Fully buried horizontal mattress suture

This is a niche technique, useful when closing narrow wounds or those where there is limited space to insert the needle driver, and when placing a buried suture is desirable. It may be employed in a variety of locations, including the scalp, ears, and lower leg, though it has been applied broadly and may be utilized in any number of anatomic locations.

This technique results in adequate wound eversion; depending on how far back the bites are taken and whether the incised wound edge is cut with an inward bevel, it may result in only modest wound-edge approximation.

As always, suture material choice depends on preference and location; while the suture material remains on the undersurface of the dermis, it does traverse the midpapillary dermis, and therefore care should be taken to utilize the smallest caliber of suture that provides adequate tensile strength. Similarly, the knot remains relatively superficial at the level of the reticular dermis, confirming the need to utilize the finest suture available.

This approach should only rarely be used in areas with a thick dermis and under marked tension, such as the chest and back. On the extremities, a 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate. A 3-0 caliber suture may be used on areas such as the lower legs if needed, though this should be utilized with caution as the larger caliber suture material has more of a tendency to spit or result in foreign body reactions.

1. 
   

   The wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is desirable.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted into the undersurface of the dermis parallel to the incision line just lateral to the incised wound edge.

   
   
3. 
   

   The first bite is executed by placing gentle pressure on the needle so that it enters the papillary dermis and then relaxing pressure to permit the needle to exit on the undersurface of the dermis.

   
   
4. 
   

   Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then reflected back in a similar fashion as on the first side.

   
   
5. 
   

   The second and final bite is executed by inserting the needle into the undersurface of the dermis on the contralateral side, with a backhand technique if desired, and completing a mirror-image loop, so that the needle exits directly across from its original entry point on the contralateral side.

   
   
6. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-4A, 4-4B, 4-4C, 4-4D, 4-4E, 4-4F).