Tangential Laceration Repair

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Tangential Laceration Repair

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Introduction

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. 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 in the elderly and in persons with very poor blood flow. 
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. Debridement 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. 

Equipment

Indications

  • Wounds with beveled (nonvertical) edges

Contraindications (Relative)

  • Skin tears in elderly individuals

  • Severe bleeding disorders

  • Extreme illness that would make wound healing difficult

  • Cellulitis in the tissues to be incised

  • Conditions that may interfere with wound healing (collagen vascular diseases, smoking, renal insufficiency, diabetes mellitus, nutritional status, obesity, chemotherapeutic agents, and corticosteroids)

  • Disorders of collagen synthesis such as Ehlers-Danlos syndrome and Marfan syndrome that affect wound healing

  • Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)

  • Uncooperative patient

The Procedure

Step 1

An angulated skin wound will have reduced blood supply to the distal portion of the shallow wound edge, often resulting in necrosis of the shallow edge. 
  • PITFALL: If a tangential wound is approximated with a simple suture (i.e., equal bites through each wound edge), an inverted or depressed scar often results.

Step 2

When repairing a tangential skin wound, take a large, deep bite with the suture needle through the broad edge and a small (2-mm) bite through the shallow edge. This path of the suture thread promotes eversion of the shallow edge and helps with the final appearance of the wound. 

Step 3

A C-shaped wound with beveled edges is often produced by a tangential injury. Use a scalpel to create vertical wound edges and undermine the edges to produce low-tension approximation. 

Step 4

Place the first suture in the middle of the wound. 

Step 5

Place another simple interrupted suture at half of the remaining distance of the unapproximated defect. 

Step 6

Continue placing simple interrupted sutures at half of the remaining distance of the unapproximated defect until the suture line is closed. 

Step 7

Alternatively, if a section requiring closure is better approximated with two additional sutures instead of three, place two additional sutures, each at one-third the total distance to finish the suture line. 

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

  • Incomplete excision of lesion

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. Sometimes it is necessary to sedate the patient to repair the laceration (see Pediatric Sedation). The maximum recommended dose of lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched after 1 day, but not to put the wound into standing water for two to three days. Have the patient dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. Have them cover the wound with a nonocclusive dressing for two to three days. A simple Band-Aid will suffice for many small lacerations. The dressing should be left in place for at least 48 hours, after which time most wounds can be opened to air. Scalp wounds can be left open if small, but large head wounds can be wrapped circumferentially with rolled gauze. 
Most uncontaminated wounds do not need to be seen by a provider until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 2 to 3 days. Give discharge instructions to the patient regarding signs of wound infection. 

Coding Information and Supply Sources

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160. 
Add together the lengths of wounds in the same classification and anatomic sites. Use separate codes for repairs from different anatomic sites. Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed. 
Simple repair is included in the codes reported for benign and malignant lesion excision (see Fusiform Excision). The billing chart cites the following wound locations: scalp, neck, axillae, external genitalia, trunk, extremities, hands, and feet (SNAGTEHF) and face, ears, eyelids, nose, lips, and mucous membranes (FEENLMM). 

Bibliography

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