This technique does not typically permit the same degree of wound-edge apposition as can be accomplished with other running 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 horizontal mattress suture, and suture material does not cross over the incised wound edge. 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 running horizontal mattress suture, a small simple interrupted suture may be placed intermittently over the horizontal mattress suture to bring the wound edges together more precisely.
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, and the knot may be somewhat buried in the context of a ridged everted repair. Moreover, since this is a running technique it may be difficult to locate a portion of suture easily amenable to cutting at the time of suture removal, as it is best to minimize the length of pulled through suture material at the time of removal.
As with any suturing technique, knowledge of the relevant anatomy is critical. When placing a running horizontal 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.
Similarly, 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 running horizontal mattress suture than with the simple running 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 or utilizing fast-absorbing gut suture material in the event that sutures will not be able to be removed in a timely fashion.