How To Repair a Laceration With Vertical Mattress Sutures

• Wounds with edges that are difficult to align or evert. These can include wounds that tend to invert, such as those of concave skin of the groin or posterior neck or loose skin over the dorsum of the elbow or hand.

• Wounds under moderate (but not marked) tension (instead of a layered closure)

Absolute contraindications

• Laceration of the face, palm, or sole, where a blind deep suture is contraindicated

Relative contraindications

• Wounds under marked tension

• Wounds that may be contaminated or relatively old and would be at higher risk of infection if closed by sutures, such as small bites to hands or feet, puncture wounds, or high-velocity missile wounds.

Wounds involving deep structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) may require specialized techniques or referral to a surgical specialist, as should those covering large areas or involving the face or hands.

• Infection

• Scarring, due to unrelieved tension on the laceration

• Cross-hatching (train tracks) due to pressure on the skin surface caused by the wide-deep loop

• Cutting of skin by sutures, particularly by the narrow-shallow loop, particularly if this loop is placed prior to the wide-deep loop

• Ischemia and necrosis, which occur more often than with simple interrupted or continuous sutures

Wound hygiene and closure techniques need not be sterile procedures. Although instruments that touch the wound (eg, forceps, needles, suture) must be sterile, clean nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients. Some operators prefer the better fit and better barrier protection of sterile gloves.

Clean procedure, barrier protection

• Face mask and safety glasses (or a face shield), head caps, gowns, gloves

• Sterile drapes, towels (for wound debridement and suturing)

• Needle driver, toothed forceps, suture material (typically, a nonabsorbable monofilament suture is used; for detailed discussion of the various types and sizes of suture material, see Lacerations)

• Sometimes splinting or other materials (for aftercare, to restrict motion or skin tension that may pull on the sutures)

• Materials used to dress the wound

• Position the patient comfortably reclined or supine.

• Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.

• In general, position yourself so that the laceration is roughly parallel to the front of your body.

• The laceration should be well lit, preferably with an overhead procedure light.

(See How To Cleanse, Irrigate, Debride, and Dress Wounds for step-by-step descriptions of wound preparation, anesthesia, and dressing; see How To Repair a Laceration With Simple Interrupted Sutures for instructions on how to handle the instruments, work with needles, and tie a surgeon's knot using instruments.)

• Cleanse, anesthetize, irrigate, and debride the wound as necessary.

• Place a sterile fenestrated drape over the wound. Place additional drapes nearby as needed to provide a large-enough sterile work area.

• In general, place the first suture in the middle of the wound. Place all subsequent sutures in the middle of each open section, until there are no gaps.

Vertical mattress suture

• The first pass of the needle (wide-deep bite) is placed farther from the wound edges (eg, > 1 cm) and deeper than the bite of a simple interrupted suture.

• Push the needle through both wound edges if this can be done with little resistance. If resistance is significant, or if you are placing a suture across a relatively wide space (as may occur with the first few sutures), pull the needle out through the center of the laceration after it passes through the first wound edge; then reattach it to the needle driver and continue the suture with a second bite, passing it into the opposite side of the wound.

• Reverse the direction of the needle in the needle driver.

• The second pass (narrow-shallow bite) is placed closer to the wound edge and begins on the same side of the laceration as the exit site of the first pass. Use forceps as needed to maintain edge eversion.  In this pass, unlike with simple interrupted sutures, the width of the bite need not be greater at the deepest part of the wound than at the surface.

• Tie the suture closed.

Vertical Mattress Suture

The first pass of the needle is the same as a large simple suture, but instead of tying off, another smaller bite is taken back across the wound to end on the starting side. Both ends are pulled up to closely align (approximate) the wound edges. Points A and B must be at the same depth, as must points C and D; this placement results in correct vertical alignment.

• Dress the wound (see Lacerations and How To Cleanse, Irrigate, Debride, and Dress Wounds).

• Splint joints whose movement will cause wound tension (eg, an elbow splint for a dorsal elbow laceration).

• Instruct the patient to keep the dressing dry and in place and to return in 2 days for a wound check.

• Instruct the patient to return if signs of infection develop (eg, increased pain, swelling, redness, fever, proximally spreading red streaks [infectious lymphangiitis]).

• Instruct the patient when to return for suture removal, which is generally based on the wound site: 3 to 5 days for the face, 6 to 10 days for the scalp and trunk, 10 to 14 days for the arms and legs, and 14 days for wounds overlying joints. Early suture removal risks wound dehiscence; however, to decrease scarring and cross-hatching of facial sutures, half of the suture line (ie, every other suture) may be removed on day 3 and the remainder are removed on day 5.

• During pre-procedure preparation of the wound, diligently inspect the wound to avoid the frequent error of failing to note associated injuries of nearby tissues, foreign bodies, or body cavity penetrations

• Avoid overly tight sutures and use cautery sparingly because both can cause tissue ischemia.

• Some operators prefer to make the narrow-shallow loop first, which saves time by facilitating placement of the wide-deep loop. However, traditional placement of the wide-deep loop first facilitates a more precise placement of the narrow-shallow loop (achieving more even edge alignment) and also prevents tearing of the skin that may occur when pulling up on the narrow loop to start the wide bite.