Chapter 5.19: The Running Vertical Mattress Suture

This is a running everting technique used for closure and epidermal approximation. Like any running technique, it may be used alone for wounds under minimal tension, such as wounds on the genitalia or traumatic lacerations. As with its interrupted counterpart, it is most 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 running 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 is 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. Occasionally, 3-0 monofilament suture may be utilized as well.

1. The needle is inserted perpendicular to the epidermis, approximately 6 mm distant to the wound edge.

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. If the needle radius is too small to complete this arc in one movement, this first step may be divided into two, with the needle first exiting between the incised wound edges and then reloaded and reinserted to exit 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 needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis approximately 3 mm from the wound edge on the same side of the incision line as the exit point.

5. The needle is rotated superficially through its arc, exiting on the contralateral side of the wound, 3 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.

7. Only the loose end of suture is trimmed.

8. The needle is then reinserted as in step (1), now just proximal (relative to the surgeon) and lateral (relative to the incised wound edge) to its exit point. This new entry point is therefore in line with the first entry point.

9. Steps (1) through (5) are then repeated sequentially, and after each set of steps the new entry point—proximal and lateral to the exit point—permits a running placement of sutures.

10. Once the end of the wound is reached, the suture material is gently tied off (Figures 5-19A, 5-19B, 5-19C, 5-19D, 5-19E, 5-19F, 5-19G).

This approach permits relatively rapid placement of an everting layer of suture material, and was proposed as an even faster technique for vertical mattress suture placement than the shorthand (near-near, far-far) technique.

Like the interrupted vertical mattress technique, this approach should be avoided when either inversion is desired or when exaggerated eversion has already been accomplished with a buried suture.

As with most transepidermal techniques, 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.

An advantage of this approach is that no suture material traverses the incised wound edge and that the suture similarly does not cross the surface of the wound. While this may be less than desirable when attempting to fine-tune epidermal apposition, it is helpful in minimizing the risk of unsightly track marks.

As with the interrupted vertical mattress approach, the second throw is placed superficial to the first, deeper far-far suture, leading to a nested placement of the suture material. This leads to both wound eversion as well as wound-edge approximation.

As a running technique, the integrity of the entire suture line rests on the security of the two anchoring knots. Since this approach is not relied on for tension relief, suture material breakage or knot failure, while undesirable, do not generally lead to catastrophic wound dehiscence. Indeed, the traction across the suture material itself affords a small degree of security which may be sufficient to maintain eversion even in the face of knot breakage.

As with the interrupted vertical mattress approach, this 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 running vertical mattress suture. 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.

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.

As with any suturing technique, knowledge of the relevant anatomy is critical. When placing a vertical 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, or that constriction may take place. That said, the vertical orientation of this approach helps minimize this risk.

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.