Should a forehead wound be closed with sutures or tissue adhesive?

Forehead Wound Closure: Sutures vs Tissue Adhesive

For most forehead lacerations, tissue adhesive (cyanoacrylate) is an appropriate first-line option that provides equivalent cosmetic outcomes to sutures with faster application time, though sutures should be used in high-tension wounds or when edges cannot be easily approximated. 1, 2

Decision Algorithm

Use Tissue Adhesive When:

• Wound edges can be easily approximated without tension 1
• The laceration is clean and not contaminated 3
• Patient has no factors that delay wound healing 1
• The wound base can be made completely dry 1

Use Sutures When:

• The wound is under high tension - tissue adhesives have 3.35 times higher risk of dehiscence compared to sutures (RR 3.35; 95% CI 1.53 to 7.33) 2
• Wound edges cannot be easily approximated and require meticulous closure 1
• Patient has factors that may delay wound healing 1
• The wound is in a high-tension area where the number needed to treat to prevent one dehiscence is 43 when choosing sutures over adhesives 4

Application Technique for Tissue Adhesive

Wound preparation is critical:

• Ensure the area is completely dry, as moisture prevents proper adhesion 1
• Provide adequate lighting and patient analgesia before repair 1
• Apply the least amount of adhesive necessary to seal the wound 1
• Use a 30-gauge needle, wooden end of cotton applicator, or micropipette for application 1

Comparative Outcomes

Cosmetic results:

• No statistically significant difference in cosmetic appearance between tissue adhesive and sutures at 3-6 weeks follow-up 5, 6
• Both methods achieve equivalent visual analog scale scores and wound evaluation scores 6

Practical advantages of tissue adhesive:

• Significantly faster application time (29.7 seconds vs 289 seconds for sutures) 6
• Less time spent on wound care by patients 5
• Higher patient satisfaction 5
• No suture removal required 1

Infection rates:

• Tissue adhesive may have lower infection rates in contaminated wounds compared to sutures (0% vs 55% by histologic criteria, 20% vs 65% by clinical criteria) 3

Critical Pitfall to Avoid

The single most important consideration is wound tension. Tissue adhesives fail significantly more often in high-tension areas, with dehiscence rates over 3 times higher than sutures 2. If there is any doubt about tension or edge approximation, default to sutures rather than risk wound breakdown 4.

Follow-Up Care

• Monitor for proper healing with good approximation of wound edges 1
• Assess for absence of significant swelling, erythema, or drainage 1
• Consider applying adhesive strips (Steri-Strips) across the wound for additional support during final healing stages if needed 1