This is a hybrid running everting technique used for closure and epidermal approximation. It incorporates a horizontal mattress component, which encourages wound eversion, and a simple running component, which encourages wound-edge apposition. This technique may also be used in patients with atrophic skin, as the broader anchoring bites of the horizontal mattress component may help limit the tissue tear-through that may be seen with a simple running suture.
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. On the face and eyelids, a 6-0 or 7-0 monofilament suture is useful. Since the goal of this technique is primarily to encourage wound-edge eversion, fine-gauge suture material may be used on the extremities as well, though if the wound is under significant tension or if the simple running component of the technique is being used to approximate wound edges under significant tension, then 5-0 suture material may be used on the extremities and neck, and thicker suture material, including 3-0, may be used on the trunk if the anticipated tension is marked.
The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.
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.
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. Alternatively, the needle may be released from the needle driver and the needle driver itself may be used to grasp the needle from the contralateral side of the wound to complete its rotation through its arc, obviating the need for surgical forceps.
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. The trailing end of suture is trimmed.
Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.
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.
The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.
The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.
The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of step (6).
Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.
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.
The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.
Starting proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge.
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.
The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.
The needle is then reloaded in a backhand fashion and inserted at 90 degrees perpendicular to the epidermis proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.
The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of step (6).
Moving proximally relative to the surgeon, the previously mentioned steps are then sequentially repeated, alternating the placement of a simple running suture with a running horizontal mattress suture, until the end of the wound is reached. At that point, a loop is left in the penultimate throw and 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 5-10A, 5-10B, 5-10C, 5-10D, 5-10E, 5-10F, 5-10G).
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