Chapter 5.10: The Running Alternating Simple and Horizontal Mattress Suture

Running combined mattress suture

This is a hybrid running everting technique used for closure and epidermal approximation. It incorporates a horizontal mattress component, which encourages wound eversion, and a simple running component, which encourages wound-edge apposition. This technique may also be used in patients with atrophic skin, as the broader anchoring bites of the horizontal mattress component may help limit the tissue tear-through that may be seen with a simple running suture.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. On the face and eyelids, a 6-0 or 7-0 monofilament suture is useful. Since the goal of this technique is primarily to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well, though if the wound is under significant tension or if the simple running component of the technique is being used to approximate wound edges under significant tension, then 5-0 suture material may be used on the extremities and neck, and thicker suture material, including 3-0, may be used on the trunk if the anticipated tension is marked.

1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

3. The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps. It is gently grasped and pulled upward with the surgical forceps as the body of the needle is released from the needle driver. Alternatively, the needle may be released from the needle driver and the needle driver itself may be used to grasp the needle from the contralateral side of the wound to complete its rotation through its arc, obviating the need for surgical forceps.

4. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges. The trailing end of suture is trimmed.

5. Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.

6. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

7. The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

8. The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.

9. The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of step (6).

10. Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.

11. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

12. The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

13. Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.

14. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

15. The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

16. The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.

17. The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of step (6).

18. Moving proximally relative to the surgeon, the previously mentioned steps are then sequentially repeated, alternating the placement of a simple running suture with a running horizontal mattress suture, until the end of the wound is reached. At that point, a loop is left in the penultimate throw and the suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-10A, 5-10B, 5-10C, 5-10D, 5-10E, 5-10F, 5-10G).

Since this technique entails alternating between a simple running and a running horizontal mattress suture, two bites should be taken from each side of the wound in succession in order to effectively combine these techniques.

This technique addresses a shortcoming in the running horizontal mattress suture, which tends to effectively evert the skin edges but may be unreliable at wound-edge apposition and coaptation. By combining these two approaches, this technique encourages excellent wound-edge eversion with its horizontal component while concomitantly permitting wound-edge apposition with the simple running component.

Moreover, a shortcoming of the traditional running horizontal mattress suture is that suture removal may be challenging. Since this technique entails alternating the mattress sutures with their simple running counterparts, suture removal is straightforward as the simple running loops are easily visualized and grasped at the time of suture removal.

As always, it is important to enter the epidermis at 90 degrees, allowing the needle to travel slightly laterally away from the wound edge before fully following the curvature of the needle when utilizing this technique. This will allow for maximal wound eversion and accurate wound-edge approximation.

Again, care should be taken to avoid skimming the needle superficially beneath the epidermis. This results from failing to enter the skin at a perpendicular angle and failing to follow the curvature of the needle. This may result in wound inversion as the tension vector of the shallow bite pulls the wound edges outward and down.

One of the advantages of the standard running horizontal mattress suture is that no suture material crosses over the incision line, and therefore the chance of leaving track marks is small. Since this technique includes a simple running component, track marks may represent a potential complication, and therefore suture material should be removed as early as possible.

As with any suturing technique, knowledge of the relevant anatomy is critical. Similarly, structures deep to the defect may be constricted. This can lead to necrosis due to vascular compromise or even, theoretically, superficial nerve damage. These concerns are more acute with the running alternating simple and horizontal mattress suture than with the simple running suture, since the wide arc of the suture material and its horizontal component incorporate more skin and underlying structures, thus increasing the risk of strangulation.

This technique may elicit an increased risk of track marks, necrosis, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, sutures should be removed as early as possible to minimize these complications, and consideration should be given to adopting other closure in the event that sutures will not be able to be removed in a timely fashion.