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The evolution of ophthalmic surgeries, in general, has resulted in procedures that are as safe as and less time-consuming than the original surgeries requiring suture placement, and, importantly, with outcomes that are enhanced.
This is true for small-incision and sutureless cataract surgeries, refractive surgeries, and no-stitch blepharoplasties, said John T. LiVecchi, MD, FACS, FSEE
However, regarding the latter, what has become evident over time is that use of an adhesive is not the answer in all cases and appropriate patient selection is a must, said Dr. LiVecchi. He is assistant clinical professor at both Drexel University College of Medicine, Philadelphia, and the University of Central Florida College of Medicine, Orlando, chairman (emeritus), Lions Eye Institute for Transplant and Research, Tampa, FL, and medical director and partner, St. Lucy’s Eye Institute, Kissimmee, FL.
“My original thinking was that if the procedure can be performed faster, with the potential to improve cosmesis and reduce the chances for infection, then we should work to enhance the technique,” he said.
In addition to the rationale of shaving minutes off the procedure by eliminating the need for sutures, Dr. LiVecchi explained that using a tissue adhesive to close the wound also creates a microbial barrier between the outside and the wound-thus, eliminating the need for both antibiotics and suture removal postoperatively.
Over two decades, Dr. LiVecchi’s idea has moved from the use of a medical grade “crazy glue”; off-label to secure silicone stent knots in dacryocystorhinostomies and as a temporary tarsorrhaphy in adults, uncooperative children, and for one blepharoplasty.
A 2-octyl, cyanoacrylate, topical skin adhesive (SurgiSeal, Adhezion Biomedical) was a step forward for patients undergoing blepharoplasty. The adhesive was as strong as or stronger than 5.0 sutures, flexible, less exothermic than other topical skin adhesives, and acted as a microbial barrier.
Dr. LiVecchi tested the adhesive in an initial study that included 100 eyelids and a retrospective follow-up study that included 180 eyelids (90 patients; average age, 66.5 years).
The adhesive was delivered using an applicator (SurgiSeal Stylus, Pfizer) to promote effective application of the adhesive on the eyelid and prevent the adhesive from running off the eyelids into the eyes.
The adhesive provided wound closure that is equivalent to a 5.0 suture or 7 days of healing, Dr. LiVecchi noted.
He reported a 94% success rate with the no-stitch procedure. Analysis of the first and follow-up studies showed a total of 11 gapes and two toxic reactions to the adhesive on two eyelids of one patient.
Importantly, no infections developed in any patients despite that no antibiotic ointment was used, even those with an adverse effect.
Allergic reactions are not a major problem with the tissue adhesive, in that an estimated 1% to 2% of patients have a reaction.
Despite the high success rate with no-stitch blepharoplasty and the seeming simplicity of the procedure, Dr. LiVecchi-who has performed in excess of 25,000 oculoplastic procedures during his career-noted that he no longer uses the tissue adhesive as his first choice for wound closures.
“I originally thought that use of a tissue adhesive was indeed a progressive and advantageous step for closing blepharoplasty incisions and would eliminate suturing completely,” he said. “I was extremely excited about the prospect of eliminating sutures and the additional inherent benefits.
“Now, I believe tissue adhesives should be used for patients who are carefully selected for the procedure,” Dr. LiVecchi said. “I currently use the tissue adhesive for stab and small incisions and in patients who are afraid of or allergic to sutures.”
An important factor in this decision was the eyelids are constantly moving, unlike other areas where tissue adhesives are used, he noted.
“This fact became a drawback to my idea of eliminating sutures entirely from blepharoplasties,” Dr. LiVecchi said. “To that end, I continue to use tissue adhesives on areas that are static for the most part.
“I still use tissue adhesives with carefully selected patients undergoing a blepharoplasty when it is indicated for the patients’ benefit,” he said. “For me, while there still is a place for tissue glue in blepharoplasty, it cannot entirely replace sutures.”
John T. LiVecchi, MD, FACS, FSEE
This article was adapted from Dr. LiVecchi’s presentation at the American Academy of Ophthalmology. Dr. LiVecchi is editor of the Ophthalmology Times “Plastic Pearls” column and a member of its editorial advisory board. He has no proprietary interest in the subject matter.