This is a hybrid running everting technique used for closure and epidermal approximation. Like any running technique, it may be used alone for wounds under minimal tension, such as wounds on the genitalia or traumatic lacerations. It is most frequently used as a secondary layer to aid in everting the wound edges when the dermis has been closed using a deep suturing technique, where the vertical mattress component helps with eversion and the simple running component aids with wound-edge approximation.
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 maybe 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 running alternating simple and vertical 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. In select high-tension areas, 3-0 monofilament suture may be utilized as well.
A simple interrupted anchoring suture is placed as follows:
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 loose end of the suture material is then trimmed.
The needle is reinserted perpendicular to the epidermis, approximately 6 mm distant from the wound edge, just proximal relative to the surgeon from its exit point.
With a fluid motion of the wrist, the needle is rotated through the dermis at a 45-degree angle toward the surgeon (and away from the prior stitch), and the needle tip exits the skin on the contralateral side, equidistant from the incised wound edge and proximal, relative to the surgeon, from its entry point.
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.
The needle is rotated superficially through its arc, exiting on the contralateral side of the wound 3 mm from the incised wound edge.
The needle is then reloaded in a standard fashion and reinserted on the ipsilateral side of the wound edge but now approximately 6 mm from the incised wound edge, yet still in line with its exit point.
The needle is then reinserted as in step (1), now just proximal (relative to the surgeon) and lateral (relative to the incised wound edge) to its exit point. This new entry point is therefore in line with the first entry point.
The needle is again passed at a 45-degree angle toward the surgeon (and away from the prior stitch), and the needle tip exits the skin on the contralateral side, equidistant from the incised wound edge and proximal, relative to the surgeon, from its entry point.
The needle is then inserted on the contralateral side of the incised wound edge, equidistant from the incised edge and further proximal relative to the surgeon.
Steps (7) through (14) are then repeated sequentially, until the end of the wound is reached.
Once the end of the wound is reached, the suture material is gently tied off (Figures 5-20A, 5-20B, 5-20C, 5-20D, 5-20E, 5-20F, 5-20G, 5-20H, 5-20I).
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