This technique should not be adopted in all areas, and there are generally better options for use in areas with a robust dermis under moderate to marked tension, such as the back and shoulders. In those locations, the buried horizontal mattress approach should only be utilized for inserting additional sutures in between already placed buried sutures, when there is insufficient space to place a set-back dermal suture or buried vertical mattress suture.
While the eversion is less pronounced than other techniques, such as the set-back dermal suture, patients may still be left with a small ridge in the immediate postoperative period. While this is desirable, it is also important to warn patients of this outcome; explaining that the technique is akin to placing a subcutaneous splint may help the patient develop reasonable and realistic expectations and reduce anxiety regarding the immediate postoperative appearance of the wound.
Wound-edge necrosis has been raised as a potential risk of horizontally oriented suture placement, but in practice this is only encountered very rarely and as a complication of tightly placed traditional horizontal mattress sutures, rather than with the buried equivalent. This is likely due to a constrictive effect on the incised wound edge, which is not typically seen with buried sutures.
The original description of this approach bears some resemblance to the butterfly suture; keeping in mind that the buried horizontal mattress suture should represent a buried version of the traditional horizontal mattress approach, however, the needle entry and exit points should both be in the undersurface of the dermis just lateral to the incised wound edge, as opposed to the butterfly suture where entry and exit occur at the juncture of the incised wound edge and the undersurface of the dermis and where the needle arcs on a diagonal.