What do you do when something weird and wild comes into your emergency department? This month, we mean lacerations over tattoos or body piercings. Cosmetic repair of injuries involving tattoos and piercings are important to our patients. We should ensure proper wound closure while preserving the underlying body art.
Tattoos and piercings are ancient practices of body modification. This form of art appreciation continues to be a popular and important cosmetic alteration for many people. Body art ranges from ear piercings ($20-30 for earlobes) to extensive tattoos that cost thousands of dollars.
Many have sentimental value and special meaning to patients, and a laceration disrupting them can be upsetting for them. Scarring left behind from improper closure can cause the formation of keloids and discoloration on tattooed skin. Lacerations involving piercings, especially the ear and belly button, can cause severe skin stretching that needs plastic surgery repair if not closed appropriately.
-Laceration repair of tattooed skin
-Combination of simple interrupted, mattress, and deep sutures
-Proper bandaging, wound care, and follow-up instructions
Watch a video of Ms. Roberts repairing a tattoo laceration with deep and simple interrupted sutures. Dissolvable sutures were applied on top of completed superficial sutures.
It is important to consider tattoo cosmetics during repair, but no skin art should take precedence over proper skin closure of an injured site. If the skin is mutilated or extensive skin surface is destroyed, closure and repair to control bleeding and promote healing are paramount and should be prioritized.
-Assure the patient that repair of the tattoo is a priority and that you will do your best to make it similar to the original. Be sure to remind them that there may be some scarring.
-Search for the right equipment, such as dissolvable and deep sutures, before starting your repair.
-Obtain a thread one size smaller than usual for skin repair involving tattoos. For example, if you are using 4.0 for a tattoo to the wrist or hand, consider using a 5.0 thread. This will aid in fewer scars and prevent skin complications during healing.
-Thread color may also be taken into consideration. For dark tattoos (such as ones with all black ink), consider contrasting thread color such as Prolene. This may be especially helpful for lining up the artwork during repair and for suture removal in the days to come.
-Clean the wound. Tattooed skin should be cleaned thoroughly to remove foreign bodies, dirt, or anything else that may cause an infection, which will worsen cosmetic outcomes, especially cellulitis or keloid formation.
-If the tattoo is on the hand, finger, or face, consider digital or nerve block. This will result in less swelling at the actual site, allowing for better approximation of the wound.
-During the repair, start in the center of the wound and work your way outward. If the skin is brought together corners first, it may misalign the tattoo or artwork.
-Consider using deep absorbable sutures in areas of tension and for deeper lacerations. Avoid deep sutures in the hand because they can cause increased risk of infection.
-Close areas of skin with tattoos with a mix of simple interrupted and mattress sutures depending on the depth and skin tension of the wound. This may take extra time and appreciation, but it will yield better cosmetic results.
-Approximate lettering (and other artwork) carefully, and use slight tenting of the skin during suture application to assist with wound healing.
-After you have completed the closure of certain areas of the tattooed skin, consider the double suture closure technique with dissolvable sutures. This is completed first by closing the wound completely with simple or interrupted sutures. After the skin is closed, the provider may complete additional dissolvable sutures on top of underlying sutures.
-Use splints to assist with wound healing.
-Do not be afraid to consult plastic surgery on difficult cases. These patients take pride in the cosmetic appearance of their art.
-Do not underestimate the healing power of dissolvable sutures for extremities.
-Avoid deep sutures in the hand.
-Consider prophylactic antibiotic use for patients with HIV or hepatitis if laceration is extensive or complicated. Otherwise, prophylactic antibiotics are not indicated.
-Do not use bacitracin or triple antibiotic cream for more than 24 hours on the wound. This can cause excessive moisture and poor healing, especially for tattoos involving red ink.
Tips of the Month: Smoking and Wound Healing
Did you know that smokers heal up to 50 percent slower than nonsmokers? All skin requires tissue oxygen, cell migration to wound sites, bacterial defense, and collagen synthesis to heal. (Br J Dermatol 2010;163:257.) Anything that causes tissue hypoxia, such as smoking, can delay wound healing. (Arch Surg 1991;126:1131.) Cigarettes also contain more than 4,000 toxic compounds that are generally unhealthy for the human body. Nicotine, carbon monoxide, and hydrogen cyanide are the most dangerous chemicals in cigarettes that disrupt healing in the body and cause chronic inflammation.
If your patient has a wound (tattoo or not), consider discussing smoking cessation with her. If she does have a tattoo and is a smoker, mention that the tattoo will not heal well or quickly if she continues to smoke.
Smoking cessation discussions during discharge are also a billable CPT code. In 2014, the Affordable Care Act began requiring insurance plans to cover many clinical preventive services. This includes tobacco use screening for all adults and adolescents, tobacco cessation counseling for tobacco users, and expanded counseling for pregnant women. (http://bit.ly/2ghzgd3.) Finally, the CPT codes used are time-based (greater than three minutes to 10 minutes  and greater than 10 minutes ). You must document the time spent counseling.
Keep in mind that ICD codes may vary based on presentation. CPT codes should be documented based on whether the patient is symptomatic or asymptomatic. If a patient is visiting your care area for a simple laceration and has no complaints related to smoking, be sure to follow appropriate CPT and ICD coding. But if the patient has a cough or other issues related to smoking and you provide cessation counseling, you may bill for symptomatic counseling.