Chapter 5.15: The Running Diagonal Mattress Suture

Victory stitch, running V mattress

This is a modification of the running horizontal mattress suture, where suture material crosses the wound on a diagonal. It is useful in low-tension environments when additional wound eversion is desired, such as the face and extremities, as it leads to marked eversion of the wound edges.

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 may be used, though fast-absorbing gut may be used on the eyelids and ears to obviate the need for suture removal. Since the goal of the running diagonal mattress suture placement is primarily to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well.

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 then 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. The trajectory of the needle, however, is designed to be on a 45-60—degree angle relative to the incision line, pointed away from the starting apex.

6. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the contralateral side, further along the incision line than its entry point.

7. The needle body is grasped with surgical forceps in the left hand 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 just proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point. The trajectory of the needle, however, is designed to be on a 45-60—degree angle relative to the incision line, pointed away from the starting apex.

9. The needle is rotated through its arc, exiting on the contralateral side of the wound (relative to the surgeon) further along the incision line.

10. Moving proximally relative to the surgeon, steps (5) through (9) are then sequentially repeated, 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 5-15A, 5-15B, 5-15C, 5-15D, 5-15E, 5-15F).

This technique ostensibly provides the benefit of decreased risk of tissue necrosis when compared with the running horizontal mattress technique, since the watershed area at risk for vascular compromise is smaller when the bites are taken at a diagonal than when they are perpendicular to the incision line. That said, in clinical experience, loosely tied running horizontal mattress sutures almost never result in wound necrosis.

This technique does, however, have the advantage of taking very short bites parallel to the incision line, so that if any track marks are left they will be very short and inconspicuous. This approach is therefore well suited to utilizing a rapidly absorbable suture, such as fast-absorbing gut, since there is little risk that a slowly degraded suture will leave track marks.

This technique is frequently used on the face, as it aids with dramatic wound eversion. Generally, if the dermis was closed using the set-back dermal suture, no additional eversion is needed; however, when the buried dermal suture or even the buried vertical mattress suture, are used, occasionally the wound edges do not evert to the desired degree.

This approach also helps minimize cross-hatched railroad track marks, since the suture material does not cross over the incised wound edge. Similarly, this technique can sometimes yield a neater immediate postoperative appearance, as even if bite sizes are not uniform this is not apparent to the observer, as only the portions of suture material parallel to the incision line are visible.

Since the suture material traverses the wound on a diagonal, it introduces a force vector across the surface of the wound that is not perpendicular to the incised wound edge. In wounds under only minimal tension due to the proper placement of deeper sutures, this is not a significant issue, since the running diagonal mattress suture is utilized largely to evert the wound edges, rather than to reduce tension across the incision line. However, if the wound is under tension, the running horizontal mattress suture may be preferable as it has the theoretical advantage of maintaining tension perpendicular to the incision line.

Like the running horizontal mattress technique, this suture does not typically permit the same degree of wound-edge apposition as can be accomplished with other running transepidermal sutures. The everting effect of the suture technique may even be associated with a small degree of gaping, and suture material does not cross over the incised wound edge. In the event that deeper sutures were carefully placed, this may not be a significant drawback, since the wound edges may be well-aligned from the placement of these deeper sutures. If not, or if there is a need for improved wound-edge apposition even after placing the running diagonal mattress suture, a small simple interrupted suture may be placed intermittently over the mattress suture to bring the wound edges together more precisely.

Suture removal with this technique may be more involved than with simple interrupted sutures, particularly if sutures are left in situ for an extended period of time and some of the suture material has been overgrown by the healing epidermis. Moreover, since this is a running technique it may be difficult to locate a portion of suture easily amenable to cutting at the time of suture removal, since it is best to minimize the length of pulled through suture material at the time of removal. For this reason, if nonabsorbable suture material is utilized, an intermittent simple running throw maybe used every 1-3 cm to aid in suture removal.

As with any suturing technique, knowledge of the relevant anatomy is critical. When placing a running diagonal mattress suture it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material.