Half-buried horizontal mattress suture
This technique is designed to bring three ends of tissue together and is often used in the context of a flap, where it permits the tip of tissue to be inset. It is also utilized to repair V-shaped lacerations. This approach may be conceptualized as a half-buried horizontal mattress suture. Since it is used only when attempting to approximate three segments of skin, it is a niche technique.
Suture choice is dependent in large part on location, though as always, the smallest gauge suture material appropriate for the anatomic location should be utilized. On the face, where this technique may be used for flap repairs, a 6-0 or 7-0 monofilament nonabsorbable suture is appropriate. On the trunk, extremities, and scalp, a 3-0 or 4-0 nonabsorbable suture material may be used. Fast-absorbing gut may also be used, obviating the need for suture removal but increasing the risk of tissue reactivity.
The flap is brought into place using buried sutures, allowing the tip to rest with only minimal tension in its desired position.
The needle is inserted into the distal edge of the distal nonflap section of skin at 90 degrees with a trajectory running toward the planned entry point in the tip.
The needle is then grasped with the surgical pickups and simultaneously released by the hand holding the needle driver. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to place the next throw.
The needle is inserted into the distal portion of the tip at the level of the superficial dermis, which should be the same depth at which it exited in the prior step. Keeping the needle running horizontally, parallel with the skin surface, it is rotated through the dermis of the tip, exiting on the proximal side of the tip at the same depth.
The needle is then reloaded in a backhand fashion and inserted into the dermis of the proximal nontip section of skin, exiting parallel to its initial entry point.
The suture material is then gently tied utilizing an instrument tie. Care should be taken to minimize tension on this suture to mitigate the risk of flap tip necrosis (Figures 5-23A, 5-23B, 5-23C, 5-23D, 5-23E, 5-23F, 5-23G).
Overview of the tip stitch.
The needle is inserted through the epidermis at 90 degrees on the nontip skin, exiting the mid-dermis.