Chapter 5.7: The Inverting Horizontal Mattress Suture

This is a niche technique designed to encourage wound-edge inversion, and is useful primarily to recreate a natural crease. It may be used to recreate the alar creases as well as to better define the helical rim, and may also be useful when recreating the mental crease.

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. Generally, this suture is used on the face and ears, and therefore a 6-0 or 7-0 monofilament suture may be best, though fast-absorbing gut may be used to obviate the need for suture removal.

1. The needle is inserted perpendicular to the epidermis in a direction parallel to the incised wound edge, approximately 5 mm from the wound edge. The needle is rotated, following its curvature, through the dermis, exiting proximal relative to the surgeon but still on the ipsilateral side of the incised wound edge.

2. The needle is then reloaded in a backhand fashion, and inserted on the contralateral side of the incision directly across from its exit point, perpendicular to the epidermis and parallel to the incised wound, now facing in the opposite direction. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the ipsilateral side, across the wound edge from the original insertion point.

3. 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 5-7A, 5-7B, 5-7C, 5-7D, 5-7E, 5-7F).

This approach is very useful when attempting to recreate a natural crease, especially since traditional everting sutures have a tendency to blunt natural creases. Since the eye is naturally drawn to skin folds and creases, this small change may have a dramatic effect on the ultimate outcome of the repair.

Unlike the traditional horizontal mattress, this technique does not result in significant compression of the underlying vascular plexus, and in fact it results in only modest tension across the wound surface.

A gap remains between the suture material and the incised wound edge, since the inversion of the wound edges causes them to be depressed relative to the surrounding skin. Therefore, track marks are unlikely with this technique.

It is helpful to take the bites of the inverting horizontal mattress suture approximately 5-mm lateral to the incised wound edge, as this leads to a relative lift on the skin lateral to the wound edge, helping to accentuate the desired wound inversion.

This technique may lead to dramatic wound inversion, and therefore should only be used when the goal is recreating a natural crease. Moreover, since wound inversion may be associated with inferior cosmesis over the long term, the benefit of accentuated inversion should be weighed against the possibility that the long-term cosmetic outcome of the suture scar may be less than ideal. The over-inversion of the wound edges caused by the suturing technique relaxes somewhat after suture removal, allowing the wound edges to meet and heal.

This technique also does not lead to dramatic wound-edge apposition, which is again an important consideration when choosing this approach. Therefore, it is best used when the deep sutures have resulted in acceptable wound-edge approximation.