With any suturing technique, knowledge of the relevant anatomy is critical. When placing this 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.
Similarly, if the knot is tied relatively tightly, 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 combined horizontal mattress and simple interrupted suture and other variants of the horizontal mattress suture than with the simple interrupted 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 techniques in the event that sutures will not be able to be removed in a timely fashion.