Atlas of Primary Care Procedures, 1st Edition

Dermatology

22

Tangential Laceration Repair

Some soft tissue injuries are caused by tangential forces that produce oblique, nonvertical, or beveled wound edges. If these beveled edges are sutured in standard fashion, an unsightly ledge of tissue often results. Uneven edges cast a shadow on vertical surfaces, and the shadow magnifies the appearance of the scar. Proper management of tangential lacerations, especially on cosmetically important areas such as the face, is essential for optimal results.

Angled or beveled wounds have a broad edge (base side) and a shallow edge. The shallow edge may heal with minimal tissue loss if the wound angle is near vertical. The distal portion (i.e., nearest the center of the wound) of the shallow edge often necroses with more pronounced wound edge angulation because of inadequate blood supply to the epidermis and upper dermis. If the shallow edge is so thin as to appear transparent at the time of injury, subsequent necrosis is almost guaranteed. A markedly shallow edge contracts and rolls inward if taped or sutured without modification.

Tangential lacerations on the hand are commonly produced by glass fragments resulting from a glass breaking while being washed in the sink. Tangential lacerations on the head and face frequently result from glancing blows or collisions. Elderly individuals often experience tangential skin wounds (i.e., skin tears) on the extremities from even minimal contact. Skin tears in the elderly represent a special management situation; because suturing skin tears on the extremities does not appear to improve outcomes, taping is recommended.

A simple repair technique for tangential wounds involves taking a large, deep bite from the broad edge and a small bite from the shallow edge. Historically, tangential lacerations have been treated by transforming the beveled edges to vertical edges. Débridement of the wound edges is tedious and time consuming, and extensive removal of tissue on the face should be approached with caution. Despite these negative factors, the effort to transform wound edges can provide gratifying cosmetic and functional results.

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INDICATIONS

  • Wounds with beveled (nonvertical) edges

CONTRAINDICATIONS

  • Skin tears in elderly individuals

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PROCEDURE

An angulated skin wound can reduce blood supply to the distal portion of the shallow wound edge, resulting in necrosis of the shallow edge (Figure 1A). If a tangential wound is approximated with a simple suture (i.e., equal bites through each wound edge) (Figure 1B), the shallow edge tends to roll under. The greater distance of a tangential wound through skin compared with a vertical wound allows more opportunity for subsequent scar retraction (Figure 1C), producing a final inverted or depressed scar (Figure 1D).

 

(1) An angulated skin wound can reduce blood supply to the distal portion of the shallow wound edge, resulting in necrosis of the shallow edge.

A large, deep bite is taken with the suture needle through the broad edge, and a small (2-mm) bite is taken on the shallow edge (Figure 2A). This path of the suture thread promotes eversion of the shallow edge and helps with the final appearance of the wound (Figure 2B).

 

(2) The simple suture repair technique for tangential wounds.

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A C-shaped wound with beveled edges (Figure 3A) is produced by a tangential injury. Use a scalpel to create vertical wound edges (Figure 3B) that will then be undermined and approximated (Figure 3C). Wider excision of tissue is performed with a vertically held scalpel on the shallow edge compared with the broad edge (Figure 3D). It is difficult to debride the skin edge unless firm countertraction is applied to the tissues. Pull firmly out from the corners of the wound with the first two fingers of the nondominant hand when performing scalpel debridement of the wound edge (Figure 3E).

 

(3) The tangential injury has produced a C-shaped wound with beveled edges.

Before closing the wound with sutures, further undermine the wound edges (Figure 4A). Place the first suture in the middle of the wound (Figure 4B) and the next two in the middle of the remaining wound edges (i.e., halving technique) until the wound is closed (Figure 4C).

 

(4) Further undermine the wound edges before closing the wound with sutures.

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CODING INFORMATION

The simple repair codes (12001–12020) are provided in Chapter 14. Intermediate (layered) closure codes (12031–12057) are provided inChapter 24. The 2002 Current Procedural Terminology (CPT®) describes complex repair as the repair of wounds that requires more than layered closure, such as scar revision, débridement of traumatic lacerations or avulsions, extensive undermining, stents, or retention sutures. The necessary preparation of complex wounds includes the creation of a defect for repair. Complex repair should not be used with excision of benign or malignant lesions.

The complex repair code reported should describe the sum of the lengths of repair for each group of anatomic sites. The sites for these codes include the following: scalp, arms, or legs (SAL); forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands, or feet (FCCMNAGHF); and eyelids, nose, ears, or lips (ENEL).

CPT® Code

Description

2002 Average 50th Percentile Fee

13100

Trunk 1.1–2.5 cm

326

13101

Trunk 2.6–7.5 cm

497

13102

Trunk, each addl. 5 cm or less (in addition to 13101)

228

13120

SAL 1.1–2.5 cm

390

13121

SAL 2.6–7.5 cm

680

13122

SAL, each addl. 5 cm or less (in addition to 13121)

240

13131

FCCMNAGHF 1.1–2.5 cm

487

13132

FCCMNAGHF 2.6–7.5 cm

813

13133

FCCMNAGHF, each addl. 5 cm or less (in add. to 13132)

329

13150

ENEL ≤1.0 cm

461

13151

ENEL 1.1–2.5 cm

639

13152

ENEL, 2.6–7.5 cm

1033

13153

ENEL, each addl. 5 cm or less (in addition to 13152)

375

13160

Secondary closure of surgical wound or dehiscence, extensive or complex

1,102

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Instruments for tangential laceration repair are included in the office surgical tray listed in Appendix A, and suggested suture removal times are listed in Appendix C. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H.

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BIBLIOGRAPHY

Bennett RG. Fundamentals of cutaneous surgery. St. Louis: CV Mosby, 1988:355–444.

Dushoff IM. A stitch in time. Emerg Med 1973;5:21–43.

Lammers RL, Trott AL. Methods of wound closure. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine, 3rd ed. Philadelphia: WB Saunders, 1998:560–598.

Perry AW, McShane RH. Fine tuning of the skin edges in the closure of surgical wounds: controlling inversion and eversion with the path of the needle—the right stitch at the right time. J Dermatol Surg Oncol 1981;7:471–476.

Stein A, Williamson PS. Repair of simple lacerations. In: Driscoll CE, Rakel RE, eds. Patient care procedures for your practice. Los Angeles: Practice Management Information Corporation, 1991:299–306.

Williamson P. Office procedures. Philadelphia: WB Saunders, 1955:215–223.

Wilson JL, Kocurek K, Doty BJ. A systemic approach to laceration repair. Postgrad Med 2000;107:77–88.

Zuber TJ. The illustrated manuals and videotapes of soft-tissue surgery techniques. Kansas City: American Academy of Family Physicians, 1998.

Zuber TJ. Wound management. In: Rakel RE, ed. Saunders manual of medical practice. Philadelphia: WB Saunders, 1996:1007–1008.

Zukin DD, Simon RR. Emergency wound care: principles and practice. Rockville, MD: Aspen Publishers, 1987:63–76.