Chapter 4.3: The Buried Vertical Mattress Suture

This technique is a workhorse approach that is widely utilized by dermatologists and plastic surgeons. It is best used in areas under mild to moderate tension, and is a highly effective approach that may be utilized on the face, as well as the extremities and trunk.

Because of the need to shift planes and the fact that the needle travels in the papillary dermis, this technique may not be particularly well suited to areas with atrophic skin.

Suture choice is dependent in large part on location, though since suture material traverses the papillary dermis and the incised wound edge, as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 suture material is effective, though theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material. This needs to be weighed against the benefit of utilizing a larger CP-2 needle, which will almost never bend even in the thickest dermis, and the benefit of adopting the 2-0 suture material, which is less likely to snap under tension or fail during tension-bearing activities, leading to attendant dehiscence. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate.

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 and final bite is executed by inserting the needle into the incised wound edge at the level of the reticular dermis. It then angles upwards 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 (Figures 4-3A, 4-3B, 4-3C, 4-3D, 4-3E, 4-3F, 4-3G, 4-3H).

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.

In areas under marked tension, such as the back, this technique should be executed with caution in order to minimize the risk of bending the needle especially when smaller needles, such as the FS and PS, are used.

While the eversion is less pronounced than is seen with other techniques, such as the set-back dermal suture, patients may still be left with a small ridge in the immediate postoperative period. While this is desirable, it is also important to warn patients of this outcome; explaining that the technique is akin to placing a subcutaneous splint may help the patient develop reasonable and realistic expectations and reduce anxiety regarding the immediate postoperative appearance of the wound.