laceration and incision repair

136

Lacerations are a commonly seen problem in clinicians’ offices, urgent care centers, and hospital emergency departments. Lacerations can be repaired with sutures, wound closure tapes, staples (see Chapter 196, Skin Stapling), or tissue adhesive (see Chapter 198, Tissue Glues).

The goals of laceration and incision repair are as follows: • Achieve hemostasis• Prevent infection• Preserve function• Restore appearance• Minimize patient discomfort

In repairing skin, it is helpful to understand the three phases of wound healing, which are listed in Box 19.1. Nonabsorbable skin sutures or staples are used to give the wound strength during the first two phases. After the nonabsorbable skin sutures or staples are removed, wound closure tapes/strips or previously placed deep absorbable sutures play an important role in the final phases of wound healing.

IndIcatIons

• Lacerations that are open and less than 12 hours old (<24 hours old on the face)

• Some bite wounds in cosmetically important areas (close follow-up recommended)

• Repair of sites where a lesion has been surgically removed

contraIndIcatIons

• Wounds more than 12 hours old (>24 hours old on the face)• Animal and human bite wounds (exceptions: facial or gaping

wounds, dog bite wounds)• Puncture wounds

EquIpmEnt

• Surgical sterile preparation (povidone iodine, chlorhexidine); alcohol swabs (not to be used inside the wound)

• Ruler in centimeters• Irrigation device for contaminated wounds: 30-mL syringe with

18-gauge angiocatheter or commercially manufactured splash shield device (Fig. 19.1) and sterile saline

• Appropriate anesthetic, usually 1% or 2% lidocaine with or with-out epinephrine (see Chapter 5, Local Anesthesia)

• 1- to 10-mL syringe• 27-gauge, 1.25-inch needle (small-gauge needles are preferred to

administer anesthesia)• Sterile drapes; fenestrated drape (applied over the lesion)• 4 × 4 gauze sponges; sterile cotton applicators are useful for he-

mostasis• Sterile pack containing 4.5-inch needle holder; curved or straight

iris scissors; one mosquito hemostat; suture scissors; Adson for-ceps with teeth; skin hook (optional)

• No. 15 scalpel blade for excisions with blade handle (single dis-posable unit also available)

• Appropriate suture (see Chapter 21, Laceration and Incision Re-pair: Suture Selection)

• Allis forceps for removal of deeper masses (optional) • Skin marking pen (for excision, if wound revision is needed) • Electrosurgical unit should be available for electrocoagulation • Specimen jar (when lesions are being excised) • Sterile or clean gloves (there has been no difference found in

infection rates between sterile vs. clean gloves) • Protective mask with plastic shield for eyes or other types of per-

sonal protective equipment

prEprocEdurE patIEnt prEparatIon

The patient should be informed of the nature of his or her laceration. If the laceration is in a cosmetically important area, consider offer-ing the option of a plastic surgeon for the repair. Advise the patient about the risks of pain, bleeding, dehiscence, infection, and scarring. In the case of lesion removal, warn that it is not always possible to be sure that the entire lesion is removed, so it could recur or require wider/deeper excision. Inform the patient that most repairs cause some permanent scarring, although attempts will be made to opti-mize the appearance. Patients should apply sunscreen to the area for at least 6 months after repair to minimize scarring. Warn the patient of the risks of hyperpigmentation or hypopigmentation, hypertrophic scars, keloids, nerve damage, alopecia, and distortion of the original anatomy. It is advisable to have the patient sign a consent form (see the consent form available at www.expertconsult.com).

Initial AssessmentThe initial evaluation before anesthesia should include a history of how the wound was sustained, factors that might impair healing, tetanus immunization history, and an assessment of peripheral neu-rovascular status.

For elective excisions, see Chapter 18, Incisions: Planning the Direction of the Incision, to plan the direction of the incision. If a trau-matic laceration is to be repaired, see Table 19.1 for essentials of wound

CHAPTER 19

Laceration and incision repairRichard P. Usatine • Wendy C. Coates

Phase 1 (Initial Lag Phase, Days 0–5)No gain in wound strength Phase 2 (Fibroplasia Phase, Days 5–14)Rapid increase in wound strength occursAt 2 weeks, the wound has achieved only 7% of its final strength Phase 3 (Final Maturation Phase, Day 14 Until Healing Is Complete)Further connective tissue remodelingUp to 80% of normal skin strength

BOX 19.1 Three Phases of Wound Healing

19 –––– LACERATION AND INCISION REPAIR 137

assessment. The clinician should consider the possibility of domestic violence in patients with traumatic wounds, especially if lacerations appear on the face or if multiple injuries of varying ages are noted.

In general, antibiotics are not needed for either wound or subacute bacterial endocarditis prophylaxis for cutaneous procedures. For sub-acute bacterial endocarditis prophylaxis guidelines, see Chapter 69, Antibiotic Prophylaxis for Prevention of Bacterial Endocarditis. Consideration should be given to coverage for Staphylococcus aureus and methicillin-resistant S. aureus infection in several situations (Box 19.2).

The following are major goals for prescribing antibiotics before or after skin surgery: • Prevention of a new wound infection • Prevention of the spread of an existing local infection • Treatment of an existing infection • Prevention of bacterial endocarditis

The clinical decision-making process of whether or not to use antibiotics before or after skin surgery is complex. The clinician must consider host factors, the anatomic location of the surgery, the sources that might contaminate the wound, and method of wound injury. Because this topic concerns wound repair after multiple types of trauma and elective procedures, the full complexity of the deci-sion-making process is beyond the scope of this chapter. Box 19.2 lists the multiple factors to be considered when making a decision about antibiotic prophylaxis for skin procedures. See Chapter 213, Prevention and Treatment of Wound Infections.

The recommendations of the American Heart Association for the prevention of bacterial endocarditis were last published in 2007. Endocarditis prophylaxis is not needed for incision or biopsy of surgically scrubbed skin. The 2007 guidelines state that antibiotic

prophylaxis is recommended for procedures on infected skin and skin structures for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infec-tive endocarditis. For individuals at highest risk for endocarditis (see Chapter 69, Antibiotic Prophylaxis for Prevention Bacterial Endocarditis) who undergo a surgical procedure that involves infected skin or skin structures, it is reasonable that the therapeu-tic regimen administered for treatment of the infection contain an agent active against staphylococci and beta-hemolytic strep-tococci, such as an antistaphylococcal penicillin or a cephalospo-rin. Vancomycin or clindamycin may be administered to patients unable to tolerate a β-lactam antibiotic or who are known or suspected to have an infection caused by methicillin-resistant S. aureus.

Cummings and Del Beccaro (1995) performed a meta-analysis of randomized studies on the use of antibiotics to prevent infection of simple wounds. They concluded that there is no evidence in pub-lished trials that prophylactic antibiotics offer protection against infection of non-bite wounds in patients treated in emergency departments. Cummings (1994) also performed a meta-analysis of randomized trials for antibiotics to prevent infection in patients with dog-bite wounds and found that prophylactic antibiotics reduce the incidence of infection in these patients.

Antibiotics have a role in the treatment of many established skin infections. However, most skin abscesses are better treated with incision and drainage than with antibiotics. For skin procedures, there is not a consensus on whether to give an antibiotic nor the appropriate timing for its administration. Recommendations for timing before the proce-dure vary from 1 hour (which is typical timing for bacterial endocar-ditis prophylaxis) to within 30 minutes of the procedure. Although a single second dose 6 hours later was the standard in the past, it is no longer currently recommended for bacterial endocarditis prophylaxis but may be advocated for further treatment of the infection.

TABLE 19.1 Essentials of Wound Assessment

Parameters Factors to Consider

Mechanism of injury Sharp vs. blunt trauma, biteDirty vs. clean Outdoors vs. kitchen sinkTime since injury Suture up to 12 hr; 24 hr on faceForeign body Explore and obtain radiograph for

metal or glassFunctional examination Neurovascular, muscular, tendonsNeed for prophylactic antibiotics If needed, give as soon as possible

and cover Staphylococcus aureus; irrigate well

Coexisting ConditionsDiabetes mellitusPeripheral vascular diseaseElderlyImmunocompromisedPrevious radiation to the siteMalnutrition (e.g., alcoholism, chemotherapy)History of previous infection or slow healingChronic steroid useObesity LocationsIncreased bacteriaAxilla, hand, mouth, anogenital areasEnd-arterial locations (fingers, toes) with diseases of vascular

compromiseOver joint spaces where there is a possibility of entering joint

(e.g., metacarpophalangeal joints) ContaminationDirty wounds, especially those sustained at farms, meatpack-

ing plants, etc.Less than optimal sterile technique (should be rare)Deep puncture woundsBites (especially human and cat bites)Presence of a retained foreign body Method of Wound InjuryCrush injury (10-fold increase in infection) with devitalized

skinPenetrating injury

BOX 19.2 Possible Antibiotic Prophylaxis Situations or When to Consider Antibiotic Prophylaxis

Fig. 19.1 Irrigation of a dirty wound using a syringe and plastic shield.

DERMATOLOGY138

Controversy exists over which bite injuries should be treated with prophylactic antibiotics. Cat- and dog-bite injuries carry the risk of infection with Pasteurella multocida, and human-bite injuries carry the risk of infection with Eikenella corrodens and S. aureus. Based on the microbiology of these wounds, amoxicillin/clavulanate provides good prophylactic coverage for the bacteria affecting most bite injuries. Alternatives include second-generation cephalosporins or clindamycin with a fluoroquinolone.

The best method for prevention of wound infections is to clean and irrigate traumatic wounds well, rather than relying on prophy-lactic antibiotics. The clinician needs to weigh the benefits and the risks of antibiotic use based on the individual patient and the cir-cumstances of the wound repair or skin surgery. The factors listed in Box 19.2 and the references at the end of this chapter should provide guidance for the clinician making decisions about antibiotic prophylaxis for skin surgery.

Local AnesthesiaIn traumatic wounds, neurovascular integrity should be assessed before administration of anesthesia. The wound should then be fully anesthetized to allow for painless examination of the tissue damage, thorough irrigation, and adequate closure. Many wounds can be ade-quately anesthetized with 1% or 2% lidocaine. Consider using lido-caine with epinephrine to provide increased hemostasis if there are no contraindications to epinephrine in the patient, the location of the wound, or the wound itself. (See Chapters 5, Local Anesthesia, and 7, Peripheral Nerve Blocks and Field Blocks.) Topical anesthet-ics are effective for wounds that do not involve mucosal surfaces. A combination of lidocaine, epinephrine, and tetracaine applied with a saturated cotton ball or as a gel formulation directly into the wound provides adequate anesthesia for many wounds.

Perform the following to minimize the pain of injecting local anesthetic: • Use a small-gauge needle (27 gauge or smaller) • Inject slowly • Inject directly into the dermis through the open wound (not

through intact skin) • Warm the anesthetic to body temperature (optional) • Buffer the anesthetic with sodium bicarbonate (10 to 1 mL) (op-

tional)

Wound PreparationAfter the initial assessment and administration of local or regional anesthetic, and antibiotics if indicated, the wound should be inspected thoroughly for foreign bodies, deep tissue layer damage, and injury to the nerve, vessel, or tendon. A radiograph should be obtained to look for retained glass or metal in wounds sustained with broken glass or metal. Complex wounds or those in cosmeti-cally important areas should be closed by a practitioner with the appropriate expertise. Hair removal is rarely necessary prior to clos-ing wounds; shaving should be avoided because it can cause soft tis-sue trauma and increase the risk of wound infections. Hair can be clipped, but mostly should just be moved or held out of the way. Eyebrows should never be shaved; they can grow back unpredictably or not at all.

CleansingAfter the wound is anesthetized, cleansing of a traumatic wound should be performed by irrigation with normal saline at approxi-mately 15 psi of pressure. This can be accomplished by attaching an 18-gauge angiocatheter or a commercially available splash shield to a 30-mL syringe (see Fig. 19.1). At least 200 mL of irrigation is rec-ommended. Moscati and associates (2007) performed a multicenter comparison of tap water versus sterile saline for wound irrigation,

showing equivalent rates of wound infection in immunocompetent patients. The tap water group irrigated their own wounds under the water tap for a minimum of 2 minutes after they had the wound anesthetized. Higher-risk wounds were excluded from the study, sug-gesting that tap water is a reasonable cleansing alternative only in low-risk lacerations. Chemical compounds such as chlorhexidine gluconate, or povidone-iodine, hydrogen peroxide, or detergents, should not be used inside wounds (these cause tissue toxicity) but may be applied to external, intact skin if desired. Greasy contami-nants can be removed with any petroleum-based product, such as bacitracin ointment. To prevent a “road rash” tattoo, wrap petro-latum gauze around the fingers and wipe off the asphalt and other foreign material embedded in the skin after anesthesia.

For elective excisions, irrigation before closure is not generally needed. If there was a ruptured cyst, if the excisional area was open a considerable time, or if there was concern about contamination, irrigation with 10 mL of saline two or three times may be performed.

DebridementAfter the cleansing process, wounds should be examined for devi-talized tissue that needs removal or debridement. This debridement may convert a jagged, contaminated wound into a clean surgical one and can be accomplished with a scalpel or sharp tissue scissors (Fig. 19.2). Preserve as much tissue as possible in case future scar revision is necessary. After debridement, wound edges should be held together to see if they are under any tension. Wounds under significant tension are best repaired by a two-layer closure. In dirty wounds, however, this may increase the incidence of infection.

Editor’s notE: Wounds of the face or areas devoid of redun-dant tissue require conservative debridement to avoid making it dif-ficult to close. Meticulous repair of complex wounds in these areas may have better cosmetic results.

UnderminingUndermining can significantly reduce skin tension when there is a gap to be closed (Fig. 19.3). Undermining may increase the risk of infection and thus should be avoided in dirty wounds. Extreme care is also needed when undermining around vital structures. Approxi-mately one-third to one half of the undermined tissue is freed up to be brought into the defect. Undermine bilaterally as far back as the wound is wide.

tEchnIquE

Ideally four principles should be incorporated in the process of clos-ing any wound: 1. Control all bleeding before closure. This can be accomplished by ap-

plying direct pressure for at least 5 minutes, adding epinephrine to the local anesthetic when appropriate, using electrocoagula-tion, or tying off bleeders with absorbable sutures.

2. Eliminate “dead space” where tissue fluid and blood can accumu-late (Fig. 19.4).

3. Accurately approximate tissue layers to each other. Scars are most visible when shadows are created by depressed or elevated tissue.

A

B

Fig. 19.2 Debridement. (A) Irregular jagged wound. (B) Excise a jagged wound or crush injury to create a more readily reparable wound.


Also be sure that anatomic areas match on each side in critical areas such as the vermilion border of the lip.

4. Approximate the wound with minimal skin tension. If there will be significant tension, undermining and deep inverted buried sutures are used to decrease the tension on the skin margin. Ideally, when the repair is completed, the wound will be tented up slightly.

Lacerations and incisions are approximated using a variety of

techniques: • Simple interrupted suture (Fig. 19.5). On completion, the skin

margins should be slightly everted (Fig. 19.6). The needle should enter the skin surface at a 90-degree angle (Fig. 19.7). The stitch should be as wide as it is deep. The suture on both sides of the wound should be of equal distance from the wound margin and

of equal depth. The final shape should appear like an Erlenmeyer flask (Fig. 19.8). As a general rule, these sutures need to be no closer than 2 mm in a fine plastic closure and can be substantially farther apart in other types of closures. The distance between sutures should equal approximately half the total distance of the sutures across the incision. Avoid tying the knots too tight. The

A

B

Scissors

C

D

Fig. 19.3 When skin margins approximate with tension, this can be relieved by undermining the margins through the use of a blade (A) or scis-sors (B and C). The usual plane is at the dermal-adipose junction. Under-mine twice as far back as the wound is wide, if possible. The proper level of undermining to mobilize the skin is shown (D). (D, Courtesy The Medical Procedures Center, Midland, Michigan.)

A

Dermis

Subcutaneousfat

Deadspace

B

Fig. 19.4 Closing the dead space. (A) Improper closure with dead space not closed, fluid or blood can accumulate. (B) Proper closure with dead space closed by deep sutures.

2x

x

A

B

Fig. 19.5 Simple interrupted suture. (A) Proper spacing. (B) Interrupted sutures after excision of a basal cell carcinoma of the elbow. (B, Courtesy The Medical Procedures Center, Midland, Michigan.)

DERMATOLOGY140

knots should be lined up on one side of the wound. The finer the suture, the closer the stitches need to be. See Chapters 20, Lac-eration and Incision Repair: Needle Selection, and 21, Lacera-tion and Incision Repair: Suture Selection, for needle and suture selection, respectively. See Chapter 22, Laceration and Incision Repair: Suture Tying, for tying techniques.

• Simple running stitch (Fig. 19.9). The advantages of the simple running stitch in sterile wounds under little or no tension are that it is quick and distributes tension evenly and provides excel-lent cosmetic results. Because there is an increased risk of con-tamination in traumatic lacerations, the simple running stitch is less desirable in these wounds. In case of infection, the entire wound closure would need to be removed. If there is significant

gaping of the wound, interrupted suture methods should be used. The relative disadvantage is that the entire stitch must be re-moved at once. With interrupted techniques, some sutures may be removed early for better cosmesis, whereas a few remaining ones can be left for prevention of dehiscence. These can be re-moved at a later date. This stitch is ideal in the scalp and is the one generally used for episiotomy repairs.

• Deep suture with inverted knot or “buried stitch” (Fig. 19.10). Deeper wounds or wounds under tension are best closed by providing struc-tural support and not relying solely on nonabsorbable superficial sutures. Well-placed, deep absorbable sutures can do much to aid in closing a wound, removing tension from the superficial skin sutures, and decreasing scarring by providing increased wound support long after the epidermal sutures have been removed. The inverted knot technique places the bulk of the knot as far below the skin mar-gins as possible to avoid suture spitting (migration of deep sutures to the skin surface). It also keeps the ends of the cut suture from protruding through the wound margin. To start the stitch, begin at the bottom of the wound (in the undermined area if undermining was used) and come up just below the epidermal-dermal junction (remember, “bottoms up!”) to start. Go straight across the incision; reenter at the same level at the opposite side; then go down to the base at the same depth as the contralateral side and tie. A skin hook may be used to help gently lift the skin up from the undermined area. Care should be taken to achieve symmetry of depth and width on both sides of the laceration. After the appropriate number of deep inverted sutures are placed to approximate the skin margins, the surface (skin) is then fully closed with the closure of choice (nonabsorbable suture, wound closure tapes, or tissue adhesive).

• Vertical mattress suture (Fig. 19.11). This suture promotes ever-sion of the skin edges. It is useful when the natural tendency of loose skin is to create inversion of the wound margins, which is to be avoided. A good example is the loose skin under the triceps muscle and thin skin in older people. The stitch is also appropri-ate when the skin is very thin because interrupted sutures have a tendency to pull through.

A

B

C

Fig. 19.6 Wound margin appearance after closure. (A) Proper eversion of the skin edges on closure (“build pyramids, not ditches”). (B) Acceptable, but not optimal, closure. (C) Improper closure because healing will lead to further contraction and scar depression.

90°

Fig. 19.7 Needle should enter the skin surface at a 90-degree angle. (Revised from Moy R. Suturing techniques. In: Usatine RP, Moy RL, Tobinick EL, Siegel DM, eds. Skin Surgery: A Practical Guide. St. Louis: Mosby; 1998:88–100.)

Fig. 19.8 Use the Erlenmeyer flask–shaped pathway to promote ever-sion of skin edges. (Revised from Moy R. Suturing techniques. In: Usatine RP, Moy RL, Tobinick EL, Siegel DM, eds. Skin Surgery: A Practical Guide. St. Louis: Mosby; 1998:88–100.)

A

B

Fig. 19.9 Running stitch. (A) This is a good stitch to use if there is no tension on the wound or after deep stitches have already been placed with good approximation of the wound edges. (B) Always keep the depth of the suture placement the same on each side. (A, Courtesy Richard P. Usatine, MD, San Antonio, Texas. B, From Moy R. Suturing techniques. In: Usatine RP, Moy RL, Tobinick EL, Siegel DM, eds. Skin Surgery: A Practical Guide. St. Louis: Mosby; 1998:88–100.)


• Horizontal mattress suture (Fig. 19.12). This suture is helpful in wounds under a moderate amount of tension; it also promotes wound edge eversion. It is especially useful on palms or soles and in patients who are poor candidates for deep sutures because of susceptibility to wound infection.

• Subcuticular running suture (Fig. 19.13). This suture is used to close linear wounds that are not under much tension; it yields an excellent cosmetic result. The two ends can be tied over the wound, or a knot can be placed at each end to prevent slippage. The ends of the suture do not necessarily need to be tied; taping under slight tension preserves approximation. Usually a poly-propylene-coated nylon works best. Steri-Strips, tapes, or tissue glue can be used to supplement this type of stitch. Special care must be taken to avoid pressure on the wound because this stitch separates easily. Applying Tegaderm or similar protective sheets provides added protection and strength.

• Three-point or half-buried mattress suture, also known as the “corner stitch” (Fig. 19.14). This suture technique is designed to permit closure of the acute corner tip of a laceration or of certain inci-sional techniques (e.g., Burow triangle) without impairing blood flow to the tip. It is an intradermal stitch in which the needle is inserted initially into the intact skin on the nonflap portion of the wound and passed through the skin at the mid-dermis level; at the same level, the suture is then passed transversely through the tip of the flap, returned on the opposite side of the wound, and brought through the skin, paralleling the point of entrance. The suture is tied by drawing the tip snugly into place in good approximation. Care should be taken not to have the knot tied over the point of the flap (caused by having the needle insertion starting too far laterally). This same approach can be used in closing a stellate lac-eration, drawing the tips together in a pursestring fashion. Repair of a “T” laceration also uses this technique (Fig. 19.15).

• Repair of a dog ear or management of excess tissue can be per-formed as shown in Fig. 19.16 (see Chapter 16, Flaps and Plasties). Fig. 19.17 reviews the steps in the repair of a C-flap laceration.

notE: In one study, otherwise healthy children with facial lacera-tions were randomized to repair using fast-absorbing catgut or nylon suture (Luck and colleagues, 2008). There were no significant dif-ferences in the rates of infection, wound dehiscence, keloid forma-tion, and parental satisfaction between the absorbable catgut and the nylon suture. Fast-absorbing catgut suture is not as easy to work with as nylon but does have the advantage of not requiring suture removal in children who may be fearful of the suture removal process.

Wound Closure Tapes or StripsWound closure tapes (Fig. 19.18) or strips, sometimes called “butterfly strips,” may be used alone for small, superficial wounds (especially in young children). When these tapes suffice to close a wound, they are easily placed without physical or psychological trauma to the patient. Wounds closed with tape are more resis-tant to infection than are sutured wounds. However, tape cannot

A Undermined area

Skinhook

2 3

41

B

C

Fig. 19.10 Deep stitch with absorbable suture material. (A) Needle should enter deep in the skin below the dermis where the undermining was accomplished (1) and exit in the upper dermis (2). The needle re-enters in the upper dermis (3) and exits below the dermis where the undermin-ing was accomplished (4). A skin hook may help elevate the skin from undermined area. (B) The deep inverted buried stitch is tied at the bottom of the wound to avoid having the knot stick out of the incision. (C) Placing the deep stitch. (C, From Moy R. Suturing techniques. In: Usatine RP, Moy RL, Tobinick EL, and Siegel DM, eds. Skin Surgery: A Practical Guide. St Louis: Mosby; 1998:88–100.)

A

Woundsurface

ab c d

ab c d

B

C

Fig. 19.11 Vertical mattress suture. (A) Cross-section. (B) Overhead view. Begin at a, and go deep under skin to b. Come out, go in at c, and exit at d. (C) Two vertical mattress sutures used to obtain wound eversion. (Courtesy Richard P. Usatine, MD, San Antonio, Texas.)

DERMATOLOGY142

provide adequate skin edge eversion or deep tissue approximation when used alone. Thus tape is most commonly used as an adjunct to sutures or staples. Tape can help reinforce wounds closed sub-cuticularly or with conventional suturing techniques. Adhesion is enhanced by the application of a sticky substance to the skin surface. Traditionally tincture of benzoin has been used for this purpose, but a preparation containing gum mastic (Mastisol) has been shown to provide stronger adhesion with possibly less risk of contact dermatitis. Wound closure tapes are especially helpful after suture removal to prevent dehiscence and may be left on until they fall off. Patients may shower with them on after the initial 24 hours.

The proper method of applying the tape or strips is to apply ben-zoin or Mastisol over the entire area, and then place the strips in a parallel fashion without overlapping and without “tacking” strips (see Fig. 19.18).

A

B

C

D

Fig. 19.12 Horizontal mattress suture. (A) Needle is passed 0.5 to 1 cm away from wound edge deeply into the wound. (B) Needle is passed through the opposite side and reenters the wound parallel to the initial su-ture. (C) Reenter the skin perpendicularly to provide some eversion of the wound edges. Enter and exit both the wound and skin at the same depth; otherwise, “buckling” and irregularities occur in the wound margin. (D) Suture is then tied as shown.

A

B

C

Fig. 19.13 (A) Subcuticular running suture. (B) Prolene was used to repair this eyebrow laceration. The ends are knotted to prevent slippage. (C) Appearance before suture removal after repair of a cheek excision. The ends are tied together to prevent slippage. (B, Courtesy Joe Deng, MD, Loma Linda, California. C, Courtesy The Medical Procedures Center, Midland, Michigan.)

Completed

2

3

1

Fig. 19.14 Three-point or half-buried mattress suture to repair a V-flap laceration.


Tissue AdhesiveTissue adhesives may be used to close certain wounds that are not under significant tension and are not at risk for infection (see Chapter 198, Tissue Glues).

Delayed Primary Closure (Tertiary Intention)Primary closure is defined by the use of sutures, tapes, or adhe-sives to close the wound at the time of initial surgery or evalu-ation. Healing by secondary intention occurs when no attempt is made to close the wound and the wound granulates in on its own. This method is used after a simple shave biopsy, in grossly contaminated or infected wounds, or in wounds that present far too late to consider closure. Delayed primary closure is healing by tertiary intention.

Delayed primary closure is used for wounds that are greater than 12 hours old (24 hours for facial lacerations) but would safely benefit from closure in a few days. Repairing them imme-diately could increase the chance of infection. After anesthetiz-ing, evaluating, and irrigating the wound, insert a small piece of petrolatum gauze between the wound edges and place the patient on an antibiotic, such as cephalexin, for 5 days. On the third day, the patient should return for definitive repair. The wound is then anesthetized, reirrigated, and closed primarily with nonabsorbable sutures (i.e., no deep sutures because they increase the chance of infection).

See Box 19.3 for a summary of key points for suture repair (also included in Appendix H, Pearls of Practice).

possIblE complIcatIons of lacEratIon rEpaIr

The following complications may occur within the first 2 weeks: • Infection• Pain• Bleeding• Dehiscence• Hematoma• Bruising and swelling• Suture spitting

Prolonged or permanent complications may include the following: • Scarring• Hypertrophic scars• Keloid formation• Hyperpigmentation• Hypopigmentation• Nerve damage• Imperfect cosmetic alignment (e.g., the vermilion border)• Suture spitting• Recurrence of an incompletely excised lesion

postprocEdurE patIEnt EducatIon

Most wounds are best protected with some sort of dressing during the first 24 to 48 hours after closure. Continued slight oozing of blood might be expected. For hemostasis, a pressure dressing should be applied. This could be folded gauze over a sterile ointment with tape over it or a nonstick type of gauze dressing covered with gauze and tape. Trade names for nonstick dressings include Xeroform, Adaptic, and Telfa. For the extremities, the use of a self-adherent wrap like Coban, CoFlex, and others provides a good pressure dressing to hold things in place. If on the lower extremities, elevation helps for 24 hours. Ice over the area for a few hours will reduce pain, swelling, and bleeding. It is not usually necessary to keep a wound completely dry after 24 hours. Therefore patients may shower after 24 hours and redress the wound after gently drying it. Moist healing (application of some type of ointment after gentle washing twice daily) aids in quicker healing. Although antibiotic ointments traditionally have been used in postsurgical wound dressing, Smack and colleagues (1996) determined that clean wounds heal just as well when white petrolatum is applied. Neomycin and bacitracin are frequent con-tact allergens. Alternatively, Tegaderm or Opsite (transparent, self-adherent, plastic wrap–type dressings that “breathe out” but do not let anything in) can be applied and left in place until the sutures are removed (Fig. 19.19). If bleeding occurs, the patient can replace the dressing after 24 to 48 hours because it is available over the counter. In addition to providing the optimal moist healing environment, these dressings provide added support to the sutured closure.

Suggestions for the timing for skin suture removal are listed in Table 19.2. See Fig. 19.20 for proper suture removal techniques. Using suture scissors (with a small hook on one of the tips to grasp the suture; see Fig. 19.21) makes removal much easier. Disposable suture removal kits are available with gauze, scissors, and pickups. Because scarring increases the longer the sutures remain in place, consider removing them a few days early and applying a tissue adhe-sive (see Chapter 198, Tissue Glues) or tape. Early removal is pos-sible only if there is little to no tension on the wound. Even when sutures are removed at the usual times, tape or tissue glues help keep the wound edges opposed. The cost of tissue glues is one barrier to this approach. Adhesive strips or another self-adherent transparent dressing can also be used.

Wounds on the face or scalp may be dressed with a thin layer of antibiotic ointment or petrolatum in lieu of a mechanical dress-ing. It is best to cover these wounds at night to avoid drying. Instruct patients to return if there are signs of wound infection,

Fig. 19.15 T-laceration repair using half-buried mattress suture tech-nique.

45°

Line to excise extra skin

Pull tip over

Close newincision

Bulging dog earCut here first

A

B

C

Fig. 19.16 Dog-ear repair. (A) Note site of initial incision of bulging dog ear. (B) Pull the tip over and excise. (C) Close the new incision for skin to lie flat.

DERMATOLOGY144

AB

C

D Cut here

E

F

Remove smallwedge of excesstissue

a

b

G

Fig. 19.17 C-flap repair. (A) Laceration. (B) The problem: the point X is often very thin and may necrose. Even if it does not, contracture will occur after healing and the slim margin along the X will be depressed, causing a more visible scar. (C) If small enough, convert the wound to an ellipse for easier repair. (D) Alternatively, excise the angled margins of skin to obtain “square” borders. (E) Undermine. (F) Close with interrupted sutures. Because side a is smaller than side b, a small wedge of tissue may need to be removed. (G) Complete closure.

Tack strips(Wrong)

Overlapping(Wrong)

No adhesiveon edges(Wrong)

Parallel(Correct)

Fig. 19.18 The red strips are the tape; rectangles illustrate where ben-zoin or Mastisol was applied to the skin.

Use 27- to 30-gauge needle for anesthesia; slow injection; warm solution.

Use 1%–2% lidocaine (epinephrine is helpful to achieve hemostasis). Avoid epinephrine or use with extreme care in fingers, toes, nose, ears, and penis. Do not use epinephrine in digital blocks.

Make elliptical excision at least three times as long as wide.Follow Langer lines.Undermine. Undermine. Undermine. Double the width of

the wound on each side.Eliminate all dead space.Use deep inverted buried absorbable sutures to reduce skin

tension (“bottoms up”).Evert skin edges slightly (“build pyramids, not ditches”).

Inversion of wound edges results in 300% increase in time for epithelial bridging.

Place interrupted sutures half as far apart as they are across. The more tension, the more sutures needed. Follow the Er-lenmeyer flask shape. The finer the suture, the more sutures needed, but the less scarring.

Edema occurs after closure. Only approximate tissues; do not strangulate.

Begin gentle washing of wound after 12–24 hours; if Steri-Strips or tissue glues are not used, apply an ointment to keep the wound moist to speed healing.

Apply Steri-Strips after suture removal.

BOX 19.3 Pearls of Suturing


including erythema, pus, lymphangitis, or fever. A routine wound check is unnecessary for patients who understand the importance of monitoring wounds for signs of infection. An instructional handout can be given (see the patient education form available at www.expertconsult.com).

concurrEnt trEatmEnt

Tetanus ProphylaxisTable 19.3 is based on the current Centers for Disease Control and Prevention recommendations for tetanus prophylaxis in wound management.

Analgesic MedicationAnalgesic medication may need to be administered for a few days depending on the extent of the trauma, the pain threshold of the patient, and the concerns of the family. For most patients, over-the-counter medications are sufficient, but in selected patients prescrip-tion medication may be indicated. If antibiotics are needed, refer to the earlier discussion under Initial Assessment.

conclusIon

In the treatment of lacerations, careful inspection, adequate irriga-tion, skilled closure, and appropriate wound care can produce the best functional and cosmetic results. The principles and steps cov-ered in this chapter show how lacerations can be repaired with max-imal skill and minimal discomfort to the patient. More advanced

A

B

Fig. 19.19 (A) The Tegaderm film patch. (B) The film applied to a newly sutured wound. It is left in place until the subcuticular suture is removed, providing moist healing and support to the wound edges. (Courtesy The Medical Procedures Center, Midland, Michigan.)

TABLE 19.2 Timing for Suture Removal

Anatomic AreaDays Until Removal

External Suture Size

Buried Absorb-able Suture Size

Face 4–5 5-0 or 6-0 5-0Scalp 10–14 4-0, staples 3-0Upper body 7–10 4-0 4-0Hand 7–10 4-0 or 5-0 4-0Lower body 10–14 4-0 3-0Over joint (splint

recommended)14–21 4-0 3-0

Modified from Coates WC. Face and scalp lacerations. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2016.

Correct

Cut herePull

Incorrect

Correct

Incorrect

Cut here

Pull

D

C

B

A

Fig. 19.20 Suture removal. (A) Cut where the suture enters the skin. (B) Cutting suture near knot leaves length of suture that is “dirty” and pulled into the tissue. (C) Pull the forceps over the wound, which approximates wound edges. (D) Pulling suture out this way tends to pull wound edges apart. Also, note dirty length of suture being pulled through wound.

Fig. 19.21 Suture removal scissors. (Courtesy The Medical Procedures Center, Midland, Michigan.)

DERMATOLOGY146

skills and knowledge can be developed through experience and by reading Chapter 16, Flaps and Plasties, and the sources listed in the Recommended Reading section.

patIEnt EducatIon GuIdEs

See the patient education and consent forms available at www.expertconsult.com.

cpt/bIllInG codEs and Icd-10-cm dIaGnos-tIc codEs

Coding and billing become very complex for laceration repair and excisions. Important factors to list for billing personnel are as follows: • Location• Size of lesion• Length of closure or excision• Simple or intermediate repair (intermediate includes either un-

dermining or placement of deep buried sutures)• Benign or malignant status• Whether a true skin lesion or subcutaneous tumor or deep tumor

(e.g., lipoma) was excised• Method of removal (shave, excision, destruction)

With an excision, when charging for the size of the lesion, also include the width of the margins. For example, if a basal cell carci-noma that has a diameter of 1 cm is being excised, there should be 0.3-cm free margins. The size charged for the excision would be 1.6 cm. Suture removal is included in the initial charge if the original sutures were placed by the same group of physicians. Suture removal can be billed if performed by an unassociated physician or group.

Anesthetic, materials, and supplies are customarily also included in the reimbursement fees. If a lesion is excised and repaired in a simple fashion (no undermining, deep sutures, flaps, or plasties), the fee for excision then includes local anesthesia, repair, any interval care for 10 days, and suture removal. If an intermediate repair is done with an excision, two codes should be charged (the excision and the repair).

For CPT/billing codes, see Table 19.4. For ICD-10-CM diagnos-tic codes, see Appendix G, Neoplasm, Skin: ICD-10 Codes. For spe-cific skin lesion sites, and to code out lacerations, go to the ICD-10 manual and look under wounds for the specific site: wound, open (by cutting or piercing instrument) (by firearms) (cut) (dissection) (incised) (laceration) (penetration) (perforating) (puncture) (with initial hemorrhage, not internal). (Laceration ICD codes are too extensive to list in detail here.) For fracture with open wound, see Fracture.

supplIErs

(See contact information at available www.expertconsult.com.)

Zerowet splash shields and Klenzalac wound irrigation systems OpsiteSmith & NephewTegaderm3M

onlInE rEsourcEs

Thomsen TW, Barclay DA, Setnick GS: Videos in clinical medi-cine: Basic laceration repair. N Engl J Med 355:e18–e22, 2006.

TABLE 19.3 Wound Management and Tetanus Prophylaxis

Previous Doses of Tetanus Toxoid*

Clean and Minor Wound All Other Wounds†

Tetanus Toxoid-Containing vaccine‡

Human Tetanus Immune Globulin

Tetanus Toxoid-Containing Vaccine‡

Human Tetanus Immune Globulin§

<3 doses or unknown Yes ¶ No Yes ¶ Yes≥3 doses Only if last dose given ≥10 yr ago No Only if last dose given ≥5 yr ago** No

Appropriate tetanus prophylaxis should be administered as soon as possible following a wound, but should be given even to patients who present late for medical attention. This is because the incubation period is quite variable; most cases occur within 8 days, but the incubation period can be as short as one day or as long as several months.*Tetanus toxoid may have been administered as diphtheria-tetanus toxoids adsorbed, diphtheria-tetanus-whole cell pertussis (no longer available in the United States), diphtheria-tetanus-acellular pertussis, tetanus-diphtheria toxoids adsorbed (Td), booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap), or tetanus toxoid.†Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite.‡The preferred vaccine preparation depends upon the age and vaccination history of the patient: • <7 years: diphtheria-tetanus-acellular pertussis • Underimmunized children ≥7 and <11 years who have not received Tdap previously: Tdap. Children who receive Tdap between age 7 and 11 years do not

require revaccination at age 11 years. • ≥11 years: a single dose of Tdap is preferred to Td for all individuals in this age group who have not previously received Tdap. Pregnant women should receive

Tdap during each pregnancy. • Td is preferred to TT for those who received Tdap previously and when Tdap is not available.§250 units intramuscularly at a different site than tetanus toxoid; intravenous immune globulin should be administered if human tetanus immune globulin is not available.¶The vaccine series should be continued through completion as necessary.**Booster doses given more frequently than every 5 years are not needed and can increase adverse effects.Modified from American Academy of Pediatrics. Tetanus (lockjaw). In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.


TABLE 19.4 CPT/Billing Codes

Benign Skin Excision

11200 Tags, up to/including 15 lesions11201 Tags, each additional 10 lesions11400 TAL <0.6 cm11401 TAL 0.6–1.0 cm11402 TAL 1.1–2.0 cm11403 TAL 2.1–3.0 cm11404 TAL 3.1–4.0 cm11406 TAL >4.0 cm11420 SNHFG <0.6 cm11421 SNHFG 0.60–1.0 cm11422 SNHFG 1.1–2.0 cm11423 SNHFG 2.1–3.0 cm11424 SNHFG 3.1–4.0 cm11426 SNHFG >4.0 cm11440 Face <0.6 cm11441 Face 0.6–1.0 cm11442 Face 1.1–2.0 cm11443 Face 2.1–3.0 cm11444 Face 3.1–4.0 cm11446 Face >4.0 cm

Malignant Skin Excision11600 TAL <0.6 cm11601 TAL 0.6–1.0 cm11602 TAL 1.1–2.0 cm11603 TAL 2.1–3.0 cm11604 TAL 3.1–4.0 cm11606 TAL >4.0 cm11620 SNHFG <0.6 cm11621 SNHFG 0.6–1.0 cm11622 SNHFG 1.1–2.0 cm11623 SNHFG 2.1–3.0 cm11624 SNHFG 3.1–4.0 cm11626 SNHFG >4.0 cm11640 Face <0.6 cm11641 Face 0.6–1.0 cm11642 Face 1.1–2.0 cm11643 Face 2.1–3.0 cm11644 Face 3.1–4.0 cm11646 Face >4.0 cm

Simple Skin Repairs12001 SNAGTE <2.6 cm12002 SNAGTE 2.6–7.5 cm12004 SNAGTE 7.6–12.5 cm12005 SNAGTE 12.6–20.0 cm12006 SNAGTE 20.1–30.0 cm12007 SNAGTE >30.0 cm12011 FEENLMM <2.6 cm12013 FEENLMM 2.6–5.0 cm12014 FEENLMM 5.1–7.5 cm12015 FEENLMM 7.6–12.5 cm12016 FEENLMM 12.6–20.0 cm12017 FEENLMM 20.1–30.0 cm12018 FEENLMM >30.0 cm12020 Superficial wound dehiscence

Intermediate Skin Repairs12031 SATAL <2.6 cm12032 SATAL 2.6–7.5 cm

Benign Skin Excision

12034 SATAL 7.6–12.5 cm12035 SATAL 12.6–20.0 cm12036 SATAL 20.1–30.0 cm12037 SATAL >30.0 cm12041 NHFG < 2.6 cm12042 NHFG 2.6–7.5 cm12044 NHFG 7.6–12.5 cm12045 NHFG 12.6–20.0 cm12046 NHFG 20.1–30.0 cm12047 NHFG >30.0 cm12051 FEENLMM <2.6 cm12052 FEENLMM 2.6–5.0 cm12053 FEENLMM 5.1–7.5 cm12054 FEENLMM 7.6–12.5 cm12055 FEENLMM 12.6–20.0 cm12056 FEENLMM 20.1–30.0 cm12057 FEENLMM >30.0 cm

Benign Tumor Excisions (e.g., lipoma)21550 Biopsy, soft tissue,

neck/thorax21555 Neck/thorax SQ*21556 Neck/thorax deep* †21930 Back/flank*22900 Abdominal wall deep* †23075 Shoulder SQ23076 Shoulder deep* †24075 Upper arm/elbow SQ*24076 Upper arm/elbow deep* †25075 Forearm/wrist SQ*25076 Forearm/wrist deep* †26115 Hand/finger SQ*26116 Hand/finger deep* †27047 Pelvis/hip SQ*27048 Pelvis/hip deep*27327 Thigh/knee SQ*27328 Thigh/knee deep* †27618 Leg/ankle SQ*27619 Leg/ankle deep* †28043 Foot SQ*28045 Foot deep*38500 Excision and/or biopsy, lymph node,

superficial41825 Gum/alveolar, no repair41826 Gum/alveolar, simple rep

Face: Face, ear, eyelid, nose, lip, or mucous membrane

FEENLMM: Face, ear, eyelid, nose, lip, or mucous membrane

NHFG: Neck, hand, foot, or external genitalia

SATAL: Scalp, axilla, trunk, arm, or legSNAGTE: Scalp, neck, axilla, genitalia, trunk, or

extremitySNHFG: Scalp, neck, hand, foot, or

genitaliaSQ: SubcutaneousTAL: Trunk, arm, or leg

Codes in bold have a 10-day global fee surgical period.The sizes listed in codes 11400 to 11646 describe lesion diameter, not the length of the skin excised.*90-Day global fee surgical period.†Deep excision includes subfascial or intramuscular lesions.

DERMATOLOGY148

RECOMMENDED READING

Coates WC. Face and scalp lacerations. In: Tintinalli J, Ma OJ, Yealy DM, et al., eds. Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2016.

Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med. 1994;23:535–540.

Cummings P, Del Beccaro MA. Antibiotics to prevent infection of sim-ple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13:396–400.

DeBoard RH, Rondeau DF, Kang CS, et al. Principles of basic wound evalu-ation and management in the emergency department. Emerg Med Clin North Am. 2007;25:23–39.

Ellis R, Ellis C. Dog and cat bites. Am Fam Physician. 2014;90(4):239–243.Fincher EF, Gladstone HB, Moy RL. Complex layered facial closures. In:

Robinson JK, Hanke CW, Siegel DM, et al., eds. Surgery of the Skin: Pro-cedural Dermatology. 3rd ed. Philadelphia: Elsevier; 2015.

Global guidelines for the prevention of surgical site infections. World Health Organization; 2016. Available at http://apps.who.int/iris/ bitstream/10665/250680/1/9789241549882-eng.pdf?ua=1.

Grossheim LF. General principles of wound management. In: Reichman EF, ed. Emergency Medicine Procedures. 2nd ed. New York: McGraw-Hill; 2013.

Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol. 1995;32:155–176.

Houck CS, Sethna NF. Transdermal anesthesia with local anesthetics in children: review, update, and future direction. Expert Rev Neurother. 2005;5:625–634.

Jose RM, Vidyadharan J, Bragg TW, et al. Mammalian bite wounds: is pri-mary repair safe? Plast Reconstr Surg. 2007;119:1967–1968.

Katz KH, Desciak EB, Maloney ME. The optimal application of surgical ad-hesive tape strips. Dermatol Surg. 1999;25:686–688.

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Le BT, Dierks EJ, Ueeck BA, et al. Maxillofacial injuries associated with domestic violence. J Oral Maxillofac Surg. 2001;59:1277–1283.

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Srivastava D, Taylor RS. Suturing technique and other closure materials. In: Robinson JK, Hanke CW, Siegel DM, et al., eds. Surgery of the Skin: Pro-cedural Dermatology. 3rd ed. Philadelphia: Elsevier; 2015.

Usatine RP, Moy RL, Tobinick EL, Siegel DM, eds. Skin Surgery: A Practical Guide. St. Louis: Mosby; 1998.

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocardi-tis: guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovas-cular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116:1736–1754.

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