Modified subcutaneous buried horizontal mattress suture, four-throw buried horizontal mattress suture
Video 4-23. Modified buried horizontal mattress suture
This is a niche technique, useful occasionally when closing wounds under significant tension. It may be employed in a variety of locations, including the scalp, trunk, and lower leg. It requires four separate throws but leads to only a minimal pulley effect, reducing its usefulness in many situations. It was originally described when used in concert with a reverse beveled excision, as with a butterfly suture approach.
As always, suture material choice depends on preference and location; while the suture material remains on the undersurface of the dermis, it does traverse the midpapillary dermis, and therefore, care should be taken to utilize the smallest caliber of suture that provides adequate tensile strength. Similarly, the knot remains relatively superficial at the level of the reticular dermis, particularly when performing this technique as described in the literature, suggesting the need to utilize the finest suture available.
On the extremities, a 4-0 absorbable suture material may be used, and on the face and areas under minimal tension, a 5-0 absorbable suture is adequate, though this technique would rarely be used. Using this technique, a 3-0 absorbable suture works well on the back, though when the area is under marked tension, a 2-0 suture may be needed as well.
The wound edge is reflected back using surgical forceps or hooks. The needle enters along the underside of the dermis adjacent to the incised wound edge, exiting set back at the undersurface of the undermined wound.
The needle is then reloaded, the skin is reflected back, and the needle is inserted through the undersurface of the undermined dermis adjacent to its exit point, exiting at the underside of the dermis adjacent to the wound.
The needle is reloaded and enters the dermal-epidermal junction directly across from its exit point, and a bite is taken following the curvature of the needle and exiting at the undersurface of the undermined dermis.
The needle is then reloaded, and the final bite is taken by entering at the undermined undersurface of the dermis and exiting in the underside of the dermis adjacent to the incised wound edge.
The suture material is then tied utilizing an instrument tie (Figures 4-23A, 4-23B, 4-23C, 4-23D, 4-23E, 4-23F, 4-23G, 4-23H, 4-23I, 4-23J, 4-23K).
Overview of the modified buried horizontal mattress suture.
The wound edge is reflected back using surgical forceps or hooks. The needle enters along the underside of the incised ...