Vertical mattress tip stitch

This technique is designed to bring three ends of tissue together, and is used in the context of a flap or M-plasty, where it permits the tip of tissue to be inset. This approach may be conceptualized as a hybrid mattress suture that encompasses the dermis of the tip of suture in its near-near step. Since it is used only when attempting to approximate three segments of skin, it is a niche technique.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the face, where this technique may be used for flap repairs, a 6-0 or 7-0 monofilament nonabsorbable suture is appropriate. On the trunk, extremities, and scalp, a 3-0 or 4-0 nonabsorbable suture material may be used. Fast-absorbing gut may also be used, obviating the need for suture removal but increasing the risk of tissue reactivity.

1. 
   

   The flap is brought into place using buried sutures, allowing the tip to rest with only minimal tension in or close to its desired position.

   
   
2. 
   

   Starting approximately 4 mm distal from the point where the flap tip will be inset, the needle is inserted perpendicular to the epidermis, approximately 6 mm distant to the wound edge.

   
   
3. 
   

   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.

   
   
4. 
   

   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.

   
   
5. 
   

   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, distal from the exit point relative to the surgeon so that it is approximately 2 mm proximal to the flap tip.

   
   
6. 
   

   The needle is rotated superficially through its arc, exiting in the undermined space.

   
   
7. 
   

   The needle is then reloaded, again in a backhand fashion, and a modest bite of the dermis in the flap tip is taken. The needle moves parallel to the skin surface and does not penetrate the epidermis of the tip.

   
   
8. 
   

   The needle is then again reloaded in a backhand fashion and is inserted into the superficial dermis on the contralateral side, exiting through the epidermis similarly to steps (5) and (6).

   
   
9. 
   

   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. Care should be taken to minimize tension on this suture to mitigate the risk of flap tip necrosis (Figures 5-24A, 5-24B, 5-24C, 5-24D, 5-24E, 5-24F, 5-24G).