closure. Midwives who have done a little research
have found that the cyanoacrylate glue
(Super Glue) sold over-the-counter and medical cyanoacrylate glues are apparently identical in composition
and rumored to the be same as the tissue
adhesive used extensively during the Vietnam War
. Some midwives have even used over-the-counter Super Glue
) successfully in lieu of suture to close the perineum
In readying in the 5th edition of Healing Passage: A Midwife's Guide to the Care
of the Tissues Involved in Birth
, I felt it was important to address this issue. This article offers an expanded version of the information you will also find in the new edition.
, a variety of cyanoacrylate adhesives were developed, some types of which are now used for surgical
purposes in Canada
. These glues polymerize on contact with basic substances such as water
to form a strong bond. The first glue developed was methyl
cyanoacrylate, which was studied extensively for its potential medical applications
and was rejected
due to its potential tissue toxicity
such as inflammation
or local foreign
body reactions. Methyl alcohol
has a short molecular chain which contributes to these complications.
revealed that by changing the type of alcohol in the compound
to one with a longer molecular chain, the tissue toxicity was much reduced
. All the medical grade tissue adhesives currently available for human use contain butyl
-esters, which are costlier to produce.
, the Tennessee Eastman lab
submitted its first application for new drug approval to the FDA
. The military
learned of this new glue and became extremely interested in its potential for use in field hospitals
units in Vietnam were overloaded. Many soldiers
were dying from chest
wounds, despite the best efforts of medics. In 1966 a special surgical team was flown to Vietnam
, trained and equipped to use cyanoacrylate adhesive. A quick spray
over the wounds stopped bleeding
and bought time
until conventional surgery
could be performed. The possibilities were immediately seized by the medical communities of Europe
and the Far East
. Meanwhile the FDA
changed standards and kept requesting additional data until Eastman was reluctantly forced to withdraw his application. (Jueneman, 1981)
(n-butyl cyanoacrylate) has been used extensively in Europe since the 1970s
for a variety of surgical applications including middle ear
and cartilage grafts
of cerebrospinal fluid
leaks, and skin
closure. It has been available in Canada
through Davis & Geck Canada, with no adverse effects reported to date. Further, laboratory studies have been done which concluded that it has no carcinogenic
potential. Tissue toxicity has only been noted when the adhesive is introduced deep in highly vascular areas (the perineum
qualifies). While I always take claims of harmlessness with a grain of salt
, if used as directed, these adhesives appear to be basically safe
(Quinn & Kissick, 1994) Current use: Although not labeled as such, over-the-counter Super Glue products contain methyl alcohol, because it is inexpensive to produce. Cyanoacrylates cure by a chemical reaction called polymerization, which produces heat
. Methyl alcohol has a pronounced heating action when it contacts tissue
and may even produce burns
if the glue contacts a large enough area of tissue. Rapid curing may also lead to tissue necrosis
. Midwives have not noted such reactions because minimal amounts are being used for perineal repair. Nevertheless, with a greater toxic potential, over-the-counter products are inappropriate for use in wound closure. (Quinn & Kissick, 1994)
Medical grade products currently available contain either butyl, isobutyl or octyl esters. They are bacteriostatic and painless
when used as directed, produce minimal thermal reaction when applied to dry skin and break down harmlessly in tissue. They are essentially inert once dry. Butyl products are rigid when dry, but provide a strong bond. Available octyl products are more flexible when dry, but produce a weaker bond.
When used for repair, ideally the wound to be closed
, fairly shallow
, with straight edges
that lie together on their own. The glue is applied to bridge
over the closed edges; it should not be used within the wound (on raw
surfaces), where it will impair epithelization
. The only currently FDA approved adhesives suitable for use as suture alternatives are veterinary products; n-butyl- cyanoacrylate tissue adhesives Vetbond (3M
) and Nexaband liquid and octyl-based Nexaband S/C (intended for topical skin closure when deep sutures have been placed). Histoacryl Blue (butyl based) (Davis & Geck) and Tissu-Glu (isobutyl based) (Medi-West Pharmaceuticals) are sold in Canada
for human use. DMSO (dimethyl sulfoxide) or acetone serve as removers. (Helmstetter, 1995; Quinn & Kissick, 1994)
How to use tissue adhesive:
Although not specifically recommended for perineal repair, tissue adhesive has been successfully used by some midwives. However, Hisotcryl Blue was used in place of interrupted
or subcuticular stitches in a small study of the closure of the superficial layer in mediolaterial clitorotomy
(episiotomy). (Adoni & Anteby) In this study, the yoni (vaginal
) mucosa and subcutaneous layers were closed with conventional suture
techniques. It might be a good alternative to offer when women refuse conventional sutures. Tissue adhesive works best when the wound
is moderately shallow. Midwives report that extremely shallow wounds tend to pull apart as healing occurs and usually require no closure of any kind. The wound should also have no pockets
to collect lochia
and should not require other sutures. However, as the study mentioned above demonstrates, it can also be used instead of subcuticular sutures after placing basting stitches
is only applied to outside surfaces
to bridge over edges
; do not apply it directly to raw surfaces. The wound edges should be straight and lie together naturally. Insert a tampon
, then clean and dry the skin thoroughly. Have your assistant stabilize the wound edges from top to bottom (be sure the edges are matched correctly). Insert your finger between the edges and pull it out to bring them forward slightly. This is to ensure that the wound edges are not rolled inward toward each other, but meet perfectly. It could also be accomplished with a tissue forceps
. Hold gauze
against the area
immediately below the apex
to catch and drips as you apply the glue. Apply tiny dots
of glue sparingly at intervals
where the wound edges meet. Or, apply a bead of tiny droplets to bridge the edges. (Thick applications do not enhance bonding and tend to crack and loosen prematurely.) Products dyed blue are easier to see. (If using Histoacryl Blue, attach a 27 g. syringe
needle to the ampoule hub to help control application.
After use, the needle should be discarded and replaced with a new needle that does not have glue within its lumen.) Be careful to apply the glue on where it is needed; glue removers should not the used in the genital
area. As long as no part of the tube tip or the attached needle contacts the tissue or bodily fluids, the tube can be reused.
Use a hair dryer
the area dry
, which takes about 30 seconds. Adhesive will stiffen
when dry. Women should observe the same precautions as those who have refused sutures entirely. Bathing
is not contraindicated but prolonged
soaking should be avoided. Expect the adhesive to flake off in 3 to 7 days. Allergic
reactions are very rare, but may include inflammation
From: AFryeMidwf@aol.com (Anne Frye)
(Various midwives 1993-95)
Adoni, A., & Anteby, E., "The Use of Histoacryl for Episiotomy Repair," Br. J. of Ob Gyn, Vol. 98, May 1991, pp. 476-8. Heimstetter, G., personal communciation, Permabond Internat. Bridgewater, NJ, 1995.
Jueneman, F, "Stick it to um," Industrial Research & Dev. Aug. 1981, p. 19.
Quinn, J., & Kissack, J., "Tissue Adhesives for Laceration
Repair During Sporting Events," Clinical J. of Sports Med., Vol. 4 No. 4, 1994, p. 245.
Sources of tissue adhesives:
Products, 3M Health Care, 3M Center Building 225 1N 07, St. Paul, MN 55144-1000, (612) 733-8477. 3M produces Vetbond Tissue Adhesive.
Products Laboratory (800) 548- 2828 distributes Nexaband products which are manufactured by Tri-Point in Raleigh, NC (919) 790-1041. These products are restricted items sold and approved for veterinary use only.
Davis & Geck-CANADA
(905) 470-3647 distributes Histoacryl Blue, which is manufactured in Germany
by B. Braun.
Medi-West Pharmaceuticals markets Tissu-Glu.