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18-11: Complex Wound Closures

Chan W. Park; Michael L. Juliano; Dana Woodhall

Clinical Summary

Horizontal and vertical mattress sutures, as well as the corner stitch (see figures for technique), may be used to manage wounds unable to be closed with simple techniques.

Management and Disposition

Vertical mattress suture is a useful technique for deep wounds. It reduces wound tension by acting as both a deep and superficial suture. Horizontal mattress suture is best used for wide, gaping wounds with a risk of increased wound tension after closure (eg, lacerations overlying a joint). Corner stitch is used to close triangular wounds or flaps. A simple interrupted suture cannot be placed to approximate the point of the flap due to a tenuous blood supply and increased chance of dehiscence. Once the corner is secured (see figures), simple sutures are used to repair the rest of the wound, with care taken to place the sutures far enough from the tip to optimize circulation.

FIGURE 18.38

Vertical Mattress Suture. The suture is placed by first taking a large deep bite of tissue approximately 1 cm away from the wound edge and exiting at the same location on the other side of the wound. A second small superficial bite is then performed in the reverse direction (A). When the bites are complete (B), tying results in nice apposition of the wound edges (C). This technique is especially useful in areas of lax skin, such as the elbow or dorsum of the hand. (Photo contributor: Michael L. Juliano, MD.)

When using a vertical mattress suture, a deep bite is taken from one edge of the wound, equidistant to the other edge of the wound. When using a vertical mattress suture, a suture knot tied in apposition of the wound edges. Illustrations A to C show the insertion of a vertical mattress suture.
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When using a vertical mattress suture, a deep bite is taken from one edge of the wound, equidistant to the other edge of the wound. When using a vertical mattress suture, a suture knot tied in apposition of the wound edges. Illustrations A to C show the insertion of a vertical mattress suture.
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When using a vertical mattress suture, a deep bite is taken from one edge of the wound, equidistant to the other edge of the wound. When using a vertical mattress suture, a suture knot tied in apposition of the wound edges. Illustrations A to C show the insertion of a vertical mattress suture.
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FIGURE 18.39

Horizontal Mattress Suture. Useful in achieving wound edge eversion, the horizontal mattress suture begins with a standard suture throw. A second bite is taken approximately half a centimeter from the first exit (A) and brought through at the original starting edge, half a centimeter from the original entry point (B and C). (Photo contributor: Michael L. Juliano, MD.)

A horizontal mattress suture is made by inserting the needle into the skin from the edge of the wound. The suture passes through the deep dermis to the suture lines on the opposite side and then exits the skin at the same distance from the edge of the wound. When making a horizontal mattress suture, two open edges of the wound are held together by sutures made horizontally on either side of the wound. Illustrations A to C depict the execution of a vertical mattress suture. In illustration A, a first pass is made through the skin. In illustration B, a second pass is made through the skin. In illustration C, the wound has been closed with a horizontal mattress suture.
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A horizontal mattress suture is made by inserting the needle into the skin from the edge of the wound. The suture passes through the deep dermis to the suture lines on the opposite side and then exits the skin at the same distance from the edge of the wound. When making a horizontal mattress suture, two open edges of the wound are held together by sutures made horizontally on either side of the wound. Illustrations A to C depict the execution of a vertical mattress suture. In illustration A, a first pass is made through the skin. In illustration B, a second pass is made through the skin. In illustration C, the wound has been closed with a horizontal mattress suture.
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A horizontal mattress suture is made by inserting the needle into the skin from the edge of the wound. The suture passes through the deep dermis to the suture lines on the opposite side and then exits the skin at the same distance from the edge of the wound. When making a horizontal mattress suture, two open edges of the wound are held together by sutures made horizontally on either side of the wound. Illustrations A to C depict the execution of a vertical mattress suture. In illustration A, a first pass is made through the skin. In illustration B, a second pass is made through the skin. In illustration C, the wound has been closed with a horizontal mattress suture.
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FIGURE 18.40

Corner Stitch for Stellate Wounds. The corner stitch may also be used to close stellate lacerations.

An illustration shows the insertion of a corner stitch for Y-shaped lacerations with a flap edge. A three-point closure of the acute corners results in approximation of the corners. An illustration shows the insertion of a corner stitch variation employed for a V-shaped lacerations.
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An illustration shows the insertion of a corner stitch for Y-shaped lacerations with a flap edge. A three-point closure of the acute corners results in approximation of the corners. An illustration shows the insertion of a corner stitch variation employed for a V-shaped lacerations.
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Pearls

  1. Utilization of a mattress suture can aid in wound edge eversion and tension reduction. These sutures are particularly useful in areas where the deep subcutaneous tissues are too fragile for deep sutures (eg, over a joint or shin).

  2. A single corner stitch may be used to close several corners of a stellate ...

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