This technique requires some practice to master, though once mastered it is straightforward to execute. The first bite may also be finessed by first reflecting the wound edge back sharply during needle insertion and then returning the edge medially after the apex has been reached. This approach helps lead the needle in the correct course without an exaggerated changed in direction with the needle driver.
A similar approach maybe utilized by surgeons who favor skin hooks over surgical forceps; here again, the hook may be used to hyper-reflect the skin edge back during the first portion of the first bite and then similarly pull the incised wound edge toward the center of the wound during the second portion of the first bite. This will encourage the needle to follow the desired heart-shaped path without necessitating a dramatic twist of the needle driver as the needle changes course. When suturing, the obviously active element (the needle and needle driver, held by the dominant hand) and the ostensibly passive element (the skin, held by forceps or a skin hook), have the potential to move in three dimensions. Thus, changing the way the needle moves through the skin can be accomplished by either adjusting the way the needle is moved through the skin with the dominant hand, adjusting how the skin is held or manipulated by the other hand, or a combination of the two. With experience, a combination is often more effective at implementing the vertical mattress suture in an elegant and efficient fashion.
The apex of the needle should be in the papillary dermis; if the needle courses too superficially, dimpling may occur. While such dimpling is sometimes almost unavoidable, such as in areas with a very thin dermis such as the eyelids, and generally resolves with time, it remains best to avoid it if possible since: (1) patients may sometimes have some concern regarding the immediate postoperative appearance, and (2) dimpling signifies that the suture material traverses very superficially, raising concern that it could be associated with an increased risk of suture spitting.
This technique, if executed appropriately, leads to both excellent wound eversion and outstanding wound-edge approximation, explaining the popularity of this approach amongst plastic surgeons and dermatologists.
A particularly well-executed traditional simple buried dermal suture is very similar to the buried vertical mattress, since the placement of the suture following the curvature of the needle results in a slight eversion of the wound edge.