Chapter 4.25: The Buried Vertical Mattress Suspension Suture

Criss-cross tie-over tacking suture, three point suspension suture

Like the tie-over suture, this technique is useful when attempting to recreate a natural sulcus when the defect lies parallel to the sulcus. It may be conceived as a hybrid between the traditional suspension suture and the tie-over suture, as it entails combining a buried vertical mattress suture with an anchoring suture that attaches to deeper structures, but rather than separately executing a buried vertical mattress suture and a tie-over suture these two steps are combined into one. Since its application is limited to areas where the buried vertical mattress suture directly overlies the natural sulcus, this represents a niche technique.

This technique is generally utilized on the face, and therefore the smallest gauge suture material with appropriate tensile strength should be utilized. Generally, a 4-0 or 5-0 absorbable suture material provides adequate security when anchoring to the periosteum. Nonabsorbable material could theoretically be utilized, and may provide a longer-lasting depressive effect on the tissue, but this benefit is likely outweighed by the increased risk of foreign-body reaction and suture material extrusion.

1. The wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is desirable.

2. While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 4 mm distant from the incised wound edge.

3. The first bite is executed by following the needle initially at 90 degrees to the underside of the dermis and then, critically, changing direction by twisting the needle driver so that the needle exits in the incised wound edge. This allows the apex of the bite to remain in the papillary dermis while the needle exits in the incised wound edge at the level of the reticular dermis.

4. Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then reflected back in a similar fashion as on the first side.

5. The second bite is executed by inserting the needle into the incised wound edge at the level of the reticular dermis. It then angles upward and laterally so that the apex of the needle is at the level of the papillary dermis. This should mirror the first bite taken on the contralateral side of the wound.

6. The suture material is then tied utilizing an instrument tie, but importantly the suture material is not cut, thus leaving a long tail.

7. Once the buried vertical mattress suture has been completed, starting from the side of the tied buried vertical mattress suture where the long tail is present, the needle is blindly inserted through the fat and deeper structures until the bone is reached. A 3-mm bite of the periosteum is then taken, and the needle is brought back up through the soft tissues into the open center of the wound on the contralateral side of the buried vertical mattress suture and lifted above the buried vertical mattress suture.

8. The suture material is then tied to the loose tail over the buried vertical mattress suture using an instrument tie, anchoring down the buried vertical mattress suture (Figures 4-25A, 4-25B, 4-25C, 4-25D, 4-25E).

Since the buried suture is anchored to the underlying periosteum, unlike the traditional suspension suture this technique can only be used when the buried suture directly overlies a natural sulcus. Therefore, it is most widely used with defects along the nasofacial sulcus, though theoretically it could be utilized over other sulci and creases as well.

A variation of this technique, the modified crisscross tie-over suture, was designed to assure that the second knot (securing the anchoring suture to the buried vertical mattress) remains buried lateral or deep to the buried vertical mattress, since the original iteration of this technique may result in the second knot riding above the buried vertical mattress suture, increasing the risk of suture abscess formation. In the modified version of this technique, the deep anchoring throw is placed ipsilateral to the loose tail, and does not encircle the buried vertical mattress suture. This encourages the second knot to remain firmly buried while resulting in the same degree of tissue suspension.

A simplified version of this technique (as shown in the figures) permits placement of the buried vertical mattress suture and the suspension suture all with a single set of knots; the suspension suture may be placed first, followed by placement of the buried vertical mattress suture, and then the suture can be tied, minimizing the number of knots that will need to be absorbed. This three-point suspension suture, or buried vertical mattress suspension suture, may be preferable to the other variations as less suture material will be left in the dermis to be hydrolyzed.

The relatively large amount of suture material that is left in situ with this technique means that the chances of foreign-body reaction, suture abscess, or suture spitting are probably higher than other suspension suture approaches. This should be taken into account before broadly adopting this approach, and while some proponents have suggested that these complications are rarely, if ever, seen, others have stated that this may be a frequent occurrence.

In the standard version of this approach, since the anchoring suture is tied directly to the loose tail of the buried vertical mattress suture, the additional torque placed on the buried suture may translate into a greater risk of suture material rupture, or at least of added tension on the dermis where the buried vertical mattress suture is anchored. Therefore, attention to detail in placing and tying the buried vertical mattress suture is of particular importance when utilizing this technique.

As with any suspension suture, there is a risk of damaging underlying structures when placing the anchoring bite of suture material. Comfort with and knowledge of the underlying anatomy, and particularly the location of neural and vascular bundles, is of paramount importance when adopting this approach.

Finally, there is a risk of creating a longstanding depression at the site of suture placement. While the immediate postoperative dimpling generally resolves, this depends largely on the patient’s fibrotic response, and an exaggerated fibrotic response may translate into a permanent depression at the site of suture placement.