Not Your Mama’s Horizontal Mattress

Think you know everything there is to know about placement of a horizontal mattress suture?  Here are some variations on this tried-and-true technique to consider in specific acute traumatic wound care situations.

The Locked Horizontal Mattress Suture

Ever placed a horizontal mattress suture and been pleased with the eversion and tension relief, but not so much with the apposition of the wound edges?  Even a meticulously placed horizontal mattress suture can occasionally cause a filleting effect on the wound.  In other words–subcutaneous fat and dermis can still be seen exposed within the wound bed after suture placement.

A potential solution? The locked horizontal mattress suture.  In this variation on the traditional horizontal mattress suture, the suture end bearing the needle is passed underneath the loop on the contralateral side, such that the suture material traverses the wound upon being tied.  The suture crossing the wound aids in apposition of the wound edges, while maintaining the traditional advantages of the horizontal mattress suture (load bearing and avoiding needle puncture near thin or macerated wound edges).

A potential drawback to mention, and one true of any locking suture, is that it causes increased compressive forces on the wound within each loop of the suture.  Thus, there is a greater risk of strangulation/necrosis, so be gentle with that knot-tying.

The Running Horizontal Mattress Suture

If you like the horizontal mattress suture but can’t imagine taking the time to throw-tie-cut-repeat over and over again for a longer wound, consider this variation.  Running the suture, as outlined in the video below, increases efficiency of placement for longer wounds.  It can be used as an initial layer for a longer, higher-tension wound in order to create a lower-tension environment for closing the wound with deep dermal sutures within the wound followed by either simple interrupted or running percutaneous sutures closer to the wound margins.

Here’s a tip on the technique from Dr. Jon Kantor, a practicing dermatologist and author of The Atlas of Suturing Techniques: on a practical level, this maneuver can make it difficult to remove the suture material. He thus recommends placement of intermittent simple loops which cross the wound margin (similar to a standard running percutaneous suture) in order to facilitate easier removal of the suture.

The Inverting Horizontal Mattress Suture

Sometimes it can be useful to translate a technique you’ve previously mastered to handle a novel situation. An example of this is the use of the inverting horizontal mattress suture.

While inversion of a wound is generally not a goal of wound closure, there are some situations where inversion may be a desired effect.  An example of this is when trying to re-create a natural crease over an area of injury, such as the nasolabial folds or the cleft of a chin.  A horizontal mattress suture placed with a 90 degree rotation relative to the usual throws is a simple way to create this effect, as described in the video below.

These variations on a commonly taught emergency medicine technique are useful ways to improve cosmesis, increase efficiency, and create novel effects in your wound closure (respectively).  Practice first, then give them a try!