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The horizontal mattress suture is useful when additional compression for wound edge hemostasis or extra eversion is desired or in wounds with a small amount of tension after deep sutures have been placed, particularly thin and fragile skin.[1] It has been described in multiple iterations: interrupted,[1] fully buried in dermal closure,[2] partially buried,[3] and running. A split-scar study showed a better cosmetic outcome than with simple running sutures,[4] although there are disadvantages; removal can be challenging and painful for the patient, and it is difficult to align the wound edges in a vertical plane precisely, because there is no suture crossing over the wound.

We use a technique that solves the problems noted above by locking the suture across the wound.

Description of Technique

  1. Top of page
  2. Description of Technique
  3. Discussion
  4. References

The suture begins like a typical horizontal mattress suture, with the needle passing though the epidermis at a 90° angle and out the opposite side of the wound (Figure 1A and B). After the needle crosses back through the wound (Figure 1C), a 1- to 2-cm loop of suture is left protruding, rather than being tightened down like a traditional horizontal mattress (Figure 1D). The knot is begun as a typical surgeon's knot, with two loops thrown around the needle driver (Figure 2A). The tip of the needle driver is then passed through the far side of the loop created in the prior step, and the free tail is grasped (Figure 2C). The needle driver is then pulled back through the loop, bringing the free end of the suture with it. The driver must pass through the loop in the direction shown to keep the loop from twisting. The knot is then laid down and tied in the usual fashion (Figure 2D). The suture is readily visible and easy to remove and creates excellent eversion (Figure 3).

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Figure 1. The suture starts like a typical horizontal mattress suture (A), crossing the wound in both directions (B, C). A 1- to 2-cm loop of suture is left protruding (D).

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Figure 2. After a typical surgeon's knot is begun (A), the needle driver is brought around the far side and through the loop created in the previous step (B). The tail is grasped (C), and the needle driver is withdrawn and pulled inferiorly (D) to lay the knot square.

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Figure 3. Excellent epidermal eversion and edge apposition with finished knots on the model (A) and a patient (B).

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Discussion

  1. Top of page
  2. Description of Technique
  3. Discussion
  4. References

A similar technique for locking a horizontal mattress suture has been described,[5] specifically for wounds with moderate tension on the volar skin of the hand. The modification reported here is modest but important because it requires no extra movements, regrasping of the needle, or threading suture through the loop, thus preserving economy of motion. It takes no longer to place or tie than a traditional horizontal mattress suture.

This technique is most useful when optimal wound edge eversion has not been achieved with deep dermal sutures, although given its ease and speed of placement, is suitable for most wounds. There are three advantages: extra eversion; precise epidermal edge apposition because the suture crosses the wound; and easy removal, especially with smaller-diameter sutures on the face. It can be placed in a running locked fashion as Hanasono and Hotchkiss noted,[5] but in practice, this does not seem to provide an optimal degree of wound edge alignment and creates some distortion of the wound due to angled vectors of tension. Vascular constriction and wound edge necrosis are theoretical risks with horizontal mattress sutures,[2] although there is little objective evidence to support this claim.[4] We have not observed necrosis or suture marks in practice.

References

  1. Top of page
  2. Description of Technique
  3. Discussion
  4. References