Video 5-38. Combined vertical mattress-dermal suture
This is a combination suture that may be conceptualized as a hybrid between a vertical mattress suture and a dermal suture. It was designed to permit closure of deep defects and simultaneously permit wound eversion with a single suture, obviating the need for bilayered closures.
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.
Typically, 5-0 monofilament nonabsorbable suture material is appropriate if there is minimal tension, and 4-0 monofilament suture may be used in areas under moderate tension. In high-tension areas, 3-0 monofilament suture may be utilized as well.
The needle is inserted perpendicular to the epidermis, approximately 6 mm distant to the wound edge.
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 between the incised wound edges.
The needle is then reloaded and inserted through the deep dermis on the contralateral wound edge.
The needle is then reloaded again in a backhand fashion and inserted through the deep dermis on the original wound edge.
The needle is then reloaded, entering from beneath the dermis on the contralateral wound edge and exiting approximately 6 mm from the wound edge.
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.
The needle is rotated superficially through its arc, exiting on the contralateral side of the wound 3 mm from the incised wound edge.
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 5-38A, 5-38B, 5-38C, 5-38D, 5-38E, 5-38F, 5-38G, 5-38H).
Overview of the combined vertical mattress-dermal suture.
The needle is inserted perpendicular to the skin far from the wound edge, exiting in the open wound space.
The needle is inserted in the deep dermis on the contralateral side.
The needle is then inserted through the deep dermis on the original side of entry.