Chapter 5.31: The Lattice Stitch

This is a niche technique designed for wounds with an atrophic dermis or under significant tension, where traditional suturing techniques do not allow for adequate tissue recruitment and wound-edge apposition or tension relief. The fundamental principle is to place several interrupted sutures parallel to the wound edge and then tie the interrupted sutures over the wound edge by incorporating the lattice, increasing the stability of the repair and broadly distributing its force.

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. A 5-0 monofilament suture material may be used if there is minimal tension, and 4-0 monofilament suture in areas under moderate tension. In select high-tension areas, 3-0 monofilament suture may be utilized as well.

1. Simple interrupted sutures are placed parallel to the incision line, forming the anchoring framework: the needle is inserted perpendicular to the epidermis, approximately 8 mm distant from the wound edge.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, running parallel to the incision line.

3. The suture material is then tied off loosely, leaving a gap between the suture material and the skin.

4. Steps (1) through (3) are then repeated on the contralateral wound edge, forming the contralateral anchoring framework.

5. A simple interrupted suture is then placed, incorporating the suture material from the anchoring framework. The needle is inserted around the anchoring suture on the far end perpendicular to the epidermis.

6. 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, on the outside of the anchoring framework.

7. 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 5-31A, 5-31B, 5-31C, 5-31D, 5-31E, 5-31F, 5-31G, 5-31H).

This technique was developed for closing wounds with an atrophic dermis or where tissue tear through is a major problem, such as on the lower legs and forearms in patients with extensive actinic damage.

The anchoring sutures are designed to broadly spread the tension across the wound edge, mitigating the risk of tissue tear through and helping to distribute tension evenly across the wound. The physics of this closure have been explored separately.

This technique has also been described incorporating multiple other approaches, such as a crossed lattice stitch, where the suture running across the wound stretches obliquely from one anchoring suture to the next; the double lattice suture, where two sutures are placed across each set of anchoring sutures; and the stacked (near-far) lattice stitch, where adjacent anchor sutures are placed at variable distances from the wound edge with some overlap.

The greatest drawbacks of this approach are time, suture material use, and the risk of oversewing and subsequent tissue necrosis, particularly with multiple closely spaced anchoring sutures. Since each suture crossing the incision requires two anchoring sutures, this technique may take significantly longer to execute than other approaches. Moreover, the excess suture material that needs to be used to incorporate this approach means that on longer closures additional packages of suture material may be needed.

Finally, placing multiple anchoring sutures parallel to the incision line may lead to impaired vascularization and an increased risk of wound-edge necrosis, since a significant proportion of the skin surrounding the wound is encompassed by suture material that has the potential to constrict the underlying vessels.

With any suturing technique, knowledge of the relevant anatomy is critical. When placing these sutures it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material.

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. Some studies have also demonstrated an increased rate of dehiscence when utilizing interrupted sutures alone without underlying dermal tension-relieving sutures, highlighting that this technique should be used either for wounds under minimal tension or in concert with deeper tension-relieving sutures.