This is a niche everting technique used for closure and epidermal approximation. It represents a cross between the vertical mattress and horizontal mattress techniques. As with many interrupted techniques, it may be used alone for wounds under minimal tension, such as those formed by either a small punch biopsy or a traumatic laceration.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Suture choice will depend largely on anatomic location and the goal of suture placement.

On the face, a 6-0 or 7-0 monofilament suture is used, though fast-absorbing gut may be used on the eyelids and ears to obviate the need for suture removal. When the goal of the hybrid mattress suture placement is solely to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well. Otherwise, 5-0 monofilament suture material is used if there is minimal tension, and 4-0 monofilament suture is useful in areas under moderate tension where the goal of suture placement is relieving tension as well as epidermal approximation. Occasionally, 3-0 monofilament suture may be utilized as well.

1. 
   

   The needle is inserted perpendicular to the epidermis, approximately 6 mm distant to the wound edge.

   
   
2. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side. If the needle radius is too small to complete this arc in one movement, this first step may be divided into two, with the needle first exiting between the incised wound edges and then reloaded and reinserted to exit on the contralateral side.

   
   
3. 
   

   The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps. It is gently grasped and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

   
   
4. 
   

   The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis approximately 3 mm from the wound edge on the same side of the incision line as the exit point, proximal from the exit point relative to the surgeon.

   
   
5. 
   

   The needle is rotated through its arc, exiting on the contralateral side of the wound 3 mm from the incised wound edge.

   
   
6. 
   

   The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-21A, 5-21B, 5-21C, 5-21D, 5-21E).