The ratio of horizontal mattress to simple running throws can be greater than 1 to 1; many surgeons favor a ratio of 2:1, while the original published description of this approach advocates a ratio of 4:1. On relatively short repairs on the face, a simple running interrupted loop may be placed at the center of the wound.
This approach helps mitigate the problem of challenging suture removal that is associated with the running horizontal mattress approach. The simple running loops are easily accessible at the time of suture removal and may be cut, thus allowing the suture material to be pulled through. An additional benefit is that the intermittent simple running loops help with wound-edge apposition, as the horizontal mattress components tend to evert the edges but do not always bring the wound edges together as elegantly as would otherwise be desired.
This technique is frequently used on the face, as it aids with dramatic wound eversion. Generally, if the dermis was closed using the set-back dermal suture, no additional eversion is needed; however, when the buried dermal suture or even the buried vertical mattress suture, are used, occasionally the wound edges do not evert to the desired degree.
This approach also helps minimize cross-hatched railroad track marks, since most of the suture material does not cross over the incised wound edge. Similarly, this technique can sometimes yield a neater immediate postoperative appearance, as even if bite sizes are not uniform this is not apparent to the observer, as only the portions of suture material parallel to the incision line are visible.
As always, 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.