Chapter 5.17: The Shorthand Vertical Mattress Suture

Donati suture

This is a modification of the vertical mattress suture, a frequently used everting technique used for closure and epidermal approximation. As with many interrupted techniques, it may be used alone for wounds under minimal tension, such as those formed by either a small punch biopsy or a traumatic laceration. Like its horizontal counterpart, it is also frequently used as a secondary layer to aid in everting the wound edges when the dermis has been closed using a deep suturing technique.

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. Suture choice will depend largely on anatomic location and the goal of suture placement.

On the face, 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. When the goal of the shorthand vertical mattress suture placement is solely to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well. Otherwise, 5-0 monofilament suture material may be used if there is minimal tension, and 4-0 monofilament suture is useful in areas under moderate tension where the goal of suture placement is relieving tension as well as epidermal approximation. In select high-tension areas, 3-0 monofilament suture may be utilized as well.

1. The needle is inserted perpendicular to the epidermis, approximately 3 mm distant from the wound edge.

2. With a fluid motion of the wrist, the needle is rotated superficially through the dermis, and the needle tip exits the skin on the contralateral side.

3. 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.

4. The needle is then reloaded in a backhand fashion and inserted 6 mm distant from the incised wound edge in line with the exit point on the ipsilateral side.

5. While gently pulling upward on the suture material in order to closely approximate the wound edges, the needle is rotated deep through its arc, exiting on the contralateral side of the wound 6 mm from the incised wound edge.

6. 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 5-17A, 5-17B, 5-17C, 5-17D, 5-17E).

This represents a variation of the standard vertical mattress suture and has been advocated as a faster placement approach for what is functionally the same technique.

As with most transepidermal techniques, it is important to enter the epidermis at 90 degrees when utilizing this technique. This will allow for maximal wound eversion and accurate wound-edge approximation.

The shorthand vertical mattress technique has been termed the near-near, far-far technique, since the suture material enters near the wound edge and exits near the wound edge, and then reenters far from the wound edge and finally exits far from the wound edge. This is in contrast with the standard vertical mattress technique, which is a far-far, near-near technique, since the first bite of suture enters and exits far from the incised wound edge and the second, nested bite of suture, enters and exits near the wound edge.

As with the simple interrupted suture, 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 problem may be particularly pronounced with the shorthand vertical mattress suture in novice hands, as the initial, superficially placed throw of suture material may be placed too superficially, resulting in suture material tear-through.

Since the second, deeper loop of suture is placed blindly when using the shorthand technique, care should be taken when working in areas with underlying vessels or nerves which could be pierced or strangulated by the deeper loop of suture. This is less of a problem when using the standard vertical mattress technique, since the deep loop is placed first, permitting full visualization of the underlying structures.

The shorthand vertical mattress technique does not typically permit the same degree of wound-edge apposition as can be accomplished with other transepidermal sutures, since the everting effect of the suture technique may even be associated with a small degree of gaping at the center of the vertical mattress suture.

As with the standard vertical mattress suture, 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.

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 techniques in the event that sutures will not be able to be removed in a timely fashion.