The vertical mattress suture is unsurpassed in its ability to evert skin wound edges. It is commonly used where wound edges tend to invert—e.g., on posterior neck, behind ear, in groin, in 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 passage of suture loops and provides good tensile strength in closing wound edges over a distance.
The vertical mattress suture can be used as an anchoring 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 inadvisable (e.g., facial skin flaps).
Early removal of vertical mattress sutures is advocated, especially if nearby simple interrupted sutures can remain in place for normal duration.
A major drawback to routine use of vertical mattress sutures on cosmetically important areas is development of crosshatch marks from the suture loops on the skin surface. After placement of a vertical mattress suture, the natural process of wound inflammation and scar retraction pulls externalized loops inward. Resulting pressure necrosis and scarring is worsened if the vertical mattress suture is tied too tightly or if large-caliber suture (3-0 or 4-0 USP) material is used.
Indications⬆⬇
Closure of wounds that tend to invert (e.g., back of neck, groin, inframammary crease, behind ear)
Closure of lax skin (e.g., dorsum of hand, over elbow)
Anchoring stitch when moving skin flap
Contraindications
Procedure⬆⬇
A far-far pass is made with the suture needle entering and exiting anesthetized skin 4–8 mm from wound edge (Fig. 16-1A). The suture needle should pass vertically through the skin surface. The far-far suture must be placed at the same distance and same depth from the wound edge (Fig. 16-1B).
Pitfall: Pass the suture needle symmetrically through the tissue. Asymmetric bites through the wound edge cause 1 edge to be higher than the other. Creation of a shelf, with 1 wound edge higher, produces cosmetically inferior scars that are prominent because they cast a shadow.
Place the needle backward in the needle driver (Fig. 16-2). The near-near pass is made shallow, within 1–2 mm of the wound edge, using a backhand pass. The near-near pass should be within the dermis.
Tie the suture snugly but gently (Fig. 16-3A). Tight sutures produce crosshatch marks (Fig. 16-3B).
Pitfall: Novice physicians often tie the suture tightly to produce additional eversion. Avoid this temptation, because it results in increased wound scarring.
Coding Information⬆
Mattress suture closures are considered a variation of single-layered closure, and codes 12001–12021 apply for wound repair. Chap. 14, Simple, Interrupted Skin Suture Placement lists the codes for simple skin suture placement.