SURGICAL GEM
Running Vertical Mattress Suturing Technique MARK A. STIFF, MD STEPHEN N.SNOW, MD The running vertical mattress suturing technique is a quick and simple method of providing skin edge eversion that is equivalent to the simple vertical mattress technique. The running stitch is relatively easy to master and provides excellent apposition of wound edges. J Dermatol Surg Oncol 1992;18:916-917.
T
he simple vertical mattress suture technique is primarily utilized to provide skin edge eversion; however, a disadvantage of the technique is that it is often time-consuming to perform. Although the shorthand vertical mattress stitch is more efficient, the suture technique still requires individual placement of the sutures.' We have refined a running vertical mattress suture technique that yields all the benefits of a standard vertical mattress suture and is much more time and energy efficient. In this technique the sequence of suture placement is identical to that which is used for the traditional vertical mattress stitch (far-far-near-near). The vertical mattress suture technique may be considered to consist of an outer (far-far) and an inner (near-near) loop. In the traditional vertical mattress suture technique, the inner and outer loops are continuous with each other in the same vertical plane; however, in the running vertical mattress suture, the entrance and exit points of the outer loop are offset from each other, resulting in a Z loop configuration when viewed from above (Figure 1, inset).
Technique The first stitch involves the placement of a simple vertical mattress suture located at the apex of the wound. After trimming of the short suture tail, the needle is then offset slightly and reinserted immediately adjacent to the initial stitch at a medium distance from the wound edge (3 to 4 mm). From here it is passed obliquely at approximately a 30" to 45" angle under the skin to exit at the far end of
From the Mohs Surgery Clinic, Madison, Wisconsin. Address correspondence and reprint requests to: Stephen Snow, MD, Mohs Surgery Clinic, 2880 University Avenue, Madison, WI 53705.
916
the opposing skin (3 to 4 mm). The exact angle is determined by the desired location of the stitch and the size of the needle used by the surgeon. The needle is then reversed in the needle holder and with a backhand motion is superficially reinserted into the near skin edge (1 to 2 mm), and passed through the opposing dermis to exit the near skin edge at an equidistant point. The needle is then again grasped in the forehand position and reinserted at the equidistant far point and passed obliquely underneath the skin, to begin the next running vertical mattress. The overall suture pattern created is a Z or semispiral configuration, with the horizontal legs representing the vertical component of the mattress and the oblique legs representing the connecting suture between them. To complete the suture line, the needle is passed far-far to exit immediately adjacent to the loop of the last stitch. After tying to this loop, the remaining suture remnants are trimmed. Suture removal is accomplished by snipping the exposed suture limb of every other stitch and removing the intervening suture section (Figures 1 to 4).
Discussion Before attempting to master the running vertical mattress suture technique, one should first master the simple vertical mattress suture. The outer loop is the most difficult to place, because the entire length of the needle is needed to traverse the oblique distance between the entry and exit sites of the needle. Correct placement of the far-far loop is important because it affects the wound closure vector forces that cause wound edge eversion. Our experience has shown that the placement of the far-far loop is most easily performed when sewing toward oneself in a forehand motion. Subsequently, the near-near loop is then placed in a slightly awkward backhand manner; however, this sequence can be readily mastered and is preferable to the alternative placement of the far-far loop with the backhand maneuver, which provides less direct control of the critical outside loop. Another point to keep in mind is that any buried dermal-subcutaneous sutures should not be placed too superficially or closely to each other that they interfere with the correct alignment of the inner loop of the running vertical mattress suture. We have found the running vertical mattress suture 0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00
J Dermatol Surg Oncol 2992;28:926-927
Figure 1. Schematic diagram showing the overall pattern of the running vertical mattress suture technique. Inset) Z-like configurationof running vertical mattress suture technique viewed from above.
STIFF AND SNOW RUNNING VERTICAL MATTRESS TECHNIQUE
917
Figure 3. Placement of near-near loop.
Figure 2. Placement of far-far loop, obliquely angled under the skin to exit the opposing skin 3 to 4 mm from the wound edge.
Figure 4. The final appearance of the everted wound closure using the running vertical mattress suture technique.
technique to be a useful technique for providing optimum skin edge eversion. Compared with a simple running suture, this technique requires a little more time to perform; however, when skin eversion is critical for an excellent cosmetic result, it is a very worthwhile procedure. It is also approximately 25% to 5090 faster and more efficient than the placement of interrupted vertical mattress sutures. As with any vertical mattress suture, one must keep in mind that suture tracking can occur if the stitches are left in place too long or under excessive tension, or both. Sutures removed within 7 days produce almost no permanent scar.2 Furthermore, as with any continuous suture line, if a knot slips or a stitch breaks, the entire
suture line is in jeopardy of disruption. For this and the aforementioned reasons, this type of suture should not be the sole means used to close a wound under excessive tension.
References 1. Snow SN, Goodman MM, Lemke BN. The shorthand vertical mattress stitch-a rapid skin everting suture technique. J Dermatol Surg Oncol 1989;15:379-81.
2. Grabb WC, Smith JW, eds. Plastic Surgery, 3rd ed. Boston: Little Brown, 1979:lZ.
Running Vertical Mattress Suturing Technique MARK A. STIFF, MD STEPHEN N.SNOW, MD The running vertical mattress suturing technique is a quick and simple method of providing skin edge eversion that is equivalent to the simple vertical mattress technique. The running stitch is relatively easy to master and provides excellent apposition of wound edges. J Dermatol Surg Oncol 1992;18:916-917.
T
he simple vertical mattress suture technique is primarily utilized to provide skin edge eversion; however, a disadvantage of the technique is that it is often time-consuming to perform. Although the shorthand vertical mattress stitch is more efficient, the suture technique still requires individual placement of the sutures.' We have refined a running vertical mattress suture technique that yields all the benefits of a standard vertical mattress suture and is much more time and energy efficient. In this technique the sequence of suture placement is identical to that which is used for the traditional vertical mattress stitch (far-far-near-near). The vertical mattress suture technique may be considered to consist of an outer (far-far) and an inner (near-near) loop. In the traditional vertical mattress suture technique, the inner and outer loops are continuous with each other in the same vertical plane; however, in the running vertical mattress suture, the entrance and exit points of the outer loop are offset from each other, resulting in a Z loop configuration when viewed from above (Figure 1, inset).
Technique The first stitch involves the placement of a simple vertical mattress suture located at the apex of the wound. After trimming of the short suture tail, the needle is then offset slightly and reinserted immediately adjacent to the initial stitch at a medium distance from the wound edge (3 to 4 mm). From here it is passed obliquely at approximately a 30" to 45" angle under the skin to exit at the far end of
From the Mohs Surgery Clinic, Madison, Wisconsin. Address correspondence and reprint requests to: Stephen Snow, MD, Mohs Surgery Clinic, 2880 University Avenue, Madison, WI 53705.
916
the opposing skin (3 to 4 mm). The exact angle is determined by the desired location of the stitch and the size of the needle used by the surgeon. The needle is then reversed in the needle holder and with a backhand motion is superficially reinserted into the near skin edge (1 to 2 mm), and passed through the opposing dermis to exit the near skin edge at an equidistant point. The needle is then again grasped in the forehand position and reinserted at the equidistant far point and passed obliquely underneath the skin, to begin the next running vertical mattress. The overall suture pattern created is a Z or semispiral configuration, with the horizontal legs representing the vertical component of the mattress and the oblique legs representing the connecting suture between them. To complete the suture line, the needle is passed far-far to exit immediately adjacent to the loop of the last stitch. After tying to this loop, the remaining suture remnants are trimmed. Suture removal is accomplished by snipping the exposed suture limb of every other stitch and removing the intervening suture section (Figures 1 to 4).
Discussion Before attempting to master the running vertical mattress suture technique, one should first master the simple vertical mattress suture. The outer loop is the most difficult to place, because the entire length of the needle is needed to traverse the oblique distance between the entry and exit sites of the needle. Correct placement of the far-far loop is important because it affects the wound closure vector forces that cause wound edge eversion. Our experience has shown that the placement of the far-far loop is most easily performed when sewing toward oneself in a forehand motion. Subsequently, the near-near loop is then placed in a slightly awkward backhand manner; however, this sequence can be readily mastered and is preferable to the alternative placement of the far-far loop with the backhand maneuver, which provides less direct control of the critical outside loop. Another point to keep in mind is that any buried dermal-subcutaneous sutures should not be placed too superficially or closely to each other that they interfere with the correct alignment of the inner loop of the running vertical mattress suture. We have found the running vertical mattress suture 0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00
J Dermatol Surg Oncol 2992;28:926-927
Figure 1. Schematic diagram showing the overall pattern of the running vertical mattress suture technique. Inset) Z-like configurationof running vertical mattress suture technique viewed from above.
STIFF AND SNOW RUNNING VERTICAL MATTRESS TECHNIQUE
917
Figure 3. Placement of near-near loop.
Figure 2. Placement of far-far loop, obliquely angled under the skin to exit the opposing skin 3 to 4 mm from the wound edge.
Figure 4. The final appearance of the everted wound closure using the running vertical mattress suture technique.
technique to be a useful technique for providing optimum skin edge eversion. Compared with a simple running suture, this technique requires a little more time to perform; however, when skin eversion is critical for an excellent cosmetic result, it is a very worthwhile procedure. It is also approximately 25% to 5090 faster and more efficient than the placement of interrupted vertical mattress sutures. As with any vertical mattress suture, one must keep in mind that suture tracking can occur if the stitches are left in place too long or under excessive tension, or both. Sutures removed within 7 days produce almost no permanent scar.2 Furthermore, as with any continuous suture line, if a knot slips or a stitch breaks, the entire
suture line is in jeopardy of disruption. For this and the aforementioned reasons, this type of suture should not be the sole means used to close a wound under excessive tension.
References 1. Snow SN, Goodman MM, Lemke BN. The shorthand vertical mattress stitch-a rapid skin everting suture technique. J Dermatol Surg Oncol 1989;15:379-81.
2. Grabb WC, Smith JW, eds. Plastic Surgery, 3rd ed. Boston: Little Brown, 1979:lZ.
