Continuous oblique mattress suture

This is a hybrid running everting technique used for closure and epidermal approximation. It incorporates an oblique mattress component, which encourages both wound eversion and wound-edge apposition. This technique may be useful for patients with atrophic skin, as the broader anchoring bites of the oblique mattress technique may help limit the tissue tear-through that may be seen with a simple running suture, while concomitantly providing improved wound-edge eversion.

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. This technique was originally described for the trunk and extremities, where a 2-0 nonabsorbable suture was advocated. Unless there is marked tension across the wound, smaller gauge suture material is preferable. Indeed, since the goal of the continuous oblique mattress suture 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, 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.

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.

   
   
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. 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.

   
   
4. 
   

   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.

   
   
5. 
   

   Starting approximately 2 mm proximal relative to the surgeon, the needle is then reinserted perpendicular to the epidermis, 3 mm from the wound edge on the right side of the wound.

   
   
6. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the contralateral side, again approximately 3 mm set back from the incised wound edge.

   
   
7. 
   

   The needle is then reloaded in a backhand fashion and inserted 3 mm proximal and approximately 6 mm distant from the incised wound edge on the same side of the incision line as the exit point.

   
   
8. 
   

   The needle is rotated through its arc, exiting on the contralateral side of the wound, again approximately 6 mm distant from the incised wound edge.

   
   
9. 
   

   Moving proximally relative to the surgeon, steps (5) through (8) are then sequentially repeated, 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 5-13A, 5-13B, 5-13C, 5-13D, 5-13E, 5-13F).