Haneke-Marini suture, modified buried vertical mattress suture
Video 4-09. Percutaneous vertical mattress suture
This technique is designed to allow for excellent tension relief while concomitantly permitting easy suture placement in relatively tight spaces. It is best suited to areas with thicker dermis, though it may also be utilized in any body area when tension-relieving sutures must be placed and where insertion of the full needle is challenging.
Some authors have advocated this technique as a replacement for standard buried suture approaches and as an easy to implement alternative to the buried vertical mattress, while others prefer to think of this as a niche approach exclusively for areas where fully buried approaches are more challenging.
Suture choice is dependent in large part on location. Because suture material travels percutaneously, exiting the epidermis and then reentering, the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 absorbable suture material is effective, though theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material, particularly where the material has exited the epidermis entirely. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension, a 5-0 absorbable suture is adequate.
The wound edge is reflected back using surgical forceps or hooks. In areas under marked tension, or where full visualization is not possible, the needle may be blindly inserted from the undermined space without reflecting back the skin.
The suture needle is inserted at a 90-degree angle into the underside of the dermis 4 mm distant from the incised wound edge.
The first bite travels from the underside of the dermis in the undermined space, passes entirely through the dermis, and exits through the epidermis directly above the entry point.
The needle is then reloaded onto the needle driver with a backhanded technique and inserted through the epidermis either directly through the same hole as the suture followed during exit or just medial to it. A shallow bite is taken, and the needle exits on the lateral margin of the incised wound edge.
The needle is then reloaded, again in a backhanded fashion, and is inserted into the contralateral incised wound edge at the same depth as it exited on the first side. The needle again follows a mirror-image superficial course through the dermis, exiting through the epidermis again approximately 4 mm from the wound edge. Alternatively, this step may be combined with the prior step and the needle can be inserted into the contralateral edge while it is still loaded from the initial pass exiting the incised wound edge.