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Video 5-08. Inverting horizontal mattress suture
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This is a niche technique designed to encourage wound-edge inversion and is useful primarily to recreate a natural crease. It may be used to recreate the alar creases as well as to better define the helical rim and may also be useful when recreating the mental crease.

Suture Material Choice

Using the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions is wise. Generally, this suture is used on the face and ears, and therefore, a 6-0 or 7-0 monofilament suture may be best, though fast-absorbing gut may be used to obviate the need for suture removal.


  1. The needle is inserted perpendicular to the epidermis in a direction parallel to the incised wound edge, approximately 5 mm from the wound edge. The needle is rotated, following its curvature, through the dermis, exiting proximal relative to the surgeon but still on the ipsilateral side of the incised wound edge.

  2. The needle is then reloaded in a backhand fashion and inserted on the contralateral side of the incision directly across from its exit point, perpendicular to the epidermis and parallel to the incised wound, now facing in the opposite direction. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the ipsilateral side, across the wound edge from the original insertion point.

  3. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-8A, 5-8B, 5-8C, 5-8D, 5-8E, 5-8F).

Figure 5-8A.

Overview of the inverting horizontal mattress technique.

Figure 5-8B.

The needle is inserted at 90 degrees, on a trajectory parallel to the wound edge.

Figure 5-8C.

The needle exits further along its trajectory along the wound but the same distance from the wound edge.

Figure 5-8D.

The needle is then inserted lateral to the contralateral wound edge, across from its exit point on the other wound edge, again on a trajectory parallel to the incised wound edge.

Figure 5-8E.

The needle then exits further along its trajectory, directly across from its original insertion point.

Figure 5-8F.

Immediate postoperative appearance.

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