Chapter 5.30: The Combined Horizontal Mattress and Simple Interrupted Suture

Rousso stitch

This is an everting technique used for closure and epidermal approximation, and is a variation on the horizontal mattress technique. 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, or as a secondary layer. Like other mattress sutures, this technique may also be used in the context of atrophic skin, as the broader anchoring bites may help limit tissue tear through that may be seen with a simple interrupted suture.

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.

A 5-0 monofilament suture material is appropriate if there is minimal tension across the wound, while 4-0 monofilament suture is used 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. Though rarely used in these locations, on the face and eyelids a 6-0 or 7-0 monofilament suture is appropriate, though fast-absorbing gut may be used on the eyelids and ears to obviate the need for suture removal.

1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

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.

4. The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.

5. The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of steps (2) and (3).

6. The needle is then reloaded in standard fashion and inserted on the ipsilateral wound edge distal to the original entry point.

7. 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.

8. 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 5-30A, 5-30B, 5-30C, 5-30D, 5-30E, 5-30F, 5-30G).

This approach may be conceptualized as a combined horizontal mattress and simple interrupted suture. Like the locking mattress sutures, this approach makes suture removal more straightforward by including a portion of suture material traversing over the incised wound edge.

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 failing 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.

Since a wide bite of dermis and epidermis is included in the suture arc, it is particularly important to avoid tying the suture material too tightly, as this could lead to wound-edge necrosis.

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

Similarly, if the knot is tied relatively tightly, 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 combined horizontal mattress and simple interrupted suture and other variants of the horizontal mattress suture than with the simple interrupted suture, since the wide arc of the suture material and its horizontal 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, 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.