The horizontal mattress suture is an everting suture technique that allows for separated wound edges to be approximated. Horizontal mattress suture spreads closure tension along the wound edge by incorporating a large amount of tissue within the passage of the suture thread. The technique is commonly used for pulling wound edges over a distance or as initial suture to anchor 2 wound edges (e.g., holding skin flap in place).
Thin skin tends to tear with placement of simple, interrupted sutures. The horizontal mattress suture is effective in closure of fragile, elderly skin or skin of individuals receiving chronic steroid therapy. Horizontal mattress suture technique also is effective in closing defects of thin skin on eyelids and 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 passage of the suture. The technique can produce effective bleeding control on vascular tissues—e.g., scalp.
Loops of suture thread that remain above the skin surface can compress skin and produce pressure necrosis and scarring. This limits use of the horizontal mattress sutures on the face.
Pressure injury commonly develops when sutures are tied too tightly. Bolsters are compressible cushions placed within extracutaneous loops of suture to prevent pressure injury to skin. Some commonly used materials in bolsters include plastic tubing, cardboard, and gauze. Skin compression injury can be reduced by early removal of horizontal mattress sutures (3–5 days), with surrounding interrupted sutures left in place longer.
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)
Contraindications
Procedure⬆⬇
Suture needle is passed from right side of wound to left side of wound (Fig. 17-1A). Entry and exit sites of wound generally are 4–8 mm from the wound edge. Do not tie suture!
The needle is placed backward in the needle driver (Fig. 17-1B), and then the suture is passed back from left side to right side (Fig. 17-1C). The second pass of the suture is 4–8 mm down the wound edge (Fig. 17-1D).
The horizontal mattress suture is tied, producing skin edge eversion (Fig. 17-2A). Tying the suture tightly produces extra eversion (Fig. 17-2B).
Pitfall: Although added eversion may appear beneficial at the time of wound closure, tight knots often produce skin pressure necrosis. Avoid the temptation to tie a horizontal mattress suture tightly.
Multiple horizontal mattress sutures are used to close a finger web wound (Fig. 17-3A and Fig. 17-3B).
This wound in groin is prone to inversion (Fig. 17-4A). Horizontal mattress suture can effectively evert edges (Fig. 17-4B).
Coding Information⬆
Mattress suture closures are considered variation of single-layered closure, and codes 12001–12021 apply for wound repair. Chap. 14, Simple, Interrupted Skin Suture Placement provides a list of these codes.