Horizontal Mattress Suture Technique

The horizontal mattress stitch is a suture technique used to close wounds. It everts skin well and spreads tension along the wound edge. This makes it ideal for holding together fragile skin as well as skin under high tension such as the distant edges of a large laceration or as the initial holding suture in complicated repairs.

The horizontal mattress is so secure that it can compromise the blood supply to the tissue contained within the stitch. This can be helpful to prevent wound bleeding, but it can cause strangulation and skin necrosis if tied too tightly. Sometimes cushioning materials can be placed within the stitch to mitigate this effect.  Like other mattress stitches, the horizontal mattress can sometimes leave small skin scars called “railroad marks;” for this reason, it is rarely used on the face, and is removed promptly even when placed elsewhere. The knot is parallel adjacent to the wound edge.

Overview

The horizontal mattress suture is an everting suture technique that spreads tension along a wound edge. This technique is commonly used for pulling wound edges together over a distance, or as the initial suture to anchor two wound edges (holding sutures).

These sutures, like the vertical mattress sutures, incorporate a large amount of tissue within the passage of the suture thread, and they can serve as effective initial sutures in holding skin flaps in place. The suture is also effective in holding fragile skin together, such as the skin of an elderly patient or a patient receiving chronic steroid therapy.

The horizontal mattress suture is initiated by inserting the needle about 4 to 8 mm from the wound edge, slightly farther from the wound edge than for placement of simple interrupted sutures. The needle passes through to the opposite wound edge, where it exits the skin. The needle is placed backward in the needle driver, inserted into the skin about 4 to 8 mm farther down that edge (the edge where the needle has just been passed through), and passed from the far side of the wound back to the near side. The needle exits the skin about 4 to 8 mm down the original wound edge from the original insertion site. The suture is tied gently on the side of the wound where the suturing began.

Steps

• Grasp the wound edge with the forceps.

• Drive the needle through the skin, using the needle holder, around 4-8mm away from the wound edge, passing the suture deep through the dermis.

• Pick up the needle with the forceps at the wound edge, before reloading the needle onto the needle holder.

• Grasp the opposing wound edge with the forceps, drive the needle deep through the other side of the wound, piercing the skin to re-emerge around 4-8mm away from the wound on the opposite side.

• Backward load your needle in your needle holder.

• Grasp the second wound edge again with the forceps and drive the needle through the skin, in vertical alignment with the other puncture site, around 1-2mm away from the wound edge. This near placement should occur at a shallow depth and should pass through the upper dermis.

• Pick up the needle with the forceps at the wound edge, before reloading the needle onto the needle holder

• Grasp the opposing wound edge with the forceps, drive the needle deep through the other side of the wound (also in the upper dermis layer), piercing the skin to re-emerge around 1-2mm away from the wound on the opposite side (also in vertical alignment with the other puncture site).

• Gently pull the suture to achieve the desired skin tension, as the wound edges close.

• Finish by performing a hand tie or instrument tie.