II. Indications

  1. High tension wound support
    1. Pull wound edges together over significant distance
    2. Holding Suture (anchor wound edges together)
  2. Holds fragile or thin skin together
    1. Using 6-0 Suture at digit web space or Eyelid
  3. Hemostatic effect (e.g. scalp)

III. Contraindications: Relative

  1. Areas at risk for scarring (e.g. face)

IV. Advantages

  1. Optimizes wound edge eversion
  2. Increased closure strength (distributes tension)
  3. Spreads tension along wound edge

V. Technique

  1. Background
    1. Use non-Absorbable Suture
    2. Four landmark sites (2 on each side of the wound)
      1. Points form a rectangle across lesion
      2. Each point is 4-8 mm from wound edge
      3. Two points parallel to lesion on right (east) side
        1. Point 1 at southeast corner of Laceration
        2. Point 4 at northeast corner (2-4 mm north of 1)
      4. Two points parallel to lesion on left (west) side
        1. Point 2 at southwest corner of Laceration
        2. Point 3 at northwest corner (2-4 mm north of 2)
    3. Images
      1. sutureHorizontalMattressLabel.jpg
  2. Step 1: Across Laceration right (east) to left (west)
    1. Enter wound at Point 1 on right side of wound
    2. Needle passes deep, below Dermis
    3. Exits at point 2 on left side of wound
  3. Step 2: Across Laceration left (west) to right (east)
    1. Continue stitch started in Step 1
    2. Enter wound at point 3 on left side of wound
    3. Exits at point 4 on right side of wound
  4. Step 3: Tie Suture
    1. Knot is between point 1-4 on right side of wound
    2. Tie snugly, but avoid tying too tightly
      1. See complications below
  5. Step 4: Final appearance
    1. Suture exposed between point 2 and 3
    2. Suture exposed between point 1 and 4

VI. Complications

  1. Suture tied too tightly, excessive pulling
    1. Excessive wound eversion
    2. Wound scarring
    3. Skin necrosis where Suture strangulates over skin

VII. Technique tips (avoid complications)

  1. Do not place Sutures too tightly (see above)
  2. Choose smaller caliber Suture Material (e.g. 5-0)
  3. Remove Sutures early (by day 4-6 for most wounds)
    1. Leave non-mattress Sutures in to prevent dehiscence
  4. Consider use of bolsters placed under Sutures
    1. Rolled 2x2 Gauze placed under points 2-3 and 1-4
    2. Prevents wound strangulation at these points

VIII. References

  1. Mortiere (1996) Wound Management, p. 50-5
  2. Snell in Pfenninger (1994), Mosby, p. 12-9
  3. Zuber (2002) Am Fam Physician 66(12):2231-6

Images: Related links to external sites (from Google)