Chapter 5.20: The Running Alternating Simple and Vertical Mattress Suture

Running combined simple and vertical mattress suture

This is a hybrid 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. 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, where the vertical mattress component helps with eversion and the simple running component aids with wound-edge approximation.

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 maybe 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 alternating simple and 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. In select high-tension areas, 3-0 monofilament suture may be utilized as well.

1. A simple interrupted anchoring suture is placed as follows:

2. 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.

3. 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.

4. 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.

5. 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.

6. The loose end of the suture material is then trimmed.

7. The needle is reinserted perpendicular to the epidermis, approximately 6 mm distant from the wound edge, just proximal relative to the surgeon from its exit point.

8. With a fluid motion of the wrist, the needle is rotated through the dermis at a 45-degree angle toward the surgeon (and away from the prior stitch), and the needle tip exits the skin on the contralateral side, equidistant from the incised wound edge and proximal, relative to the surgeon, from its entry point.

9. 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.

10. The needle is rotated superficially through its arc, exiting on the contralateral side of the wound 3 mm from the incised wound edge.

11. The needle is then reloaded in a standard fashion and reinserted on the ipsilateral side of the wound edge but now approximately 6 mm from the incised wound edge, yet still in line with its exit point.

12. 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.

13. The needle is again passed at a 45-degree angle toward the surgeon (and away from the prior stitch), and the needle tip exits the skin on the contralateral side, equidistant from the incised wound edge and proximal, relative to the surgeon, from its entry point.

14. The needle is then inserted on the contralateral side of the incised wound edge, equidistant from the incised edge and further proximal relative to the surgeon.

15. Steps (7) through (14) are then repeated sequentially, until the end of the wound is reached.

16. Once the end of the wound is reached, the suture material is gently tied off (Figures 5-20A, 5-20B, 5-20C, 5-20D, 5-20E, 5-20F, 5-20G, 5-20H, 5-20I).

This approach permits relatively rapid placement of an everting layer of vertical mattress sutures, and the incorporation of the simple loops means that it is even faster to place than the running vertical mattress suture, since the simple loops require only a single forehand throw of suture material versus the two throws needed for each vertical mattress suture.

The presence of the simple loops also affords easier suture removal, as the loops of interrupted suture may be easily grasped and cut at the time the sutures are removed.

Of course, 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 the interrupted vertical mattress approach, the second throw of the vertical mattress component 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. Similarly, each of the simple sutures should be placed by taking a larger bite of tissue at their deep portion in order to better evert the wound edges.

Unlike many other running techniques, this approach relies on the suture material traversing the wound at a 45-degree angle in order to permit the individual vertical mattress components to remain perpendicular to the incised wound edge and simultaneously allow the running nature of this technique to progress along the length of the wound. While this results in a neat postoperative appearance, with visible suture material sitting perpendicular to the incised wound edge, it also means that the tension vector of the sutures is at an angle to the underlying tension across the incised wound edge.

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 weaving of the suture material itself affords a small degree of security that may be sufficient to maintain eversion even in the face of knot breakage.

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.