Outcomes of tissue adhesives versus sutures for pediatric facial laceration repair: a retrospective observational study

Background

In the pediatric population, facial lacerations are among the most common injuries presenting to the emergency department (1, 2), accounting for 30%–40% of all pediatric traumatic wounds (1, 3). Management should be rapid, minimally painful, non-traumatic, with favorable long-term cosmetic outcomes (4, 5).

Primary wound closure has been achieved using sutures, the gold standard for >100 years (6, 7). However, young children are typically non-compliant with procedures and experience substantial distress during suturing or wound manipulation (2, 4, 8). Fear and anxiety associated with needle insertion and suturing may contribute to persistent psychological trauma and healthcare-related anxiety (9, 10).

Consequently, suture repair in young children often necessitates sedation or local/general anesthesia. These interventions are time-consuming, resource-intensive, and associated with inherent anesthetic risks (5, 11, 12). The Centers for Disease Control and Prevention reports that ∼50% of emergency departments regularly experience overcrowding, resulting in prolonged waiting times that exacerbate stress for injured children and their caregivers (3, 13).

To address these challenges, tissue adhesives, particularly cyanoacrylate-based products, have gained increasing acceptance as alternative methods of wound closure (14, 15). Potential advantages include rapid application (typically under 1 min), elimination of needle-related pain and anxiety, avoidance of removal visits, and reduced needlestick injuries to healthcare workers (16–18). Nevertheless, concerns persist regarding their suboptimal outcomes or suitability for certain wounds, as their use is generally limited to superficial lacerations with low wound tension, good edge approximation, and relatively short length <5 cm (6–8, 19).

Randomized controlled trials have compared tissue adhesives with sutures for pediatric facial lacerations. Some studies demonstrated comparable cosmetic outcomes (20–22) while others suggested slightly inferior results with tissue adhesives (23, 24). According to a Cochrane systematic review, tissue adhesives are an alternative to sutures for simple traumatic lacerations; however, the overall quality of evidence was moderate (25).

At our institution, emergency physicians increasingly employ tissue adhesives to repair facial lacerations in pediatric patients. However, real-world data comparing outcomes between adhesives and sutures remains limited. Evaluating the comparative effectiveness of these techniques is therefore necessary to inform clinical decision-making and optimize patient care.

Therefore, we aimed to compare scar cosmesis between tissue adhesives and sutures, evaluate complication rates, examine anesthesia requirements, and assess parental satisfaction and preferences for repair methods in children with facial lacerations. We hypothesized that tissue adhesives would demonstrate non-inferior cosmetic outcomes compared with sutures while offering procedural advantages in the pediatric emergency department.

Methods

Study design, setting, and timeframe

This retrospective observational study was conducted in the emergency department of King Fahad Medical City, a tertiary care facility in Riyadh, Saudi Arabia. We examined patients with facial lacerations who presented to the facility between January and December, 2025.

Study population

We included pediatric patients aged ≤14 years who presented to the emergency department with superficial facial lacerations in low-mobility areas (forehead, chin, and cheek).

Patients were excluded if they had lacerations repaired 1 year or more before evaluation, lacerations extending into muscle or requiring deep-layer closure, connective tissue disorders such as Ehlers–Danlos syndrome, animal bite injuries, heavily contaminated wounds requiring debridement, delayed presentation beyond 24 h, and diabetes mellitus or immunodeficiency.

A ≥3-month post-repair cosmetic scar assessment was performed during follow-up visits or through caregiver-submitted standardized photographs obtained after wound healing. Follow-up data were collected through electronic medical record review and caregiver report within 30 days following repair.

Allocation to repair method

The choice of wound closure technique (tissue adhesive vs. sutures) was not randomized but determined by the treating emergency physician based on routine clinical practice, primarily guided by wound characteristics and patient age and cooperation. Tissue adhesives were preferentially used for superficial, low-tension facial lacerations with good edge approximation, while sutures were selected for larger, deeper, or higher-tension wounds, or when precise edge alignment was required. In a small number of patients (n = 6), a combined-closure technique was used in which one or two deep absorbable anchoring sutures were placed to achieve edge approximation prior to topical application of cyanoacrylate adhesive; these patients were classified for analysis by the dominant superficial closure method (tissue adhesive) consistent with an intention-to-treat approach. We acknowledge that this physician-directed allocation produced systematic between-group differences in wound size and patient age that are inherent to pragmatic clinical practice; we therefore frame the comparison as a real-world evaluation of outcomes within the indications for which each technique is currently used at our institution, rather than as a head-to-head test under matched conditions. To partially address residual confounding, we examined cosmetic outcomes after stratifying photographed patients by laceration size category (1–3 cm vs. >3 cm).

Wound closure materials

Tissue adhesive repair was performed using a cyanoacrylate-based topical skin adhesive (2-octyl cyanoacrylate; Dermabond®, Ethicon, Somerville, NJ, USA). Suture repair was performed using absorbable synthetic sutures (polyglactin 910; Vicryl® or Vicryl Rapide®, Ethicon, Somerville, NJ, USA), with suture size selected according to wound location, depth, and patient age. All materials were commercially available and applied in accordance with manufacturer recommendations and standard clinical practice. Of note, topical anesthetic preparations such as LET (lidocaine–epinephrine–tetracaine) or LAT (lidocaine–adrenaline–tetracaine) gel were not available in our emergency department during the study period. Anesthesia for suture repair was therefore restricted to infiltrated local anesthesia (1% lidocaine) or, when local infiltration alone was insufficient because of patient distress or inability to cooperate, ketamine-based conscious sedation administered according to institutional protocols. The absence of needle-free topical anesthesia is an important contextual feature of our practice setting, as its availability would likely have permitted suture repair without infiltration in a proportion of younger children and could have altered the closure technique selected.

Outcome assessment

Caregivers and the plastic surgeon assessing cosmetic outcomes were not blinded to the wound repair method, as assessment was based on clinical follow-up and photographic review of healed scars. We acknowledge that, although the retrospective study design did not permit prospective blinding at the time of repair, the photographic component of the surgeon's assessment could in principle have been performed under blinded conditions — for example, by cropping images to the immediate scar field, removing visit-related metadata, and presenting them in randomized order without group identifiers. This was not done in the present study and is a methodological limitation that we have flagged in the Limitations section; we will incorporate blinded photographic review into any prospective replication. Caregivers were provided with written instructions for standardized photography of the healed scar (perpendicular angle, distance of approximately 30–40 cm, natural daylight where possible, neutral background, and where feasible a centimeter ruler in the frame), and were asked to submit at least two views. Photographs not meeting minimum interpretability criteria (severe blur, oblique angle obscuring the scar, or inadequate lighting) were excluded from professional assessment. We acknowledge that photographic evaluation cannot capture three-dimensional contour, scar pliability, or symptomatic features such as itch or tenderness, and that lighting and angle variability may attenuate or exaggerate apparent scar severity; this limitation is discussed further below.

Sample size

No a priori sample size calculation was performed, as this was a retrospective observational study. The sample size represents a convenience sample of all eligible pediatric patients with facial lacerations who presented to the emergency department during the study period and met the inclusion criteria.

Data collection

Data were collected through retrospective chart review using a structured data collection form. Information was organized into demographic characteristics, laceration features, scar evaluation, and wound-related complications. Cosmetic outcomes were assessed using a General Numeric Score (GNS), in which caregivers and plastic surgeons rated scar appearance from 0 (worst) to 100 (best), and the Stony Brook Scar (SBS) evaluation scale, a 5-point composite measure assessing scar width, height, color, suture marks, and overall appearance.

Statistical analysis

Statistical analyses were performed using SPSS software, version 26 (IBM Corp., Armonk, NY, USA). Categorical variables were compared using the chi-square test and are expressed as frequencies and percentages. Continuous variables are reported as mean ± standard deviation. Given the non-parametric distribution of continuous variables, the Kruskal–Wallis test was applied for group comparisons. Correlations were assessed with Spearman's rank correlation coefficients. A P-value <0.05 was considered significant for all analyses. Because allocation to repair method was clinician-directed and produced systematic between-group differences in laceration size and patient age, we performed a pre-specified exploratory subgroup comparison of cosmetic outcomes restricted to lacerations 1–3 cm in length, the size category in which both techniques were used, in order to reduce the influence of differential wound severity on between-group comparisons.

Results

Study population and demographics

A total of 280 pediatric patients with facial lacerations were included (Table 1). Most wounds were repaired with sutures (n = 196, 70.0%), followed by tissue adhesives (n = 78, 27.9%), with other methods used infrequently (n = 6, 2.1%). The mean patient age was 52.79 ± 33.65 months. Repair methods differed by age (P = 0.011), with tissue adhesives used more often in younger children (≤48 months: 67.9%) than sutures (50.5%) (Table 1). The cohort comprised 166 males (59.3%) and 114 females (40.7%), with no significant sex differences across groups (p = 0.815). Most patients were Saudi nationals (97.1%); fathers were the primary caregivers most present (73.6%).

Table 1. Sociodemographic and clinical characteristics by repair method (N = 280).

P-value <0.05 considered statistically significant.

Chi-square test for categorical variables; Kruskal–Wallis test for continuous variables. SD, standard deviation.

Injury characteristics

Most injuries occurred at home (88.2%), and were more frequent on weekdays (67.9%) (Table 1). Slip-and-fall incidents were the leading mechanism (53.6%), chronic medical conditions were rare (2.5%).

The forehead was the most frequently injured site (38.2%) (Figure 1). Nearly all patients presented with a single laceration (98.2%). Wound size differed across repair methods (P < 0.001) (Table 1). Tissue adhesives were used predominantly for smaller wounds measuring 1–3 cm (82.1%), and were rarely applied to wounds >3 cm (3.8%). Sutures were used for 23.5% of lacerations >3 cm. Almost all wounds were clean (99.6%).

Procedural characteristics

Anesthesia requirements varied significantly by repair method (P < 0.001) (Table 1). All tissue adhesive repairs were performed without anesthesia, whereas suture repairs required local anesthesia in 76.0% of cases and conscious sedation in 21.4%. Time to repair was shorter with tissue adhesives (0.8 ± 0.4 h) than with sutures (2.1 ± 0.9 h) (P < 0.001). Associated injuries were rare (1.1%), occurring more often in the tissue adhesive group (3.8%) (P = 0.020) (Table 1).

Caregiver attitudes and follow-up

For future similar injuries, 80.7% of all 280 caregivers (n = 226), asked as a hypothetical preference question independent of the technique used in their child's repair, indicated a preference for tissue adhesives (Table 2). Twenty percent of patients sought additional medical care, most commonly for suture removal (37.5%), wound dehiscence (31.8%), wound infection (14.6%), or planned follow-up (13.2%). Requests for additional cosmetic opinions (2.1%) and dressing changes (0.7%) were infrequent.

Table 2. Caregiver attitudes and post-repair outcomes (N = 280).

More than one response allowed. GNS = General Numeric Score.

Cosmetic outcomes

Photographs for professional cosmetic assessment were submitted for 81 patients (28.9%): 52 (64.2%) treated with sutures and 29 (35.8%) with tissue adhesives. Across all photographed patients, caregiver-rated scar appearance on GNS (0–100) averaged 63.21 ± 30.47. The fact that fewer than one third of eligible caregivers submitted photographs introduces a substantive risk of selection bias in this subgroup: caregivers may have been more likely to submit photographs when the healed scar appeared either notably good (sharing a positive outcome) or notably poor (seeking reassurance), and the proportions of photograph submission also differed between the suture and tissue adhesive groups. The cosmetic comparisons that follow should therefore be interpreted with this caveat in mind, in addition to the formal discussion in the Limitations section.

Plastic surgeon assessment revealed scars wider than 2 mm in 53.1%, elevation or depression in 40.7%, darker coloration in 18.5%, and visible suture marks in 19.8% (Table 3). Overall scar appearance was rated as good in 75.3% of cases. Among photographed patients, mean caregiver and plastic surgeon GNS scores were 75.40 ± 19.99 and 76.26 ± 25.79, respectively, and the mean SBS score was 3.36 ± 1.53 (Table 3).

Table 3. Cosmetic scar characteristics on plastic surgeon assessment, with caregiver and plastic surgeon summary scores (N = 81).

When comparing repair methods in photographed patients (Table 4), individual scar characteristics and overall appearance (P = 0.224) were similar. The plastic surgeon's total SBS score was significantly higher for sutures (3.67 ± 1.40) than for tissue adhesives (2.71 ± 1.53) (P = 0.009). Plastic surgeon GNS scores were comparable between groups (78.85 ± 23.61 vs. 70.64 ± 28.33; P = 0.109).

Table 4. Association between repair method, patient characteristics, and cosmetic outcome (N = 81).

P-values from chi-square test for categorical variables and Kruskal–Wallis test for continuous variables. *P < 0.05; all other comparisons non-significant (P > 0.05).

*Allowed more than one answer.

GNS, General Numeric Score; SBS, Stony Brook Scar Evaluation Scale.

Note on the “tissue adhesive” group entries for suture removal (n = 6) and suture marks (n = 6): these reflect six patients in whom a combined-closure technique was used, in which one or two deep absorbable anchoring sutures were placed for edge approximation prior to topical application of cyanoacrylate adhesive. These patients were classified by the dominant superficial closure method (tissue adhesive) for analysis, in keeping with an intention-to-treat approach. The deep anchoring sutures account for the recorded entries for suture removal (planned removal of any non-absorbed material at follow-up) and for the visible suture marks observed on photographic assessment in this subgroup.

Among photographed patients, tissue adhesive repairs were associated with shorter delays to repair (1.13 ± 0.35 h vs. 2.15 ± 0.80 h; P < 0.001) and no anesthesia use (100% vs. 0%; P < 0.001) (Table 4). Additional medical visits were more common following suture repair, particularly for wound infection (28.8% vs. 7.1%) and suture removal (40.4% vs. 21.4%), with overall reasons differing between groups (P = 0.011) (Table 4).

Correlation analysis

Spearman analysis revealed a positive association between plastic surgeon GNS scores and caregiver evaluations (r = 0.380, P < 0.001) (Table 5). A significant positive correlation was found between the plastic surgeon total SBS scores and GNS ratings (r = 0.346, P = 0.002) (Table 5).

Table 5. Spearman correlation with plastic surgeon global numeric scale (N = 81).

Spearman's rank correlation coefficient.

P < 0.01;.

P < 0.001.

Caregiver perceptions aligned with professional assessments, supporting the utility of caregiver-reported satisfaction in evaluating cosmetic outcomes following pediatric facial laceration repair.

Discussion

Contemporary systematic reviews and observational studies published within the past decade have demonstrated comparable cosmetic outcomes, low complication rates, reduced procedure time, and decreased need for anesthesia when tissue adhesives are used for low-tension, superficial facial wounds in children (6, 26–28). Updated pediatric emergency care guidelines and pain management frameworks emphasize minimizing procedural distress and sedation exposure whenever possible, reinforcing the clinical value of tissue adhesives (29–32). Our findings align with this evolving evidence base, demonstrating equivalent cosmetic outcomes and high caregiver satisfaction, while highlighting procedural efficiencies that remain highly relevant in current high-volume emergency department settings.

Across 280 patients, cosmetic outcomes were broadly similar between repair methods (see Limitations for the caveats that qualify this comparison). Notably, no patient treated with tissue adhesives required anesthesia. Eliminating anesthesia reduces procedural distress, medication-related risks, and resource utilization. Tissue adhesive repair was also significantly associated with a shorter time to treatment, likely due to procedural simplicity and the absence of anesthesia preparation. This −60% reduction in treatment time is valuable in busy emergency departments.

The preponderance of younger children and males in this study aligns with previous epidemiological reports showing higher facial injury risk among boys aged 2–6 years due to increased physical activity and risk-taking behavior (33–35). Most injuries occurred at home and were related to falls, aligning with developmental behavior of this age group (36, 37). Home-based falls account for 70%–85% of facial lacerations in children <5 years (38, 39).

The forehead, chin, and eyebrows emerged as the most common laceration sites, consistent with the biomechanics of forward falls in toddlers and young children (40, 41). When young children fall, they typically land face-first due to a higher center of gravity and proportionally larger head size, resulting in impact to the forehead and periorbital regions (42–45).

Cosmetic outcomes did not differ significantly between repair methods, consistent with prior randomized controlled trials and systematic reviews (20, 21, 46, 47). Among patients with photographic follow-up, most achieved good overall scar appearance regardless of repair method. This finding is noteworthy given that 53.1% of scars exceeded 2 mm in width, suggesting acceptable outcomes even in less-than-ideal wound conditions. The mean SBS score (3.36) indicates generally favorable cosmesis, comparable with prior reports using this validated scale (48, 49).

Repair method selection reflected appropriate clinical judgment. Tissue adhesives were used predominantly for shorter lacerations (1–3 cm), while larger lacerations (>3 cm) were more frequently sutured. These patterns reflect appropriate clinical selection criteria, as tissue adhesives are best suited for shorter, lower-tension lacerations with good edge approximation. Achieving comparable cosmetic outcomes despite differing wound characteristics strengthens evidence for tissue adhesive efficacy within appropriate indications. Within the 1–3 cm size stratum in which both techniques were used, adhesives and sutures yielded comparable cosmetic results, supporting adhesives as the preferred option for short, low-tension, well-approximated facial lacerations in young children.

Our findings differ from earlier studies suggesting inferior cosmetic outcomes with tissue adhesives, which often included high-tension or high-mobility wounds now recognized as suboptimal for adhesive use (23, 24, 50). The strict inclusion of low-tension, low-mobility facial lacerations in our study likely contributed to the favorable outcomes observed with tissue adhesives (51, 52). This underscores the importance of appropriate patient selection for tissue adhesives.

The moderate correlation between caregiver and plastic surgeon cosmetic assessments validates caregiver-reported outcomes as a reasonable proxy in assessing pediatric scar cosmesis (53, 54). Similar correlations have been reported previously, with correlation coefficients ranging from 0.35 to 0.52 (55, 56). A correlation in this range reflects partial concordance between lay and expert evaluation.

Caregiver acceptance of tissue adhesives was high, with 80.7% indicating a preference for future facial use. This likely reflects shorter procedure time, avoidance of anesthesia, and reduced psychological distress (16, 17, 57, 58). Consistent with prior studies, tissue adhesive application exhibited shorter delays to repair and was more likely to require no anesthesia compared to suture patients. Tissue adhesive application typically takes 1–2 min compared to 10–20 min for suture repair, saving time in busy emergency departments (59, 60). The elimination of painful needle-based local anesthesia and suturing may reduce medical anxiety in children and caregivers (61–66). Conversely, 19.3% of caregivers indicated they would not choose tissue adhesive again, a proportion worth explaining given the simplicity of these wounds. Likely contributors include expectation mismatch (the term “skin glue” may imply no scar at all), misinterpretation of benign early findings such as premature edge separation or sloughing of the adhesive film as treatment failure, and the absence of structured pre-discharge counseling about the expected appearance of an adhesive-closed wound. Anticipatory guidance at the time of repair may therefore be a low-cost intervention to improve perceived outcomes without altering the technique itself.

Patients treated with sutures were more likely to seek follow-up care. Reduced follow-up needs may lower healthcare costs and family burden while decreasing additional costs and inconvenience (67, 68). Economic analyses have demonstrated cost savings of 15%–30% with tissue adhesive use (69, 70). Furthermore, elimination of suture removal visits reduces the risk of additional procedural anxiety and potential complications such as retained sutures or wound disruption during removal (71, 72).

The high prevalence of pediatric facial lacerations in emergency departments underscores the need to optimize treatment approaches (73, 74). Tissue adhesives may help address emergency department overcrowding (5, 13). By reducing procedure time and eliminating the need for procedural sedation in many cases, tissue adhesives can improve patient flow and resource utilization in busy emergency departments (75, 76).

Limitations

This study has limitations inherent to its retrospective design, including potential selection bias and unmeasured confounding in repair choice (77, 78). The most important methodological limitation is that we did not formally adjust for laceration size or wound severity in the comparison of cosmetic outcomes between repair methods, despite the fact that wound size differed markedly between groups (tissue adhesive group: 82.1% in the 1–3 cm category and only 3.8% >3 cm; suture group: 23.5% >3 cm). Because larger and higher-tension wounds are independently associated with poorer cosmetic outcomes regardless of closure technique, the absence of size-adjusted analysis means the cosmetic comparison reported here cannot determine the wound-size threshold above which sutures should be preferred over adhesives. Identifying this threshold is the question of greatest practical relevance to pediatric emergency clinicians and remains the principal gap that future prospective work should address. The blinded photographic re-evaluation of these healed scars by an independent assessor — which was feasible in this dataset but not performed — is also a missed opportunity that we acknowledge. Because allocation to repair method was determined by the treating physician on clinical grounds, the two groups differed systematically in the directions that most strongly favor adhesives a priori: tissue adhesives were applied predominantly to shorter, lower-tension wounds and to younger children, whereas sutures were used for larger or higher-tension lacerations and in older children. Both factors are independently associated with cosmetic outcome and with caregiver perception, and we cannot fully disentangle their contribution from any intrinsic effect of the closure technique itself. Caregiver-reported satisfaction in particular is susceptible to confounding by the procedural experience — a child who was calm and required no needle is more likely to have a satisfied caregiver regardless of the eventual scar — and our finding that caregivers preferred adhesives for future use must be read in this light rather than as a pure cosmetic preference. Topical anesthetic gels (LET/LAT) were not available at our institution during the study period; this represents both a methodological limitation and a service gap, as their availability would likely have permitted needle-free suture repair in a proportion of younger children and altered the apparent procedural advantage of adhesives. The use of caregiver-submitted photographs for professional cosmetic assessment introduces additional uncertainty, as photographs cannot capture three-dimensional contour, pliability, or symptomatic features and are vulnerable to lighting and angle variability; assessors were not blinded to repair method. Six patients in the “tissue adhesive” group received a combined-closure technique with deep absorbable anchoring sutures and were classified by their dominant superficial method, which accounts for entries in Table 4 for suture removal and suture marks within this group; this classification is conservative and is unlikely to bias the comparison in favor of adhesives. The retrospective design and variable follow-up timing limited assessment of long-term scar maturation beyond the early post-healing period. The relatively small number of patients with photographic follow-up may also introduce selection bias (79, 80). Additionally, the absence of long-term follow-up (beyond the immediate post-healing period) limits assessment of scar maturation, which is particularly relevant in pediatrics (81–84). Variability in adhesive application technique across providers may have further influenced outcomes. While all providers used commercially available cyanoacrylate adhesives, variations in technique, number of layers applied, and post-procedure wound care instructions may have affected outcomes (85, 86). Similarly, suture technique varied among providers, including choice of suture material, suture size, and spacing between stitches, all of which can influence cosmetic outcomes (87, 88).

Despite these limitations, our findings reinforce, in a Saudi tertiary-centre cohort, what is already established practice in much of the international literature: for short, superficial, low-tension, well-approximated pediatric facial lacerations — the wound profile that dominated our tissue adhesive group — cyanoacrylate adhesives should be considered the preferred first-line closure technique rather than merely “a viable alternative,” given that infiltrated suture repair in this wound profile imposes avoidable procedural distress and resource use without a demonstrated cosmetic benefit. The clinically more difficult and unresolved question — the laceration size and tension threshold above which suture repair becomes preferable — was not directly addressed by this study and remains a priority for prospective research (25, 89–98).

Conclusions

The procedural benefits found in this study, combined with equivalent cosmetic outcomes, minimal complication rates, and high caregiver acceptance, support tissue adhesives as a first-line option for clean, superficial pediatric facial lacerations with good wound edge approximation.

Recommendations for future research

Future studies should prioritize prospective, randomized controlled designs to minimize selection bias and strengthen causal inference when comparing tissue adhesives and sutures. Standardized criteria for wound selection and repair technique should be implemented to reduce variability across providers. Long-term follow-up studies extending to at least 12–18 months are recommended to assess scar maturation and late cosmetic outcomes. Subsequent research should incorporate standardized photographic documentation and objective scar assessment tools, such as spectrophotometry or digital scar analysis, to enhance reproducibility and reduce subjectivity in cosmetic evaluation.

Comprehensive cost-effectiveness analyses are warranted to quantify the economic impact of reduced procedure time, elimination of anesthesia, and fewer follow-up visits, including indirect costs borne by families and caregivers.

Finally, the development and validation of pediatric-specific patient- and caregiver-reported outcome measures would further improve assessment of satisfaction, psychological impact, and overall care experience, supporting a more patient-centered approach to pediatric facial laceration management.

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Footnotes

Edited by: Juliet Haarbauer-Krupa, Emory University, United States

Reviewed by: Jordan Evans, Cardiff and Vale University Health Board, United Kingdom

Giora Weiser, Shaare Zedek Medical Center, Israel

Abbreviations CDC, Centers for Disease Control and Prevention; GNS, General Numeric Score; SBS, Stony Brook Scar Evaluation Scale.