II. Indications: Wound sites with wound edge inversion risk

  1. Posterior neck
  2. Concave skin surface

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)

V. Technique

  1. Background
    1. Uses Far-far, near-near system
    2. Use non-Absorbable Suture
    3. Four landmark sites (2 on each side of the wound)
      1. Point 1 (Far right side): 4-8 mm from wound edge
      2. Point 2 (Near right side): 1-2 mm from wound edge
      3. Point 3 (Near left side): 1-2 mm from wound edge
      4. Point 4 (Far left side): 4-8 mm from wound edge
    4. Images
      1. sutureVerticalMattressLabel.jpg
  2. Step 1: Far-Far Stitch
    1. Enter wound at Point 1 on far right side of wound
    2. Needle passes deep, below Dermis
    3. Exits at point 2 on far left side of wound
  3. Step 2: Near-Near Stitch
    1. Continue stitch started in Step 1
    2. Enter wound at point 3 on near left side of wound
    3. Exits at point 4 on near right side of wound
  4. Step 3: Tie Suture
    1. Knot is between point 2-3 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 3 and 4
    2. Suture exposed between point 1 and 2

VI. Complications

  1. Suture tied too tightly, excessive pulling
    1. Excessive wound eversion
    2. Wound scarring and railroad track wound appearance
    3. Skin necrosis where Suture exposed over skin
  2. Sutures not placed to consistant depth or distance
    1. See Technique tips below
    2. Results in scar with irregular surface
    3. Irregular surface may be quite evident (esp. face)

VII. Technique tips (avoid complications)

  1. Do not place Sutures too tightly
  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. Place Sutures symmetrically
    1. Point 1-2 are the same distance from wound as 3-4
    2. All Point 1s line up along edge of wound
      1. Similarly, all Point 2s line up, Point 3s ...
    3. Asymmetric Suture placement results in irregular scar
      1. See Complications above

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 [PubMed]

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