Chapter 4.8: The Percutaneous Vertical Mattress Suture

Haneke-Marini suture, modified buried vertical mattress suture

This technique is designed to allow for excellent tension relief while concomitantly permitting easy suture placement in relatively tight spaces. It is best suited to areas with thicker dermis, though it may also be utilized in any body area when tension-relieving sutures must be placed and where insertion of the full needle is challenging.

Some authors have advocated this technique as a replacement for standard buried suture approaches, and as an easy to implement alternative to the buried vertical mattress, while others prefer to think of this as a niche approach exclusively for areas where fully buried approaches are more challenging.

Suture choice is dependent in large part on location. Because suture material travels percutaneously, exiting the epidermis and then reentering, the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 absorbable suture material is effective, though theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material, particularly where the material has exited the epidermis entirely. 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. In areas under marked tension, or where full visualization is not possible, the needle may be blindly inserted from the undermined space without reflecting back the skin.

2. The suture needle is inserted at a 90-degree angle into the underside of the dermis 4 mm distant from the incised wound edge.

3. The first bite travels from the underside of the dermis in the undermined space, passes entirely through the dermis, and exits through the epidermis directly above the entry point.

4. The needle is then reloaded onto the needle driver with a backhanded technique, and inserted through the epidermis either directly through the same hole as the suture followed during exit, or just medial to it. A shallow bite is taken and the needle exits on the lateral margin of the incised wound edge.

5. The needle is then reloaded, again in a backhanded fashion, and is inserted into the contralateral incised wound edge at the same depth as it exited on the first side. The needle again follows a mirror-image superficial course through the dermis, exiting through the epidermis again approximately 4 mm from the wound edge. Alternatively, this step may be combined with the prior step and the needle can be inserted into the contralateral edge while it is still loaded from the initial pass exiting the incised wound edge.

6. The needle is then loaded in a standard fashion and inserted either through the same hole or just lateral to it, following a deeper course and exiting the undersurface of the dermis into the undermined space.

7. The suture material is then tied utilizing an instrument tie (Figures 4-8A, 4-8B, 4-8C, 4-8D, 4-8E, 4-8F, 4-8G, 4-H, 4-8I, 4-8J, 4-8K).

This technique is ideal for use in areas where placement of a traditional buried suture is challenging due to limited space, such as the scalp and lower leg. Even using small semicircular needles and with extensive undermining, it may be difficult to insert the body of needle into the undersurface of the dermis in these anatomic locations.

This technique may also be useful when placing an additional suture between two reasonably tightly set sutures, and where full retraction of the wound edge is, therefore, impossible.

This approach may also be used when it is difficult to visualize the undersurface of the dermis, since the needle throws may be placed in an almost blind fashion. The skin is grasped gently to make it taut and the needle is inserted through the undermined space, exiting on the outside of the skin. This may be executed by feel, an approach well suited to the scalp, where minimal dermal elasticity may preclude full exposure of the undersurface of the undermined dermis.

Finally, this technique may be utilized when a buried suture needs to be placed in an area that has not been undermined; the initial suture placement, entering from the underside of the dermis, can be performed blindly by sliding the needle through the superficial fat and entering from the underside of the dermis.

Since suture material exits the skin and then reenters, dimpling will likely occur. Patients should be warned that this is expected and will resolve with time. Reentering the skin through the same hole may help minimize the risk of dramatic dimpling, though this also increases the chance that the suture material could be cut by the needle.

Setting back the first throw far from the incised wound edge may result in overeversion; the chief drawback of overeversion is that the dermis may overhang the center of the incised wound edge, barring the epidermal edges from approximating appropriately, leading to a slightly wider final scar. This may be easily solved by carefully beveling the dermis to allow the epidermal edges to meet unimpeded.