The patient will usually have fallen onto a coarse surface
such as a blacktop or macadam road. Most frequently, the
skin of the face, forehead~ chin, hands and knees are
abraded. When pigmented foreign particles are impregnated
within the dermis adventita, tattooing will occur. An
explosive form of tattooing can also be seen with the use of
firecrackers, firearms, and homemade bombs.
What to do:
Cleanse the wound with nondestructive agents (e.g., normal
saline, SurClens, 1% povidone-iodine in normal saline) and provide tetanus prophylaxis.
With explosive tattooing, particles are generally deeply
emhed ded and will require plastic surgical consultation.
Any particles embedded in the dermis may become permanent
tattoos. Abrasions that are both large (more than several
square centimeters) and uniformly deep into the dermis or below (so that
no skin appendages, such as hair follicles, to provide a
reservoir of regenerating basal epithelium remain), may
also require consultation and/or skin grafts.
With abrasions and abrasive tattooing, the area can usually
be adequately anesthetised by applying lidocaine jelly, viscous lidocaine
or gauze soaked with a mixture of lidocaine, tetracaine and epinephrine directly onto the wound for approximately 5 minutes. If this. is not successful,
locally infiltrate with 1% buffered lidocaine using a 25-gauge 3" needle for large
areas.
The wound should now be cleaned with a surgical scrub
brush, saline and surgical soap. When impregnated material
remains, use a sterile stiff toothbrush to clean the wound
or use the side of a #10 scalpel blade to scrape away any
debris. While working, continuously cleanse the wound
surface with gauze soaked in normal saline to reveal any
additional foreign particles. Large granules may be removed
with the tip of a #11 blade.
Wounds should be left open with antibiotic ointment
applied. The patient should be instructed to gently wash
the area 3-4 times per day and continue applying the
ointment until the wound becomes dry and comfortable under
a new coat of epithelium, which may require a few weeks.
An alternative to the above when the wound has been
adequately cleansed, is to use the same antibiotic ointment with a closed dressing of
Adaptic gauze and a scheduled dressing change within 2-3
days.
Provide wound care instructions that include danger signs of infection.
What not to do:
Do not ignore embedded particles. If they cannot be
completely removed, inform the patient about the probability
of permanent tattooing and arrange a plastic surgical
consultation.
Discussion:
The technique of tattooing involves painting pigment on the
skin, and then injecting it through the epidermis into the
dermis with a needle. As the epidermis heals, the pigment
particles are ingested by macrophages and permanently bound
into the dermis. Immediate care of traumatic tattoos is
important because once the particles are embedded and
healing is complete, it becomes difficult to remove them
without scarring. It is advisable for a patient to protect
a dermabraded area from sunlight for approximately 1 year to
minimize excessive melanin pigmentation of the site.
