Suture Techniques: Simple Interrupted, Horizontal Mattress & Vertical Mattress

1. Simple Interrupted Suture

Technique

When to Use

• Most common general-purpose closure - the default skin suture
• Precise edge alignment in areas of moderate tension
• When partial suture removal over time is anticipated (alternating sutures can be removed early while leaving others for support)
• Wounds where edema or impaired healing is a concern (less vascular compromise than running sutures)
• Can be used as buried (deep dermal, absorbable) or epidermal (non-absorbable) sutures

Preferred Suture Materials

• Fitzpatrick's Dermatology, p. 3747
• Pye's Surgical Handicraft, p. 3143

2. Horizontal Mattress Suture

Technique

1. Place the first pass just like a simple interrupted suture (through both wound edges)
2. Instead of tying, reinsert the needle ~5 mm along the wound (horizontal/parallel to the wound edge) from the exit point
3. Pass back through both sides of the wound parallel to the first pass, at the same distance from the wound edge
4. Tie the two free ends together, everting the edges

Horizontal mattress suture - Fitzpatrick's Dermatology

When to Use / Preferred Situations

• High-tension wounds where simple sutures would cut through or tissue would pull apart (e.g., back, shoulder, scalp with little subcutaneous tissue)
• Wounds where strong eversion is needed but subcutaneous tissue is sparse
• Hemostasis in highly vascular wounds (the horizontal loop compresses vessels)
• As temporary bridging sutures in high-tension closures - placed first to approximate edges, allowing buried sutures to be placed more easily, then removed
• Half-buried variant (Gillies corner stitch / 3-point stitch): ideal for suturing the tip/apex of V-shaped flaps (M-plasty, V-Y plasty, rotation flaps) - minimizes flap tip necrosis by avoiding trauma to the dermal vascular plexus
• Can use bolsters (pledgets) under the knot to spread tension and prevent tissue necrosis

Preferred Suture Materials

• Non-absorbable monofilament: Nylon (Ethilon) or Polypropylene (Prolene) 2-0 to 4-0 depending on site and tension
• Must be removed within 1-2 weeks (site-dependent) to avoid suture track scarring and tissue necrosis
• Bolsters or cotton pledgets may be used to protect skin under the knot

Caution: Not recommended on the face. The horizontal and vertical mattress stitches cause more ischemia inside their loops than simple sutures. Alternating the side of the wound on which the knot is tied can reduce wound tension.

• Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 800
• Fitzpatrick's Dermatology, p. 3747

3. Vertical Mattress Suture (Donati Stitch / Far-Near-Near-Far)

Technique

1. Outer (far) pass first: Enter skin far from the wound edge (8-10 mm), pass deep across the wound, exit far on the opposite side - like an exaggerated simple suture
2. Inner (near) pass back: Reverse direction, reinsert the needle very close to the wound edge on the same side as the exit, pass more superficially (just dermis), exit close to the wound edge on the first side
3. Two ends are now on the same side - tie with an instrument tie while everting edges
4. Leave ~2 cm of short end outside skin before tying

Vertical mattress suture steps - Fitzpatrick's Dermatology

When to Use / Preferred Situations

• When maximum wound eversion is needed (the deep far pass everts + closes dead space; the superficial near pass precisely aligns the epidermal edges)
• Combines function of a buried deep suture + epidermal suture in one stitch - useful when layered closure is not possible
• Wounds with significant dead space beneath the skin
• High-tension wounds on the trunk, back, extremities
• When tissue has a strong tendency to invert (wound edges that keep rolling inward)
• Useful when you cannot place buried sutures (infected wound, limited access)

Preferred Suture Materials

• Non-absorbable monofilament: Nylon (Ethilon) or Polypropylene (Prolene) 2-0 to 4-0 for body; 4-0 to 5-0 for less-tension sites
• Must be removed within 1-2 weeks - high risk of paired suture track scars ("railroad tracks") if left too long, especially since this is a high-tension suture that can embed into skin
• Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 799-800
• Fitzpatrick's Dermatology, p. 3748
• Pye's Surgical Handicraft, p. 3145

Side-by-Side Comparison Table

Recommended Video Links for Seminar Presentation

• Simple Interrupted Suture (CSL - HD) - focused technical execution
• Simple Interrupted + Instrument Tie (CHOP) - great for showing the knot technique

• Horizontal Mattress Suture (CSL) - general info + technique demonstration

• Vertical Mattress Stitch (CSL) - focused technical execution
• Interrupted Vertical Mattress (A.S.A. Series) - includes measurements (8-10 mm bite)