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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.6 Rio de Janeiro Nov./Dec. 2009
Cyanoacrylate adhesives for the synthesis of soft tissue*
Sybele SaskaI; Ana Maria Minarelli GasparII; Eduardo Hochuli-VieiraIII
IDentist, Master Studies in Biotechnology
under course - Instituto de Química de Araraquara Universidade
Estadual Paulista (UNESP) - São Paulo (SP), Brazil
IIPh.D. Professor Assistant of Anatomy Department of Morphology, Faculdade de Odontologia de Araraquara Universidade Estadual Paulista (UNESP) - São Paulo (SP), Brazil
IIIPh.D., Professor Assistant of Surgery and Buco-Maxillo-Facial Surgery Department of Diagnosis and Surgery, Faculdade de Odontologia de Araraquara Universidade Estadual Paulista (UNESP) - São Paulo (SP), Brazil
BACKGROUND: Tissue adhesives have been used for
the synthesis of wound due to their painless application and quick and easy
OBJECTIVES: The purpose of this study was to analyze and compare the compatibility of the adhesives ethylcyanoacrylate (Super Bonder) and butyl-cyanoacrylate (Histoacryl), and to compare the reparation of incisions in the dorsum of rats with suture and the respective adhesives.
METHODS: Fifteen rats were used. Two surgical pockets were created in their dorsum. A polyethylene tube (10mm x 1mm) was implanted in each one. Each tube was filled with the adhesives Super Bonder(left side) and Histoacryl (right side). The incisions on the left side were closed with Super Bonder, and the incisions on the right side, with Histoacryl. A median incision between the two other incisions was made and closed with braided silk suture. The animals were killed after, 7, 35 and 120 days.
RESULTS: The adhesives used in the present study did not promote inflammatory reaction when used for the synthesis of incisions. However, when implanted subcutaneously, they caused an inflammatory reaction within 120 days. Reaction is more severe with Histoacryl.
CONCLUSIONS: Super Bonder and Histoacryl can be used effectively in the healing of incised tissues; they aid in the suture of incisions. However, these adhesives can be used for the synthesis of wounds, lacerations or cutaneous incisions.
Keywords: tissue adhesives; cyanoacrylates; hemostatics; suture techniques; materials testing; rats
The use of tissue adhesives to perform soft tissue synthesis, especially in areas of difficult access, has become a common practice in surgical procedures. These adhesives are widely used to close wounds, especially in children, owing to the fact that it is a painless, quick, easy to perform method that produces minimum scars, except if there are complications. Wound closure with conventional suture techniques in general presents higher rate of defects when compared to closure using adhesives 1.
These adhesives are excellent hemostatic agents to promote hemostasis of peripheral vessels 2-8. Another function of tissue adhesives is to promote tissue sealing preventing extravasation of lymphatic fluids, for example, cyanoacrylate-based adhesives which are impermeable and do not require reexamination of wounds once closed 9.
Alkyl-2-cyanoacrylates were primarily synthesized in 1949 by Ardis 10, but only in 1959 their adhesive properties were reported by Coover.11 This group of adhesives has different types of cyanoacrylates whose only modification is length of lateral chain, such as methyl (R=CH3), ethyl (R=C2H5), butyl and isobutyl (R=C4H9) and octyl-cyanoacrylate (R=C8H17).12 Cyanoacrylates are polymerized in few seconds when in contact with water and surfaces such as endothelium, mucosa, skin, blood and bone, degrading into cyanoacetate and formaldehyde with slight exothermal reaction. Because they are liquid, they can penetrate into irregular surfaces of tissues, promoting strong adhesion 8,13,14. Toxicity of these adhesives is related with speed of degradation and size of chain, that is, the larger the lateral chain, the slower the degradation speed and histotoxicity, and also the larger the lateral chain, the longer the cure time 13,14.
Many authors throughout the years have analyzed the biocompatibility of cyanoacrylate adhesives 14,15 and observed that methyl-cyanoacrylate is the one that has the highest grade of histotoxicity causing edema and tissue necrosis, being contraindicated for clinical use 16. Ethyl-cyanoacrylate adhesives do not present inflammatory reaction despite the fact that they have greater degradation speed 4,17,18.
The use of n-butyl-2-cyanoacrylate, one of the most widely used adhesives in facial and mouth surgeries in humans 3,7,19-22, in animal facial and dorsum surgeries 5,23,24, promotes faster healing without complications compared to conventional suture, reduces the surgical time and eliminates the need to remove the postoperative suture. Moreover, it has a bacteriostactic effect and hemostatic action better than the suture. Ellis and Shakick20 concluded that Histoacryl® is an ideal tissue adhesive to close skin surface concerning safety, reliability, effectiveness of pulling resistance and cost.
Ethyl-cyanoacrylate adhesives used in wound synthesis in humans have presented satisfactory results, without adverse events or cosmetic complications and immediate hemostasis when compared to conventional technique with suture 17,25. In the dorsum of animals, ethyl-cyanoacrylate has also promoted immediate hemostasis, simplified and abbreviated the operative procedure and did not interfere in the process of repair, which prevented suppuration, tissue necrosis or retraction of wound margins on the operated areas in relation to suture thread use 26.
Therefore, the purpose of the present study was to analyze the biocompatibility of cyanoacrylate adhesives, such as ethyl-cyanoacrylate (Super Bonder®) and n-butyl-2-cyanoacrylate (Histoacryl®) and to histologically compare tissue repair of incisions made on rat dorsum with suture thread and adhesives Super Bonder® and Histoacryl®.
MATERIAL AND METHOD
The sample comprised 15 rats Rattus Norvegicus Holtzman, male, weighting on average 200 grams. Animals were anesthetized with intramuscular administration of ketamine hydrochloride (25 mg/kg) and xylazine hydrochloride (5mg/kg). After trichotomy and sterilization of the dorsal region, three 2 cm-incisions were made 2 cm apart one from the other, longitudinally in relation to the animal body. The animal experimentation protocol was approved by the Animal Experimentation Ethics Committee of Faculdade de Odontologia de Araraquara- UNESP.
Before coaptation of incision, connective tissue was positioned laterally using a blunt pair of scissors, forming surgical sites measuring approximately 3 cm from the incision already made and about 3 cm from the sites. Two surgical sites were made, one on the left and the other on the right, where a tube of polyethylene was inserted in each site (Kit Delton - Dentsply) measuring 10 mm long and 1 mm internal diameter (Figure 1A), with one of the extremities closed using heated clamps. These tubes were sterilized in the autoclave. Lateral walls of each polyethylene tube served as positive control, control group. The tubes were filled using an insulin syringe with the respective experimental materials:
Group A: ethyl-cyanoacrylate (Super Bonder®, Loctite - Brazil).
Group B: butyl-cyanoacrylate (Histoacryl®, B Braun - Germany).
After the tubes were filled up with adhesive, we applied sterile solution at 0.9% in the tube extremities to cause polymerization of the material before the implementation into the surgical sites. After the procedure, the tubes with experimental material were carefully introduced into the surgical sites and maintained parallel to the central incision. The experimental material in group A was introduced in the surgical site on the left, and the experimental material in group B was introduced in the surgical site on the right side.
Next, the incisions on the left (Group I) were brought together and Super Bonder® adhesive was applied, midline incisions (group II) were sutured with silk thread 4-0 (Ethicon - Johnson & Johnson, Brazil), and on the right side (Group III), incisions were brought together with Histoacryl® adhesive (Figure 1B).
After 7, 30 and 120 days post-surgery, animals were again anesthetized following the protocol described above and the dorsal region was trichotomized. The incision and implant areas were surgically removed. Next, animals were euthanized with superdosage of the same anesthetic drug used. Specimens were fixed in Bouin solution for 48 hours and processed according to the routine technique for paraffin inclusion, where semi-serial 6 m sections were made transversally to the skin and later they were stained with hematoxylin-eosin.
Group A - Super Bonder®
In the period of 7 days, there was marked inflammatory infiltrate in the tube extremity where the connective tissue had direct contact with the adhesive; on the lateral sides and in the other extremity of the tube there was moderate inflammatory reaction with mono and polymorphonuclear cells. The capsule formed by dense connective tissue adjacent to the tube wall; loose connective tissue close to implants in organization; blood stasis, remnant material and close to the adhesive and the tube, giant cells such as foreign body (Figure 2A and 2B). After 30 days, there was mild inflammatory infiltrate, with presence of macrophages and foreign body type giant cells close to the remnant adhesive and the tube; blood stasis (Figure 2C and 2D). At 120 days, there was moderate inflammatory infiltrate containing mainly monocytes, lymphocytes and presence of few basophils, and few giant cells on the tissue close to the remnant adhesive and the polyethylene tube (Figure 2E and 2F).
Group B - Histoacryl®
On day 7, this group showed moderate inflammatory infiltrate with the predominance of monocytes and lymphocytes in the extremity of the tube close to the adhesive and blood stasis. Close to the remnant material and the tube laterals there was the presence of giant cells (Figure 3A and 3B). After 30 days, there was moderate inflammatory infiltrate with vasoconstriction, similar to Group A (Figure 3C). After 120 days, the inflammatory infiltrate went from moderate to mild, with mononuclear cells (lymphocytes and monocytes) and few basophils; presence of few giant cells in the tissue surrounding the remnant adhesive. There was increased amount of remnant material when compared to Group A (Figure 3D). In the lateral portion of the polyethylene tube there were giant cells close to the inflammatory infiltrate surrounding the tube on day 30 (Figure 3E) and on 120 days, there was still the presence of foreign body type giant cells and mild inflammatory infiltrate in the fibrous connective tissue close to the polyethylene tube (Figure 3F).
Group I - Super Bonder®
On day 7, keratinized paved stratified epithelium presented reorganization, with absence of continuity solution on the surface, presence of necrotic tissue above the incision. The surrounding connective tissue was disorganized with few inflammatory cells and collagen fibers, with major fibroblastic activity (loose connective tissue). Presence of remnant material enveloped by connective tissue (Figure 4A). Upon 30 days, the epithelial tissue was repaired and presented continuity solution with presence of kerato-hyaline cells and the repaired connective tissue had many thick bundles of unmodeled collagen fibers with normal characteristics. Absence of remnant material and inflammatory cells (Figure 4B). On day 120, there were characteristics of normal tissue with dense collagen fibers organized in parallel, capillary vessels, glandular ducts and hair follicles (Figure 4C).
Group II - Silk thread suture 4-0
On day 7, the epithelium did not present continuity surface, and the surrounding connective tissue was undergoing organization stage; necrotic tissue and blood clot on the wound site; mild to moderate inflammatory response in the surrounding connective tissue was observed in the specimens (Figure 5A). On day 30, healing was complete with normal epithelium, contiguous to the surface; there were kerato-hyaline cells on the surface and fibrous connective tissue with normal characteristics (Figure 5B). After 120 days, fibrous connective tissue with normal characteristics with many glandular ducts, hair follicles and blood capillaries (Figure 5C).
Group III- Histoacryl®
The specimens presented histological characteristics similar to the groups previously described. On day 7, the keratinized paved stratified epithelium presented reorganization, absence of continuity solution with the surface and presence of necrotic tissue over the wound. The underlying tissue was also disorganized, with few inflammatory cells such as monocytes and lymphocytes and many fibroblasts and remnant material enveloped by giant cells (Figure 6A). On day 30, we observed repaired epithelial tissue, also presenting continuity solution with kerato-hyaline cells, and the connective tissue presented dense and fibrous with normal characteristics, with great amount of thick and compact collagen fibers in relation to the surrounding connective tissue, which had a poorly defined bundle organization, similar to that in Group I. There was absence of remnant material and inflammatory cells (Figure 6B). On day 120, collagen fibers were also dense and fibrous with more uniform reorganization than the surrounded connective tissue, especially close to lamina propria, where there were glandular ducts, hair follicles and capillaries in the repaired connective tissue (Figure 6C).
Cyanoacrylate derivates do not replace sutures, but provide an alternative to tissue synthesis in some situations. Skin wounds such as incisions or lacerations may be repaired by bringing together the wound borders without requiring occlusive dressings. Currently, plastic surgeons have been using them in multiple situations, especially in cosmetic surgeries 12, in small cuts or for approximation of lacerations with suture support 27.
In the present study, during tissue synthesis with both adhesives ethyl-cyanoacrylate (Super Bonder®) and butyl-cyanoacrylate (Histoacryl®) we could observe the immediate and effective hemostatic effect, compared to conventional suture; Histoacryl® promoted a more effective hemostatic effect than Super Bonder® and it may be due to the fact that Histoacryl® is more fluid, which provides better flowability over the tissue surface into the wound site and promotes better hemostatic effect. Another possibility is that the lateral chain with four carbons may transform it into a more effective adhesive as a hemostatic agent. In the literature there are no data that relate the difference between the hemostatic effects provided by different cyanoacrylate adhesives. Some have reported that these adhesives provide immediate hemostatic effect compared to conventional suture technique 2,3,8.
A foreign body reaction was observed close to adhesives Super Bonder® and Histoacryl® and the polyethylene tube (control) in Groups A and B, observed in all specimens on days 7 and 30, with the presence of many giant cells especially around the adhesives. After 120 days, the number of giant cells was reduced and we could observe only some giant cells close to the adhesives and the tube. However, when the adhesives were enveloped by connective tissue in small amounts, during repair of incision synthesis, there were no foreign body type giant cells in any of the analyzed specimens. It confirms that this foreign body reaction that persists up to day 120 postoperative in Groups A and B is the polyethylene tube, because it promotes this type of reaction. Concerning the giant cells around Super Bonder® and Histoacryl® adhesives, they can make phagocytosis of the material remnants, that is, complete and late elimination of adhesive is made by foreign body reaction 3. Therefore, the number of giant cells is directly related with quantity of material present in tissues. The results described with Super Bonder® and Histoacryl® confirmed the literature data concerning the use of these adhesives, and the foreign body reaction was only observed when there was persistence of remnant material close to richly vascularized tissues 12,28, because when the adhesive was eliminated within the first 7 days postoperative, there was no foreign body reaction in the tissues around the tissue adhesive 2,8,28,29. According to Gonzalez et al.,30 the risks of foreign body reaction and infection are reduced owing to the biocompatibility and bacteriostactic effect of cyanoacrylates, respectively.
At the synthesis site of both tissue adhesives, the process of inflammatory reaction resulted from a mild form within the first seven days; the suture thread promoted a mild to moderate inflammatory reaction. The most intense inflammatory reaction observed with the suture may be owed to the surgical trauma resulting from the needle penetration and the suture thread in tissues representing insult factors and additional irritation evidenced by higher intensity of inflammatory reaction. After 30 days, there were no more inflammatory cells such as monocytes, lymphocytes and basophils in repaired tissues using both adhesive and suture thread. According to Weber and Chapman13 and Toriumi et al.,12 the smaller the ester chain, the greater the histotoxicity owing to faster degradation. However, we observed that Super Bonder® did not cause more inflammatory reaction than Histoacryl® in specimens in which there was coaptation of incision margins.
Confirming the results of Santos et al.26 and Souza et al.31 that used Super Bonder® and suture to bring together the incision in the dorsum of a rat, they observed that the adhesive was less aggressive than the suture. When using Histoacryl® for closing the incision on the dorsum of pigs it was also observed that the adhesive did not promote inflammation in relation to suture 8.
In specimens in which we implemented polyethylene tubes with the respective adhesives in richly vascularized tissue, inflammatory reaction persisted for up to 120 days in Groups A and B; it was more intense in Group B, Histoacryl®, probably owing to greater quantity of remnant material and slower degradation, which promoted greater inflammatory reaction in relation to Group A, or Super Bonder®. On the other hand, there are studies that reported that cyanoacrylates in contact with richly vascularized tissues promoted more marked inflammatory reaction than when in contact with tissues such as bone and cartilage 12,29. Owing to greater vascularization, products released during degradation (cyanoacetate and formaldehyde) are more exposed to vascularization and lead to greater inflammatory response. When synthesis of lacerations, wound or shallow incisions is made with cyanoacrylate, there is no inflammatory reaction 8,26. Similar results to those observed by other researchers when using ethyl-cyanoacrylate in bone tissue 18,29,30 in animal dorsum 26,31, or when used butyl-cyanoacrylate in the dorsum 3,8 and in bone tissue 14, showing that Super Bonder® and Histoacryl® are biocompatible with the analyzed structures.
However, the use of these adhesives is limited to the closure of lacerations and incisions in low tension areas because it provides resistance to tension that is lower than conventional suture. Butyl-cyanoacrylate32 and octyl-cyanoacrylate33 when compared to suture thread 5-0 present tension resistance similar to that of suture thread. Cyanoacrylates are effective only in deep wounds when associated with subcutaneous sutures 34, even though when there is a wound in low tension areas, cyanoacrylate adhesives are the material of choice for this type of synthesis.
Cyanoacrylate adhesives such as Super Bonder® and Histoacryl® have a number of advantages, such as acceptable cosmetic results, absence of complications, considerable cost-benefit (especially when using Super Bonder®), do not require local anesthesia for closure procedure, there is no need to remove the suture (they are eliminated within 5 to 10 days), serve as a barrier against microorganism penetration 22,23, in addition to shorter surgical time compared to conventional suture 3,8.
Based on the used methodology, we concluded that adhesives Super Bonder® and Histoacryl® when used for soft tissue synthesis enable healing of incised tissues, without promoting inflammatory reaction. Moreover, adhesives facilitate the approximation of incised margins reducing the surgical time compared to suture thread use. Super Bonder® adhesive promoted lower inflammatory reaction that Histoacryl® in the subcutaneous layer of rats, and these adhesives caused no tissue necrosis. Therefore, cyanoacrylate adhesives may be used for wound synthesis, lacerations or cutaneous incisions.
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Mailing Address: Funding: None * Study performed
at the Department of Morphology and Diagnosis and Surgery, Faculdade de Odontologia
de Araraquara Universidade Estadual Paulista (UNESP) - São Paulo
Rua Humaitá, 1680 Araraquara
14.803 901 São Paulo
Faculdade de Odontologia de Araraquara - UNESP
Departamento de Morfologia.
Tel./Fax: 16 3301 6492 / 3301-6600 ramal: 6765
Conflict of interest: None
* Study performed at the Department of Morphology and Diagnosis and Surgery, Faculdade de Odontologia de Araraquara Universidade Estadual Paulista (UNESP) - São Paulo (SP), Brazil.