Horizontal Mattress Suture

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Horizontal Mattress Suture

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Introduction

The horizontal mattress suture is an everting suture technique that allows separated wound edges to be approximated. The horizontal mattress suture evenly distributes the closure tension along the wound edge by incorporating a large amount of tissue within the passage of the suture thread. The technique is commonly employed for pulling wound edges over a distance or as the initial suture to anchor two wound edges (e.g., holding a skin flap in place). 
Thin skin tends to tear with placement of simple, interrupted sutures. The horizontal mattress suture is effective in the closure of fragile, elderly skin or the skin of individuals receiving chronic steroid therapy. The horizontal mattress suture technique also is effective in closing defects of thin skin on the eyelid and in the finger and toe web spaces. Control of bleeding is another advantage of this suture. Hemostasis develops when a large amount of tissue is incorporated within the passage of a suture. The technique can produce effective bleeding control on vascular tissues such as the scalp. 
Certain skin defects tend to have skin edges that roll inward. Inversion of the wound edge can retard healing and promote wound complications. The horizontal mattress suture produces strong everting forces on the wound edge and can prevent inversion in susceptible wounds in the intergluteal cleft, groin, or posterior neck. The running horizontal mattress suture is also useful for wounds under moderate tension, especially when a more rapid closure is desired. 
After placement of horizontal mattress sutures, the loops of suture thread that remain above the skin surface can compress the skin and produce pressure necrosis and scarring. This scarring potential limits the use of the horizontal mattress sutures on the face. Pressure injury commonly develops when the sutures are tied too tightly. Bolsters are compressible cushions placed within the extracutaneous loops of suture to prevent pressure injury to the skin. Some of the commonly used materials in bolsters include plastic tubing, cardboard, and gauze. 
Skin compression injury can be reduced by early removal of horizontal mattress sutures. Some authorities recommend removal in 3 to 5 days, with the surrounding interrupted sutures left in place longer. Early suture removal is especially valuable when the horizontal mattress technique is employed in cosmetically important body locations such as the head and neck. 
The half-buried horizontal mattress suture combines elements of the horizontal mattress suture with an intradermal closure. It can be used to approximate the corner of a flap (see Corner Suture) or to close normal suture lines, especially along the edges of a flap. This allows for minimum disruption of blood flow to the edge and tip of the newly created flap. 

Equipment

  • Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.

  • Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.

Indications

  • Closure of thin or atrophic skin (e.g., elderly skin, eyelids, individuals on chronic steroid therapy)

  • Eversion of skin defects prone to inversion (e.g., posterior neck, groin, intergluteal skin defects)

  • Closure of bleeding scalp wounds

  • Closure of web space skin defects (e.g., finger or toe web spaces)

  • Closure of wounds under high tension

Contraindications (Relative)

  • Skin with poor blood flow

  • Severe bleeding disorders

  • Local infection

The Procedure

Horizontal Mattress Suture

Step 1
The suture needle is passed from the right side of the wound to the left side of the wound, in a manner similar to when starting a simple interrupted suture. 
Step 2
The entry and exit sites of the wound generally are 4 to 8 mm from the wound edge. Do not tie the suture! The needle is placed backward in the needle driver, and then the suture is passed back from the left side to the right side. 
  • Pearl: The distance down the suture line for the second pass is about one half to two thirds of the suture width across the wound.

Step 3
The second pass should be a mirror image of the first pass, making sure that the same suture width and depth of penetration is maintained. 
Step 4
The horizontal mattress suture is tied, producing skin edge eversion. Tying the suture tightly produces extra eversion. 
  • PITFALL: Although the added eversion may appear beneficial at the time of wound closure, tight knots often produce skin pressure necrosis. Avoid the temptation to tie the horizontal mattress suture tightly.

Step 5
Bolsters can cushion the skin from the pressure produced by the extracutaneous loops of a horizontal mattress suture. Gauze is used in these bolsters. 
Step 6
Horizontal mattress sutures are often used to close a finger web wound. 

Running Mattress Suture

Step 7
The running mattress suture may be used to quickly close a longer laceration. Start by placing a simple interrupted suture but cutting off only the short tail. 
Step 8
The needle is then placed backward in the needle driver, and the suture is passed back from the left side to the right side as before. 
Step 9
Rather than securing a completed horizontal mattress stitch, the leading end travels laterally again and then reenters the skin to begin the next horizontal mattress in the series. 
Step 10
When the end of the laceration is reached, the last loop of suture is used as the tail to tie off the suture. 
Step 10
Step 10

Complications

  • Bleeding

  • Infection

  • Scar formation

  • Suture marks, especially if left in place for more than 7 days

  • Tissue strangulation and wound edge necrosis if sutures are tied too tightly

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. Sometimes it is necessary to sedate the patient to repair the laceration (see Pediatric Sedation). The maximum recommended dose of lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched after 1 day but not to put the wound into standing water for 2 to 3 days. Have the patient use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. Have them cover the wound with a nonocclusive dressing for 2 to 3 days. A simple adhesive bandage (Band-Aid) will suffice for many small lacerations. The dressing should be left in place for at least 48 hours, after which time most wounds can be opened to air. Scalp wounds can be left open if small, but large head wounds can be wrapped circumferentially with rolled gauze. 
Most uncontaminated wounds do not need to be seen by a provider until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 2 to 3 days. Give discharge instructions to the patient regarding signs of wound infection. 

Coding Information and Supply Sources

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. The mattress suture closures are considered a variation of single-layered closure, and the codes 12001 to 12021 apply for wound repair. 
Add together the lengths of wounds in the same classification and anatomic sites. Use separate codes for repairs from different anatomic sites. Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed. 

Bibliography

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2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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