Vertical Mattress Suture Placement

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

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Introduction

The classic vertical mattress suture (also known as the far-far/near-near suture) is unsurpassed in its ability to evert skin wound edges. It is commonly employed where wound edges tend to invert, such as on the posterior neck, behind the ear, in the groin, in the inframammary crease, or within concave body surfaces. Because lax skin may also invert, the vertical mattress stitch has been advocated for closure on the dorsum of the hand and over the elbow. 
The vertical mattress suture incorporates a large amount of tissue within the passage of the suture loops and provides good tensile strength in closing wound edges over a distance. It is commonly used as the anchoring or tension-reducing stitch when moving a skin flap or at the center of a large wound. The suture also can accomplish deep and superficial closure with a single suture. The vertical mattress suture can provide deeper wound support in situations when buried subcutaneous closure is not advisable (e.g., facial skin flaps). Early removal of vertical mattress sutures is advocated, especially if nearby simple interrupted sutures can remain in place for the normal duration. 
After placement of a vertical mattress suture, the natural process of wound inflammation and scar retraction pulls the externalized loops inward. The potential pressure necrosis and scarring is worsened if the vertical mattress suture is tied too tightly or if a large-caliber suture material is used. 
A variation of the vertical mattress suture, known as the shorthand technique or near-near/far-far technique, has been advocated by some physicians. This variation places the near-near pass of suture first, allowing the clinician to pull up the suture strings to elevate the skin for placement of the far-far loop. The variation is advocated because it can be placed more rapidly than the classic technique. Care must be taken not to tear the skin when lifting the skin after the initial pass. 

Equipment

  • Instruments for simple interrupted skin suture placement are found in Appendix G and can be ordered through local surgical supply houses.

  • Suture materials can be ordered from Ethicon, Somerville, NJ (http://ecatalog. ethicon.com/EC_ECATALOG/ethicon/default.asp).

    A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations appear in Appendix E.

Indications

  • Closure of wounds that tend to invert (e.g., back of the neck, groin, inframammary crease, behind the ear)

  • Closure of lax skin (e.g., dorsum of the hand, over the elbow)

  • Anchoring or tension-reducing stitch when moving a skin flap

Contraindications

  • Skin without enough laxity to close without significant risk of sutures pulling through the skin

  • Closure of defects on breast tissue (use a running intracutaneous suture closure)

  • Presence of cellulitis, bacteremia, or other active infection

  • Uncooperative patient

The Procedure

Classic Vertical Mattress

Step 1
The far-far pass is started with the suture needle entering (and exiting) the anesthetized skin 4 to 8 mm from the wound edge. Pass the suture needle vertically through the skin surface. 
Step 2
Place the far-far suture at the same distance and the same depth from the wound edge on both sides. 
  • PITFALL: Pass the suture needle symmetrically through the tissue. Asymmetric bites through the wound edge can cause one edge to be higher than the other. The creation of a shelf, with one wound edge higher, produces cosmetically inferior scars that are prominent because they cast a shadow.

Step 3
Place the needle backward in the needle driver. Make the shallower near-near pass within 1 to 2 mm of the wound edge, using a backhand pass. The near-near pass should be mostly within the dermis. 
Step 4
Tie the suture snugly but gently. Once the wound closure is started and the tension created by the closure is relieved by the vertical mattress suture, the rest of the closure may be accomplished using additional vertical mattress sutures or simple interrupted sutures. 
  • Pearl: If a lot of tension is created by pulling the wound closed, small cloth bolsters made by rolling up the edge of a sponge may be used under the external loops of the suture to spread out the pressure on the skin surface, thereby decreasing the likelihood of necrosis at these points.

  • PITFALL: Overly tight sutures may produce crosshatch marks.

  • PITFALL: Novice providers often tie the suture tightly to produce additional eversion. Avoid this temptation, because it results in increased wound scarring.

Inverted or Shorthand Vertical Mattress

Step 1
The inverted vertical mattress suture is very similar in placement and function to the classic vertical mattress suture, but the placement order is different. First make the shallow near-near pass within 1 to 2 mm of the wound edge, using a backhand pass and with the needle placed backward in the needle driver. 
Step 2
Then make the far-far pass with the suture needle entering and exiting 4 to 8 mm from the wound edge. Pass the suture needle vertically through the skin. 
Step 3
Tie the suture snugly but gently. Once the wound closure is started and the tension created by the closure is relieved by the vertical mattress suture, the rest of the closure may be accomplished using additional vertical mattress sutures or simple interrupted sutures. 
  • Pearl: If a lot of tension is created by pulling the wound closed, small cloth bolsters made by rolling up the edge of a sponge may be used under the external loops of the suture to spread out the pressure on the skin surface, thereby decreasing the likelihood of necrosis at these points.

  • PITFALL: Tight sutures may produce crosshatch marks.

  • PITFALL: Novice providers often tie the suture tightly to produce additional eversion. Avoid this temptation, because it results in increased wound scarring.

Complications

  • Suture marks (i.e., railroad marks or Frankenstein marks) from the suture loops on the skin surface

  • Sutures pulling through the skin, especially with closures without enough laxity to close without significant tension

  • Bleeding

  • Infection

  • Scar formation

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched in 1 day but not to put the wound into standing water for 3 days. Have the patient dry the area well after washing. Have the patient use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. Consider removing the vertical mattress sutures after about half of the time of the removal of adjacent sutures. 

Coding Information

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160. 
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

Gault DT, Brain A, Sommerlad BC, et al. Loop mattress suture. Br J Surg.  1987;74:820–821. [View Abstract]
Jones JS, Gartner M, Drew G, et al. The shorthand vertical mattress stitch: evaluation of a new suture technique. Am J Emerg Med.  1993;11:483–485. [View Abstract]
Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. Am Fam Physician .  1991;44:1625–1634. [View Abstract]
Snow SN, Goodman MM, Lemke BN. The shorthand vertical mattress stitch—a rapid skin everting suture technique. J Dermatol Surg Oncol.  1989;15:379–381. [View Abstract]
Stasko T. Advanced suturing techniques and layered closures. In: Wheeland RG, ed. Cutaneous Surgery . Philadelphia: WB Saunders;  1994:304–317.
Stegman SJ, Tromovitch TA, Glogau RG. Basics of Dermatologic Surgery . Chicago: Year Book Medical Publishing,  1982.
Swanson NA. Atlas of Cutaneous Surgery . Boston: Little, Brown;  1987:30–35.
Usatine RP, Moy RL, Tobinick EL, et al. Skin Surgery: A Practical Guide . St. Louis: Mosby;  1998.
Zuber TJ. Basic Soft-Tissue Surgery . Kansas City: American Academy of Family Physicians;  1998.
Zuber TJ. The mattress sutures: vertical, horizontal, and corner stitch. Am Fam Physician .  2002;66:2231–2236. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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