Chapter 5.16: The Vertical Mattress Suture

Donati suture, Allgöwer-Donati Suture

This is a frequently used everting technique used for closure and epidermal approximation. As with many interrupted techniques, it may be used alone for wounds under minimal tension, such as those formed by either a small punch biopsy or a traumatic laceration. Like its horizontal counterpart, it is also frequently used as a secondary layer to aid in everting the wound edges when the dermis has been closed using a deep suturing technique.

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. Suture choice will depend largely on anatomic location and the goal of suture placement.

On the face, a 6-0 or 7-0 monofilament suture may be used, though fast-absorbing gut may be used on the eyelids and ears to obviate the need for suture removal. When the goal of the vertical mattress suture placement is solely to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well. Otherwise, 5-0 monofilament suture material is used if there is minimal tension, and 4-0 monofilament suture is useful in areas under moderate tension where the goal of suture placement is relieving tension as well as epidermal approximation. In select high-tension areas, 3-0 monofilament suture may be utilized as well.

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. If the needle radius is too small to complete this arc in one movement, this first step may be divided into two, with the needle first exiting between the incised wound edges and then reloaded and reinserted to exit on the contralateral side.

3. The needle body is grasped with surgical forceps in the left hand 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 needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis approximately 3 mm from the wound edge on the same side of the incision line as the exit point, between the exit point and the incised wound edge.

5. The needle is rotated superficially through its arc, exiting on the contralateral side of the wound 3 mm from the incised wound edge.

6. 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 5-16A, 5-16B, 5-16C, 5-16D, 5-16E, 5-16F).

This technique is generally used for its pronounced effect on wound eversion. Therefore, while it is appropriate for most skin closures, it should be avoided when either inversion is desired or when exaggerated eversion has already been accomplished with a buried suture.

As with most transepidermal techniques, it is important to enter the epidermis at 90 degrees, allowing the needle to travel slightly laterally away from the wound edge before fully following the curvature of the needle when utilizing this technique. This will allow for maximal wound eversion and accurate wound-edge approximation.

As with the simple interrupted suture, care should be taken to avoid skimming the needle superficially beneath the epidermis. This results from failing to enter the skin at a perpendicular angle and to follow the curvature of the needle.This may result in wound inversion as the tension vector of the shallow bite pulls the wound edges outward and down.

An advantage of this approach is that no suture material traverses the incised wound edge and that the suture similarly does not cross the surface of the wound. While this may be less than desirable when attempting to fine-tune epidermal apposition, it is helpful in minimizing the risk of unsightly track marks.

This technique is sometimes referred to as a far-far, near-near suture, based on its entry and exit points; the needle is first inserted far from the incised wound edge, and then again exits far from the wound edge on the contralateral side. It is then reinserted near the wound edge on the ipsilateral side and exits near the wound edge on the contralateral side.

Note that the second throw is placed superficial to the first, deeper far-far suture, leading to a nested placement of the suture material. This leads to both wound eversion as well as wound-edge approximation.

The Allgöwer technique involves performing a half-buried vertical mattress suture: (1) The needle is passed from the far entrance point to the interior of the wound. (2) A buried vertical mattress bite is then taken on the contralateral side, by entering the underside of the dermis and exiting at the incised wound edge. The needle then passes back to the original side, entering near the incised wound edge so that one-half of the wound is closed with a standard vertical mattress suture and the other is closed with a buried vertical mattress.

This technique does not typically permit the same degree of wound-edge apposition as can be accomplished with other transepidermal sutures. In the event that deeper sutures were carefully placed, this may not be a significant drawback, since the wound edges may be well-aligned from the placement of these deeper sutures. If not, or if there is a need for improved wound-edge apposition even after placing the vertical mattress suture, additional interrupted sutures may be helpful.

Suture removal with this technique may be more involved than with simple interrupted sutures, particularly if sutures are left in situ for an extended period of time and some of the suture material has been overgrown by the healing epidermis.

As with any suturing technique, knowledge of the relevant anatomy is critical. When placing a vertical mattress suture it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material, or that constriction may take place. That said, the vertical orientation of this approach helps minimize this risk.

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, sutures should be removed as early as possible to minimize these complications, and consideration should be given to adopting other closure techniques in the event that sutures will not be able to be removed in a timely fashion.