Chapter 5.21: The Hybrid Mattress Suture

This is a niche everting technique used for closure and epidermal approximation. It represents a cross between the vertical mattress and horizontal mattress techniques. 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.

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 is 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 hybrid 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. Occasionally, 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, 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.

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, proximal from the exit point relative to the surgeon.

5. The needle is rotated 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 5-21A, 5-21B, 5-21C, 5-21D, 5-21E).

This technique has been advocated as a cross between a vertical and horizontal mattress suture, affording the benefits of both a vertical and horizontal mattress 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.

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.

As with the vertical mattress technique, 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.

In practice, this technique does not typically afford significant benefits over a horizontal mattress suture, and like other mattress approaches it does not typically permit the same degree of wound-edge apposition as can be accomplished with other transepidermal sutures, since the everting effect of the suture technique may even be associated with a small degree of gaping at the center of the vertical mattress suture. 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.

As with other mattress techniques, 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.

With any suturing technique, knowledge of the relevant anatomy is critical. When placing a hybrid 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.

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.