Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Shadow Effect of a Retracted Scar
• Creating a Proper Closure
• Suturing Symmetric Amounts of Tissue
• Wound Edge Eversion
• Alternative Method

• The simple, interrupted skin suture has been one of the most commonly used wound closure techniques. The simple suture can be used alone or in conjunction with deep sutures to provide optimal wound healing and cosmesis.
• Properly placed interrupted skin sutures incorporate symmetric amounts of tissue from each wound edge, evert skin edges, and provide wound edge opposition without tissue strangulation. Interrupted skin sutures allow precise adjustments between stitches.
• Proper timing for suture removal allows for adequate healing (i.e., strength to developing scar) and minimizes development of suture marks. Interrupted skin sutures also permit removal of selected stitches (e.g., every other stitch) to individualize the time sutures are present.
• Wound edge eversion is an important goal when placing interrupted skin sutures. Healing wounds have a natural tendency to become inverted with retraction that occurs within scars. Indented or inverted scars can cast a shadow on adjacent surfaces, and shadow magnifies appearance of scar.
• Everted wounds are created so that the final scar is flat and not inverted. Eversion is accomplished by incorporating a greater amount of deep tissue in the needle path, which pushes together deep tissue, causing upward lift to the wound edges.
• Nonabsorbable suture materials—e.g., nylon—generally are selected for interrupted suture placement. Smaller-caliber sutures (5-0 and 6-0) tend to produce less skin marking and scarring than larger-caliber sutures (3-0 and 4-0). Placement of tightly clustered sutures close to the wound edge distribute skin edge tension better than placement of widely spaced sutures placed back from wound edge. Suggested suture removal times are listed in Appendix C, Recommended Suture Removal Times.
• Wound adhesives are alternate means for wound closure. Some practitioners believe that wound edge eversion is superior with suture closure, but adhesives can produce good cosmetic results for wounds with closely approximated edges. Wound adhesives are costly (>$40 for single applications) and probably will not eliminate need for simple interrupted closures.

• Superficial wounds that can be closed in single layer
• Eversion of wound edges after approximation with mattress or buried sutures
• Marking of skin for correct anatomic approximation (e.g., vermilion border)
• Closure of wounds over areas of movement—e.g., flexor creases or on dorsum of fingers

Relative Contraindications

• Closure of defects on breast tissue (use running intracutaneous suture closure)
• Widely separated wound edges that are better approximated with deeply buried sutures
• Presence of cellulitis, bacteremia, or other active infection
• Uncooperative patient

• Retracted scar on vertical surface—e.g., face—produces a shadow that magnifies appearance of scar (Fig. 14-1A). Wound edges should be everted at closure (Fig. 14-1B) so that subsequent scar retraction will produce a final scar that is flat (Fig. 14-1C).
• Poorly performed, ``scooped'' passage of suture needle across both wound edges (Fig. 14-2A) fails to create proper closure. Stitch should be deeper than it is wide. Needle should enter skin vertically (Fig. 14-2B) and exit skin vertically.
• Symmetric amounts of tissue from each wound edge should be included in passage of suture. Uneven bites of tissue in distance from the edge or depth of passage (Fig. 14-3A) produce closure with uneven edges (Fig. 14-3B). The resulting scar casts a shadow and is cosmetically inferior.
• Pitfall: Forcefully pushing or twisting the needle when passing it through tissue causes the body of the needle to bend or break. Follow the curve of the needle; do not apply twisting or torquing forces to needle. Regrasp (remount) needle in center of wound rather than force small needle through both wound edges. If the needle bends, remove it and open another suture pack. Broken needle tips can result in hours of frustrating searching to find the broken piece.
• The proper needle path to produce wound edge eversion is in the shape of a flask (Fig. 14-4A). The nondominant hand is used to push down on both wound edges (Fig. 14-4B), causing tissue in the deep portion of the wound to move toward the center of the wound (Fig. 14-4C). The needle enters the skin vertically and exits the skin vertically. When the nondominant hand relaxes, the tissue returns to its natural position.
• The suture path is flask shaped, and with tying, suture produces eversion. Place antibiotic ointment over the sutured wound and apply pressure dressing.
• Pitfall: Pushing down on the wound edges with your fingers increases the risk for inadvertent needlestick. Instruments can be used to push down on the wound edges. If fingers are used, exert added care to minimize the risk of needle injury.
• The alternative method to produce a flask-shaped path is technically more difficult. As the needle enters the right wound edge, the nondominant hand grasps tissue beneath the wound edge using Adson forceps and pulls tissue to the center of the wound (Fig. 14-5A). Before the needle passes through the opposite wound edge, deep tissue is pulled to the center of the wound with a backhanded technique using Adson forceps (Fig. 14-5B). Place antibiotic ointment over the sutured wound and apply a pressure dressing.
• Pitfall: Avoid traumatizing skin or deep tissue with forceps. Traumatized tissue may necrose, creating excessive time to healing and inferior cosmetic results.

• All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives ± adhesive strips on skin surface. If layered closure is required, use alternate codes: intermediate closure codes 12031–12057 or complex repair codes 13100–13160.
• Add together the lengths of the wounds in the same classification and anatomic sites. Débridement 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 Chap. 12, 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).

CPT code	Description	2002 average 50th percentile fee (US$)
12001	Simple repair SNAGTEHF 2.5 cm	151
12002	Simple repair SNAGTEHF 2.6–7.5 cm	200
12004	Simple repair SNAGTEHF 7.6–12.5 cm	250
12005	Simple repair SNAGTEHF 12.6–20.0 cm	328
12006	Simple repair SNAGTEHF 20.1–30.0 cm	438
12007	Simple repair SNAGTEHF >30.0 cm	570
12011	Simple repair FEENLMM 2.5 cm	186
12013	Simple repair FEENLMM 2.6–5.0 cm	228
12014	Simple repair FEENLMM 5.1–7.5 cm	289
12015	Simple repair FEENLMM 7.6–12.5 cm	372
12016	Simple repair FEENLMM 12.6–20.0 cm	512
12017	Simple repair FEENLMM 20.1–30.0 cm	657
12018	Simple repair FEENLMM >30.0 cm	861
12020	Treatment of superficial wound dehiscence, simple closure	309

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