Chapter 5.13: The Running Oblique Mattress Suture

Continuous oblique mattress suture

This is a hybrid running everting technique used for closure and epidermal approximation. It incorporates an oblique mattress component, which encourages both wound eversion and wound-edge apposition. This technique may be useful for patients with atrophic skin, as the broader anchoring bites of the oblique mattress technique may help limit the tissue tear-through that may be seen with a simple running suture, while concomitantly providing improved wound-edge eversion.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. This technique was originally described for the trunk and extremities, where a 2-0 nonabsorbable suture was advocated. Unless there is marked tension across the wound, smaller gauge suture material is preferable. Indeed, since the goal of the continuous oblique mattress suture is primarily to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well, though if the wound is under significant tension, then 5-0 suture material may be used on the extremities and neck, and thicker suture material, including 3-0, may be used on the trunk if the anticipated tension is marked.

1. The needle is inserted perpendicular to the epidermis, approximately 6-mm distant to the wound edge.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

3. The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps. It is gently grasped and pulled upward with the surgical forceps as the body of the needle is released from the needle driver. Alternatively, the needle may be released from the needle driver and the needle driver itself may be used to grasp the needle from the contralateral side of the wound to complete its rotation through its arc, obviating the need for surgical forceps.

4. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges. The trailing end of suture is trimmed.

5. Starting approximately 2 mm proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, 3 mm from the wound edge on the right side of the wound.

6. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the contralateral side, again approximately 3 mm set back from the incised wound edge.

7. The needle is then reloaded in a backhand fashion and inserted 3 mm proximal and approximately 6 mm distant from the incised wound edge on the same side of the incision line as the exit point.

8. The needle is rotated through its arc, exiting on the contralateral side of the wound, again approximately 6 mm distant from the incised wound edge.

9. Moving proximally relative to the surgeon, steps (5) through (8) are then sequentially repeated, until the end of the wound is reached. At that point, a loop is left in the penultimate throw and the suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-13A, 5-13B, 5-13C, 5-13D, 5-13E, 5-13F).

Like the running alternating simple and horizontal mattress approach, this technique addresses a shortcoming in standard mattress sutures, which tend to effectively evert the skin edges but may be unreliable at wound-edge apposition and coaptation. As a hybrid approach, this technique encourages excellent wound-edge eversion with its mattress component while concomitantly permitting slightly improved wound-edge apposition.

Suture removal with this approach is easier than with a running horizontal or vertical mattress approach, as there is less of a tendency for the transepidermal portion of the sutures to become quickly overgrown with healing epidermis.

In the context of atrophic skin, the modest bites of epidermis taken with a traditional running suture may be insufficient and result in suture tear-through. The larger bites taken with the continuous oblique mattress suture may help mitigate some of these concerns in the context of atrophic skin.

As with the running horizontal mattress suture, no suture material crosses over the incision line, and therefore the chance of leaving track marks is small. The oblique portions of the suture may tend to constrict with postoperative edema, which may result in obliquely oriented short track marks if sutures are not removed in a timely fashion.

As always, knowledge of the relevant anatomy is critical. Structures deep to the defect may be constricted. This can lead to necrosis due to vascular compromise or even, theoretically, superficial nerve damage. These concerns are more acute with the continuous oblique mattress suture than with the simple running suture, since the wide arc of the suture material and its oblique component incorporate more skin and underlying structures, thus increasing the risk of strangulation.

This technique may elicit an increased risk of track marks, necrosis, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, as noted previously, sutures should be removed as early as possible to minimize these complications, and consideration should be given to adopting other closure in the event that sutures will not be able to be removed in a timely fashion.