Video 5-32. Combined horizontal mattress and simple interrupted suture
This is an everting technique used for closure and epidermal approximation and is a variation on the horizontal mattress technique. As with many interrupted techniques, it may be used alone for wounds under minimal tension, such as those formed by either a small punch biopsy or a traumatic laceration, or as a secondary layer. Like other mattress sutures, this technique may also be used in the context of atrophic skin, as the broader anchoring bites may help limit tissue tear-through that may be seen with a simple interrupted suture.
With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Suture choice will depend largely on anatomic location and the goal of suture placement.
A 5-0 monofilament suture material is appropriate if there is minimal tension across the wound, while 4-0 monofilament suture is used in areas under moderate tension where the goal of suture placement is relieving tension as well as epidermal approximation. In select high-tension areas, 3-0 monofilament suture may be utilized as well. Though rarely used in these locations, on the face and eyelids, a 6-0 or 7-0 monofilament suture is appropriate, though fast-absorbing gut may be used on the eyelids and ears to obviate the need for suture removal.
The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.
With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.
The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps. It is gently grasped and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.
The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.
The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of steps (2) and (3).
The needle is then reloaded in standard fashion and inserted ...