Atlas Các Kỹ Thuật Khâu Vết Thương Và Tạo Hình Thẩm Mỹ (Atlas of Suturing Techniques)

235
5-0 mono ilament suture material is
used i there is minimal tension, and
4-0 mono lament suture is use ul in areas
under moderate tension where the goal
o suture placement is relieving tension
as well as epidermal approximation. In
select high-tension areas, 3-0 mono la-
ment suture may be utilized as well.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
6 mm distant to the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep mar-
gin than at the sur ace, and the needle
tip exits the skin on the contralateral
side. I the needle radius is too small
to complete this arc in one move-
ment, this rst step may be divided
into two, with the needle rst exiting
between the incised wound edges
and then reloaded and reinserted to
exit on the contralateral side.
3. The needle body is grasped with
surgical orceps in the le t hand and
pulled upward with the surgical
orceps as the body o the needle
is released rom the needle driver.
Alternatively, the needle may be
released rom the needle driver and
the needle driver itsel may be used
to grasp the needle rom the contra-
lateral side o the wound to complete
its rotation through its arc, obviating
the need or surgical orceps.
The Vertical Mattress Suture
C H A P T E R 5 . 1 6
Synonyms
Donati suture, Allgöwer-Donati Suture
Video 5-16. Vertical mattress
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a requently used everting technique
used or closure and epidermal approxima-
tion. As with many interrupted techniques,
it may be used alone or wounds under
minimal tension, such as those ormed by
either a small punch biopsy or a traumatic
laceration. Like its horizontal counterpart,
it is also requently used as a secondary
layer to aid in everting the wound edges
when the dermis has been closed using a
deep suturing technique.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono la-
ment suture may be used, though ast-
absorbing gut may be used on the eyelids
and ears to obviate the need or suture
removal. When the goal o the vertical
mattress suture placement is solely to
encourage wound-edge eversion, ne-
gauge suture material may be used on
the extremities as w ell. Otherw ise,

236
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
4. The needle is then reloaded in a
backhand ashion and inserted at
90 degrees perpendicular to the epi-
dermis approximately 3 mm rom
the wound edge on the same side
o the incision line as the exit point,
between the exit point and the
incised wound edge.
5. The needle is rotated super cially
through its arc, exiting on the contra-
lateral side o the wound 3 mm rom
the incised wound edge.
Figure 5-16A. Overview o the vertical mattress
suture.
A
Figure 5-16B. The needle is inserted at 90 degrees
to the skin, prior to angling slightly outward a ter it
pierces the epidermis.
B
Figure 5-16C. The needle curves deep under the
wound, exiting on the contralateral side.Note that in
larger wounds, or when working with smaller needles,
the needle may exit through the center o the wound
prior to being reinserted.
C
Figure 5-16D. The needle is then reinserted on the
ipsilateral side, closer to the wound margin, again
entering at 90 degrees to the wound sur ace.
D
Figure 5-16E. The needle ollows a more superfcial
course, exiting on the contralateral side, closer to the
wound margin than the original suture entry point.
E
6. The suture material is then tied o
gently, with care being taken to mini-
mize tension across the epidermis and
avoid overly constricting the wound
edges (Figures 5-16A through 5-16F).

237
The Vertical Mattress Suture
Figure 5-16F. Immediate postoperative appearance.
F
Tips and Pearls
This technique is generally used or its
pronounced e ect on wound eversion.
There ore, while it is appropriate or
most skin closures, it should be avoided
when either inversion is desired or when
exaggerated eversion has already been
accomplished with a buried suture.
As w ith m ost transepiderm al
techniques, it is important to enter the
epidermis at 90 degrees, allowing the
needle to travel slightly laterally away
rom the wound edge be ore ully ol-
lowing the curvature o the needle when
utilizing this technique. This will allow
or maximal wound eversion and accurate
wound-edge approximation.
As with the simple interrupted suture,
care should be taken to avoid skimming
the needle super cially beneath the epi-
dermis. This results rom ailing to enter
the skin at a perpendicular angle and to
ollow the curvature o the needle.This
may result in wound inversion as the
tension vector o the shallow bite pulls
the wound edges outward and down.
An advantage o this approach is that
no suture material traverses the incised
wound edge and that the suture similarly
does not cross the sur ace o the wound.
While this may be less than desirable
when attempting to ne-tune epidermal
apposition, it is help ul in minimizing the
risk o unsightly track marks.
This technique is sometimes re erred
to as a ar- ar, near-near suture, based on
its entry and exit points; the needle is rst
inserted ar rom the incised wound edge,
and then again exits ar rom the wound
edge on the contralateral side. It is then
reinserted near the wound edge on the
ipsilateral side and exits near the wound
edge on the contralateral side.
Note that the second throw is placed
super cial to the rst, deeper ar- ar
suture, leading to a nested placement o
the suture material. This leads to both
wound eversion as well as wound-edge
approximation.
The Allgöwer technique involves per-
orming a hal -buried vertical mattress
suture: (1) The needle is passed rom the
ar entrance point to the interior o the
wound. (2) A buried vertical mattress bite
is then taken on the contralateral side, by
entering the underside o the dermis and
exiting at the incised wound edge. The
needle then passes back to the original
side, entering near the incised wound
edge so that one-hal o the wound is
closed with a standard vertical mattress
suture and the other is closed with a bur-
ied vertical mattress.
Drawbacks and Cautions
This technique does not typically permit
the same degree o wound-edge apposi-
tion as can be accomplished with other
transepidermal sutures. In the event that
deeper sutures w ere care ully placed,
this may not be a signi cant drawback,
since the w ound edges may be w ell-
aligned rom the placement o these
deeper sutures. I not, or i there is a need
or improved wound-edge apposition
even a ter placing the vertical mattress
suture, additional interrupted sutures
may be help ul.
Suture removal with this technique
may be more involved than with simple

238
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
interrupted sutures, particularly i sutures
are le t in situ or an extended period o
time and some o the suture material has
been overgrown by the healing epidermis.
As with any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing a vertical mattress suture
it is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material, or that constriction may
take place. That said, the vertical orien-
tation o this approach helps minimize
this risk.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
References
Bolster M, Schipper C, Van Sterkenburg S,
Ruettermann M, Reijnen M. Single inter-
rupted sutures compared with Donati sutures
after open carpal tunnel release: a prospec-
tive randomised trial. J Plast Surg Hand Surg.
2013;47(4):289-291.
Dietz UA, Kuhfuss I, Debus ES, Thiede A. Mario
Donati and the vertical mattress suture of the
skin. World J Surg. 2006;30(2):141-148.
Trimbos JB, Mouw R, Ranke G, Trimbos KB,
Zwinderman K. The Donati stitch revisited:
favorable cosmetic results in a randomized
clinical trial. J Surg Res. 2002;107(1):131-134.
Zuber TJ. The mattress sutures: vertical, hori-
zontal, and corner stitch. Am Fam Physician.
2002;66(12):2231-2236.

239
eversion, ne-gauge suture material
may be used on the extremities as well.
Otherw ise, 5-0 mono lament suture
material may be used i there is minimal
tension, and 4-0 mono lament suture is
use ul in areas under moderate tension
where the goal o suture placement is
relieving tension as well as epidermal
approximation. In select high-tension
areas, 3-0 mono lament suture may be
utilized as well.
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately 3 mm
distant rom the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated super cially through
the dermis, and the needle tip exits
the skin on the contralateral side.
3. The needle body is grasped with
surgical orceps in the le t hand and
pulled upward with the surgical
orceps as the body o the needle is
released rom the needle driver.
4. The needle is then reloaded in a
backhand ashion and inserted 6 mm
distant rom the incised wound edge
in line with the exit point on the ipsi-
lateral side.
5. While gently pulling upward on the
suture material in order to closely
approximate the wound edges, the
needle is rotated deep through its
arc, exiting on the contralateral side
o the wound 6 mm rom the incised
wound edge.
The Shorthand Vertical
Mattress Suture
C H A P T E R 5 . 1 7
Synonym
Donati suture
Video 5-17. Shorthand
vertical mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a modi cation o the vertical
mattress suture, a requently used evert-
ing technique used or closure and epi-
dermal approximation. As with many
interrupted techniques, it may be used
alone or wounds under minimal tension,
such as those ormed by either a small
punch biopsy or a traumatic laceration.
Like its horizontal counterpart, it is also
requently used as a secondary layer to
aid in everting the wound edges when
the dermis has been closed using a deep
suturing technique.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono la-
ment suture may be used, though ast-
absorbing gut may be used on the eyelids
and ears to obviate the need or suture
removal. When the goal o the short-
hand vertical mattress suture placement
is solely to encourage w ound-edge

240
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-17C. The suture material is grasped with the
nondominant hand and gently pulled upward, bringing
the wound edges upward, as the needle is reinserted
ar rom the incised wound edge.
6. The suture material is then tied o
gently, with care being taken to mini-
mize tension across the epidermis and
avoid overly constricting the wound
edges (Figures 5-17A through 5-17E).
Figure 5-17A. Overview o the shorthand vertical mat-
tress suture.
A
Figure 5-17B. The needle is inserted near the incision
line perpendicularly through the epidermis and passes
superfcially through the dermis, exiting on the contra-
lateral side near the incision line.
B
C
Figure 5-17D. The needle ollows a course deep
through the dermis, exiting ar rom the wound edge on
the contralateral side.
D
Figure 5-17E. Immediate postoperative appearance
a ter placing a single shorthand vertical mattress
suture.
E

241
The Shorthand Vertical Mattress Suture
Tips and Pearls
This represents a variation o the stan-
dard vertical mattress suture and has
been advocated as a aster placement
approach or what is unctionally the
same technique.
As w ith m ost transepiderm al
techniques, it is important to enter the
epidermis at 90 degrees when utiliz-
ing this technique. This will allow or
maximal wound eversion and accurate
wound-edge approximation.
The shorthand vertical mattress tech-
nique has been termed the near-near,
ar- ar technique, since the suture material
enters near the wound edge and exits near
the wound edge, and then reenters ar
rom the wound edge and nally exits ar
rom the wound edge. This is in contrast
with the standard vertical mattress tech-
nique, which is a ar- ar, near-near tech-
nique, since the rst bite o suture enters
and exits ar rom the incised wound edge
and the second, nested bite o suture,
enters and exits near the wound edge.
Drawbacks and Cautions
As with the simple interrupted suture,
care should be taken to avoid skimming
the needle super icially beneath the
epidermis. This results rom ailing to
enter the skin at a perpendicular angle
and ailing to ollow the curvature o the
needle. This problem may be particularly
pronounced with the shorthand vertical
mattress suture in novice hands, as the
initial, super cially placed throw o suture
material may be placed too super cially,
resulting in suture material tear-through.
Since the second, deeper loop o suture
is placed blindly when using the short-
hand technique, care should be taken
when working in areas with underlying
vessels or nerves which could be pierced
or strangulated by the deeper loop o
suture. This is less o a problem when
using the standard vertical mattress tech-
nique, since the deep loop is placed rst,
permitting ull visualization o the under-
lying structures.
The shorthand vertical mattress tech-
nique does not typically permit the same
degree o wound-edge apposition as can
be accomplished with other transepider-
mal sutures, since the everting e ect o
the suture technique may even be asso-
ciated with a small degree o gaping at
the center o the vertical mattress suture.
As with the standard vertical mattress
suture, suture removal with this tech-
nique may be more involved than with
simple interrupted sutures, particularly
i sutures are le t in situ or an extended
period o time and some o the suture
material has been overgrown by the heal-
ing epidermis.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
References
Jones JS, Gartner M, Drew G, Pack S. The short-
hand vertical mattress stitch: evaluation of
a new suture technique. Am J Emerg Med.
1993;11(5):483-485.
Snow SN, Goodman MM, Lemke BN. The shorthand
vertical mattress stitch—a rapid skin evert-
ing suture technique. J Dermatol Surg Oncol.
1989;15(4):379-381.

242
is solely to encourage w ound-edge
eversion, ne-gauge suture material
may be used on the extremities as well.
Otherw ise, 5-0 mono lament suture
material may be used i there is minimal
tension, and 4-0 mono lament suture is
use ul in areas under moderate tension
where the goal o suture placement is
relieving tension as well as epidermal
approximation. In select high-tension
areas, 3-0 mono lament suture may be
utilized as well.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
6 mm distant rom the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated deep through the der-
mis, and the needle tip exits the skin
on the contralateral side. I the nee-
dle radius is too small to complete
this arc in one movement, this rst
step may be divided into two, with
the needle rst exiting between
the incised wound edges and then
reloaded and reinserted to exit on
the contralateral side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping the
needle tip, which can be easily dulled
by repetitive riction against the sur-
gical orceps. It is gently grasped
and pulled upward with the surgi-
cal orceps as the body o the needle
is released rom the needle driver.
The Locking Vertical
Mattress Suture
C H A P T E R 5 . 1 8
Synonym
Loop mattress suture
Video 5-18. Locking vertical
mattress suture
Access to video can be found via

Application
This technique, also known as the loop
mattress suture, is a locking variation o
the vertical mattress suture that may be
used or closure and epidermal approx-
imation. Unlike the standard vertical
mattress suture, this technique adds a
section o suture crossing over top o
the incised wound edge, which may be
use ul to aid in wound-edge apposition.
As with many interrupted techniques,
it may be used alone or wounds under
modest tension, such as those ormed
by either a small punch biopsy or a trau-
matic laceration.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono la-
ment suture may be used, though ast-
absorbing gut may be used on the eyelids
and ears to obviate the need or suture
removal. When the goal o the lock-
ing vertical mattress suture placement

243
The Locking Vertical Mattress Suture
Alternatively, the needle may be
released rom the needle driver and
the needle driver itsel may be used
to grasp the needle rom the contra-
lateral side o the wound to complete
its rotation through its arc, obviating
the need or surgical orceps.
4. The needle is then reloaded in a
backhand ashion and inserted at
90 degrees perpendicular to the epi-
dermis approximately 3 mm rom
the wound edge on the same side
o the incision line as the exit point.
5. The needle is rotated super cially
through its arc, exiting on the con-
tralateral side o the wound 3 mm
rom the incised wound edge. Suture
material is not pulled tight, however,
and a loop o suture, ormed by the
exit o the suture material laterally
and its reentry medially, is le t in
place.
6. In order to lock the suture over top
o the wound, the needle is passed
through the loop ormed by the exit
and entry o suture material on the
contralateral side.
Figure 5-18A. Overview of the locking vertical
mattress suture.
A
Figure 5-18B. The needle is inserted at 90 degrees to
the skin, and follows the curvature of the needle, exit-
ing at the contralateral side.
B
Figure 5-18C. The needle is then reloaded in a back-
hand fashion and inserted just medial to its exit point.
C
Figure 5-18D. The needle follows a shallow course
and exits on the contralateral side, medial to the origi-
nal insertion point.
D
7. The suture material is then tied o
gently, with care being taken to mini-
mize tension across the epidermis and
avoid overly constricting the wound
edges (Figures 5-18A through 5-18F).

244
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-18E. The needle is then passed through the
loop created by its exit and subsequent reentry on the
contralateral side.
E
Figure 5-18F. Immediate postoperative appearance,
showing the locking portion of the suture traversing the
incised wound edge.
F
Tips and Pearls
This approach may be conceptualized
as a hybrid between a vertical mattress
suture, a simple interrupted suture, and
a pulley suture. Like the vertical mat-
tress suture, this technique leads to pro-
nounced wound-edge eversion. Like the
simple interrupted suture, this approach
a ords excellent wound-edge approxima-
tion. And like the pulley suture, the mul-
tiple loops lead to a reduction in needed
tension across the suture material.
As with most transepidermal techniques,
it is important to enter the epidermis at
90 degrees, ollowing the curvature o the
needle when utilizing this technique. This
will allow or maximal wound eversion
and accurate wound-edge approximation.
As with the simple interrupted suture,
care should be taken to avoid skimming
the needle super cially beneath the epi-
dermis. This results rom ailing to enter
the skin at a perpendicular angle and to
ollow the curvature o the needle. This
may result in wound inversion as the
tension vector o the shallow bite pulls
the wound edges outward and down.
Note that the second throw is placed
super cial to the rst, deeper ar- ar
suture, leading to a nested placement o
the suture material. This leads to both
wound eversion as well as wound-edge
approximation, and the nal loop o
suture material traversing the incised
wound edge permits the wound edges
to be precisely matched.
Be ore orming the nal locking loop, it
is help ul to pull through the bulk o the
suture material, leaving only a modest
tail and a small residual loop. This will
help reduce the risk o the suture material
tangling during pull through.
Drawbacks and Cautions
This technique ideally results in an
everted wound with excellent wound-
edge apposition due to the presence o
the locking loop over the sur ace o the
incised wound edge. In practice, the lock-
ing step may lead to wound-edge inver-
sion, and there ore this approach should
be used selectively.
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing a vertical mattress suture
it is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material, or that constriction may
take place. That said, the vertical orien-
tation o this approach helps minimize
this risk.
This technique may elicit an increased
risk o track marks, necrosis, and other

245
The Locking Vertical Mattress Suture
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
Reference
Gault DT, Brain A, Sommerlad BC, Ferguson DJ. Loop
mattress suture. Br J Surg. 1987;74(9):820-821.

246
mono lament suture is use ul in areas
under moderate tension where the goal
o suture placement is relieving tension
as w ell as epidermal approximation.
Occasionally, 3-0 mono lament suture
may be utilized as well.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
6 mm distant to the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep
margin than at the sur ace, and the
needle tip exits the skin on the con-
tralateral side. I the needle radius
is too small to complete this arc in
one movement, this rst step may
be divided into two, with the nee-
dle rst exiting between the incised
wound edges and then reloaded and
reinserted to exit on the contralateral
side.
3. The needle body is grasped with
surgical orceps in the le t hand,
with care being taken to avoid
grasping the needle tip, which can
be easily dulled by repetitive ric-
tion against the surgical orceps. It
is gently grasped and pulled upward
with the surgical orceps as the
body o the needle is released rom
the needle driver. Alternatively, the
needle may be released rom the
The Running Vertical
Mattress Suture
C H A P T E R 5 . 1 9
Video 5-19. Running vertical
mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a running everting technique used
or closure and epidermal approxima-
tion. Like any running technique, it may
be used alone or wounds under minimal
tension, such as wounds on the geni-
talia or traumatic lacerations. As with
its interrupted counterpart, it is most
requently used as a secondary layer to
aid in everting the wound edges when
the dermis has been closed using a deep
suturing technique.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono la-
ment suture may be used, though ast-
absorbing gut may be used on the eyelids
and ears to obviate the need or suture
removal. When the goal o the running
vertical mattress suture placement is
solely to encourage wound-edge eversion,
ne-gauge suture material may be used
on the extremities as well. Otherwise,
5-0 mono ilament suture material is
used i there is minimal tension, and 4-0

247
The Running Vertical Mattress Suture
needle driver and the needle driver
itsel may be used to grasp the nee-
dle rom the contralateral side o
the wound to complete its rotation
through its arc, obviating the need
or surgical orceps.
4. The needle is then reloaded in a
backhand ashion and inserted at
90 degrees perpendicular to the epi-
dermis approximately 3 mm rom
the wound edge on the same side
o the incision line as the exit point.
5. The needle is rotated super cially
through its arc, exiting on the con-
tralateral side o the wound, 3 mm
rom the incised wound edge.
6. The suture material is then tied o
gently, with care being taken to
minimize tension across the epider-
mis and avoid overly constricting
the wound edges.
7. Only the loose end o suture is
trimmed.
8. The needle is then reinserted as in
step (1), now just proximal (relative
to the surgeon) and lateral (relative
Figure 5-19A. Overview o the running vertical
mattress suture.
A
Figure 5-19B. Starting at the distal wound apex, the
needle is inserted through the skin ar rom the incised
wound edge at 90 degrees, exiting on the contralateral
side ar rom the incised wound edge.
B
Figure 5-19C. The needle is then reloaded in a back-
hand ashion and inserted near to the wound edge,
ollowing a superfcial arc, exiting on the contralateral
side, medial to the original entry point. The suture
material is then tied, orming an anchoring vertical
mattress suture.
C
to the incised wound edge) to its exit
point. This new entry point is there-
ore in line with the rst entry point.
9. Steps (1) through (5) are then repeated
sequentially, and a ter each set o
steps the new entry point—proximal
and lateral to the exit point—permits
a running placement o sutures.
10. Once the end o the wound is reached,
the suture material is gently tied o
(Figures 5-19A through 5-19G).

248
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-19D. The needle is then advanced along the
length o the wound and inserted ar rom the incised
wound edge, again exiting on the contralateral side o
the wound ar rom the incised wound edge.
D
Figure 5-19E. The needle is then reloaded in a back-
hand ashion and inserted near to the incised wound
edge ollowing a shallow course and exiting on the
contralateral side o the wound.
E
Figure 5-19F. The needle is then advanced along the
wound and inserted, again ar rom the incised wound
edge, and the pattern is repeated.
F
Figure 5-19G. Immediate postoperative appearance.
G
Tips and Pearls
This approach permits relatively rapid
placement o an everting layer o suture
material, and was proposed as an even
aster technique or vertical mattress
suture placement than the shorthand
(near-near, ar- ar) technique.
Like the interrupted vertical mattress
technique, this approach should be
avoided when either inversion is desired
or when exaggerated eversion has already
been accomplished with a buried suture.
As with most transepidermal tech-
niques, it is important to enter the epi-
dermis at 90 degrees, allowing the needle
to travel slightly laterally away rom the
wound edge be ore ully ollowing the
curvature o the needle when utilizing
this technique. This will allow or maxi-
mal wound eversion and accurate wound-
edge approximation.
An advantage o this approach is that
no suture material traverses the incised
wound edge and that the suture similarly
does not cross the sur ace o the wound.
While this may be less than desirable
when attempting to ne-tune epidermal
apposition, it is help ul in minimizing the
risk o unsightly track marks.
As with the interrupted vertical mat-
tress approach, the second throw is
placed super cial to the rst, deeper ar-
ar suture, leading to a nested placement

249
The Running Vertical Mattress Suture
o the suture material. This leads to both
wound eversion as well as wound-edge
approximation.
Drawbacks and Cautions
As a running technique, the integrity o
the entire suture line rests on the secu-
rity o the two anchoring knots. Since
this approach is not relied on or ten-
sion relie , suture material breakage or
knot ailure, while undesirable, do not
generally lead to catastrophic w ound
dehiscence. Indeed, the traction across
the suture material itsel a ords a small
degree o security which may be su -
cient to maintain eversion even in the
ace o knot breakage.
As with the interrupted vertical mat-
tress approach, this technique does
not typically permit the same degree
o w ound-edge apposition as can be
accomplished with other transepidermal
sutures, since the everting e ect o the
suture technique may even be associated
with a small degree o gaping at the center
o the running vertical mattress suture. In
the event that deeper sutures were care-
ully placed, this may not be a signi cant
drawback, since the wound edges may
be well-aligned rom the placement o
these deeper sutures.
Suture removal with this technique
may be more involved than with simple
interrupted sutures, particularly i sutures
are le t in situ or an extended period o
time and some o the suture material has
been overgrown by the healing epidermis.
As with any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing a vertical mattress suture
it is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material, or that constriction may
take place. That said, the vertical orien-
tation o this approach helps minimize
this risk.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
References
Kolbusz RV, Bielinski KB. Running vertical
mattress suture. J Dermatol Surg O ncol.
1992;18(6):500-502.
Stiff MA, Snow SN. Running vertical mattress
suturing technique. J Dermatol Surg Oncol.
1992;18(10):916-917.

250
and vertical mattress suture placement is
solely to encourage wound-edge eversion,
ne-gauge suture material may be used on
the extremities as well. Otherwise, 5-0
mono lament suture material is used i
there is minimal tension, and 4-0 mono-
lament suture is use ul in areas under
moderate tension where the goal o suture
placement is relieving tension as well as
epidermal approximation. In select high-
tension areas, 3-0 mono lament suture
may be utilized as well.
Technique
1. A simple interrupted anchoring
suture is placed as ollows:
2. The needle is inserted perpendicular
to the epidermis, approximately one-
hal the radius o the needle distant
to the wound edge. This will allow
the needle to exit the wound on the
contralateral side at an equal distance
rom the wound edge by simply ol-
lowing the curvature o the needle.
3. With a f uid motion o the wrist,
the needle is rotated through the
dermis, taking the bite wider at the
deep margin than at the sur ace,
and the needle tip exits the skin on
the contralateral side.
4. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping the
needle tip, which can be easily dulled
by repetitive riction against the sur-
gical orceps. It is gently grasped
The Running Alternating
Simple and Vertical
Mattress Suture
C H A P T E R 5 . 2 0
Synonym
Running combined simple and vertical
mattress suture
Video 5-20. Running alternating
simple and vertical mattress
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a hybrid running everting tech-
nique used or closure and epidermal
approximation. Like any running tech-
nique, it may be used alone or wounds
under minimal tension, such as wounds
on the genitalia or traumatic lacerations.
It is most requently 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 verti-
cal mattress component helps with ever-
sion and the simple running component
aids with wound-edge approximation.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono lament
suture maybe used, though ast-absorbing
gut may be used on the eyelids and ears to
obviate the need or suture removal. When
the goal o the running alternating simple

251
The Running Alternating Simple and Vertical Mattress Suture
and pulled upward with the surgical
orceps as the body o the needle is
released rom the needle driver. Alter-
natively, the needle may be released
rom the needle driver and the needle
driver itsel may be used to grasp the
needle rom the contralateral side o
the wound to complete its rotation
through its arc, obviating the need or
surgical orceps.
5. The suture material is then tied o
gently, with care being taken to
minimize tension across the epider-
mis and avoid overly constricting
the wound edges.
6. The loose end o the suture material
is then trimmed.
7. The needle is reinserted perpendicu-
lar to the epidermis, approximately
6 mm distant rom the wound edge,
just proximal relative to the surgeon
rom its exit point.
8. With a f uid motion o the wrist,
the needle is rotated through the
dermis at a 45-degree angle toward
the surgeon (and away rom the
prior stitch), and the needle tip exits
the skin on the contralateral side,
equidistant rom the incised wound
edge and proximal, relative to the
surgeon, rom its entry point.
9. The needle is then reloaded in a
backhand ashion and inserted at 90
degrees perpendicular to the epider-
mis approximately 3 mm rom the
wound edge on the same side o the
incision line as the exit point.
10. The needle is rotated super cially
through its arc, exiting on the con-
tralateral side o the wound 3 mm
rom the incised wound edge.
11. The needle is then reloaded in a
standard ashion and reinserted on
the ipsilateral side o the wound
edge but now approximately 6 mm
rom the incised wound edge, yet
still in line with its exit point.
Figure 5-20A. Overview o the running alternating
simple and vertical mattress technique.
A
12. 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 there-
ore in line with the rst entry point.
13. The needle is again passed at a
45-degree angle toward the surgeon
(and away rom the prior stitch),
and the needle tip exits the skin on
the contralateral side, equidistant
rom the incised wound edge and
proximal, relative to the surgeon,
rom its entry point.
14. The needle is then inserted on the
contralateral side o the incised
wound edge, equidistant rom the
incised edge and urther proximal
relative to the surgeon.
15. Steps (7) through (14) are then
repeated sequentially, until the end
o the wound is reached.
16. Once the end o the wound is
reached, the suture material is gently
tied o (Figures 5-20A through 5-20I).

252
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-20B. Placement o the anchoring suture.
Note the entry and exit o the suture at 90 degrees.
B
Figure 5-20C. The simple running component begins.
Note that the path o suture ollows a diagonal relative
to the wound edge.
C
Figure 5-20D. The vertical mattress component—the
needle is inserted medial to its exit point and ollows
a superfcial path, exiting on the contralateral wound
edge.
D
Figure 5-20E. The running component continues, with
the needle entering the skin lateral to its exit point and
continuing along a diagonal path across the wound
edge.
E
Figure 5-20F. The intermittent simple loop is placed,
directly across the wound edge.
F
Figure 5-20G. Appearance a ter the placement o the
frst set o running and vertical mattress sutures.
G

253
The Running Alternating Simple and Vertical Mattress Suture
Figure 5-20H. The vertical mattress component
continues.
H
Figure 5-20I. Immediate postoperative appearance,
prior to cleaning the wound. Note that the wound-edge
approximation is better where the simple loops are
present, though wound edges are well-everted overall.
I
Tips and Pearls
This approach permits relatively rapid
placement o an everting layer o vertical
mattress sutures, and the incorporation
o the simple loops means that it is even
aster to place than the running vertical
mattress suture, since the simple loops
require only a single orehand throw o
suture material versus the two throws
needed or each vertical mattress suture.
The presence o the simple loops also
a ords easier suture removal, as the
loops o interrupted suture may be eas-
ily grasped and cut at the time the sutures
are removed.
O course, like the interrupted verti-
cal mattress technique, this approach
should be avoided when either inversion
is desired or when exaggerated eversion
has already been accomplished with a
buried suture.
As with the interrupted vertical mat-
tress approach, the second throw o the
vertical mattress component is placed
super cial to the rst, deeper ar- ar
suture, leading to a nested placement o
the suture material. This leads to both
wound eversion as well as wound-edge
approximation. Similarly, each o the sim-
ple sutures should be placed by taking a
larger bite o tissue at their deep portion
in order to better evert the wound edges.
Drawbacks and Cautions
Unlike many other running techniques,
this approach relies on the suture material
traversing the wound at a 45-degree angle
in order to permit the individual vertical
mattress components to remain perpen-
dicular to the incised wound edge and
simultaneously allow the running nature
o this technique to progress along the
length o the wound. While this results in
a neat postoperative appearance, with vis-
ible suture material sitting perpendicular
to the incised wound edge, it also means
that the tension vector o the sutures is at
an angle to the underlying tension across
the incised wound edge.
As a running technique, the integrity o
the entire suture line rests on the security
o the two anchoring knots. Since this
approach is not relied on or tension relie ,
suture material breakage or knot ail-
ure, while undesirable, do not generally
lead to catastrophic wound dehiscence.
Indeed, the weaving o the suture material
itsel a ords a small degree o security
that may be su cient to maintain ever-
sion even in the ace o knot breakage.

254
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing a vertical mattress suture
it is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material, or that constriction may
take place. That said, the vertical orien-
tation o this approach helps minimize
this risk.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
Reference
Krunic AL, Weitzul S, Taylor RS. Running com-
bined simple and vertical mattress suture:
a rapid skin-everting stitch. Dermatol Surg.
2005;31(10):1325-1329.

255
relieving tension as well as epidermal
approximation. Occasionally, 3-0 mono-
lament suture may be utilized as well.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
6 mm distant to the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep
margin than at the sur ace, and the
needle tip exits the skin on the con-
tralateral side. I the needle radius
is too small to complete this arc in
one movement, this rst step may
be divided into two, with the nee-
dle rst exiting between the incised
wound edges and then reloaded and
reinserted to exit on the contralateral
side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping the
needle tip, which can be easily dulled
by repetitive riction against the sur-
gical orceps. It is gently grasped
and pulled upward with the surgical
orceps as the body o the needle is
released rom the needle driver.
4. The needle is then reloaded in a
backhand ashion and inserted at
90 degrees perpendicular to the epi-
dermis approximately 3 mm rom
the wound edge on the same side
o the incision line as the exit point,
The Hybrid Mattress Suture
C H A P T E R 5 . 2 1
Video 5-21. Hybrid mattress
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche everting technique used
or closure and epidermal approxima-
tion. It represents a cross between the
vertical mattress and horizontal mattress
techniques. As with many interrupted
techniques, it may be used alone or
wounds under minimal tension, such
as those ormed by either a small punch
biopsy or a traumatic laceration.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement.
On the ace, a 6-0 or 7-0 mono lament
suture is used, though ast-absorbing gut
may be used on the eyelids and ears to
obviate the need or suture removal.
When the goal o the hybrid mattress
suture placement is solely to encourage
wound-edge eversion, ne-gauge suture
material may be used on the extremities
as well. Otherwise, 5-0 mono lament
suture material is used i there is minimal
tension, and 4-0 mono lament suture is
use ul in areas under moderate tension
where the goal o suture placement is

256
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
proximal rom the exit point relative
to the surgeon.
5. The needle is rotated through its arc,
exiting on the contralateral side o
the wound 3 mm rom the incised
wound edge.
6. The suture material is then tied o
gently, with care being taken to mini-
mize tension across the epidermis and
avoid overly constricting the wound
edges (Figures 5-21A through 5-21E).
Figure 5-21A. Overview o the hybrid mattress suture
technique.
A
Figure 5-21B. The needle is inserted at 90-degrees,
“ ar” rom the incised wound edge, exiting on the contra-
lateral wound edge, again relatively ar rom the edge.
B
Figure 5-21C. The needle is reloaded in a backhand
ashion and inserted “near” the incised wound edge.
C
Figure 5-21D. The needle exits the contralateral side
o the wound, again “near” the wound edge.
D
Figure 5-21E. Immediate postoperative appearance.
Note the subtle trapezoidal confguration and
pronounced wound eversion.
E
Tips and Pearls
This technique has been advocated as a
cross between a vertical and horizontal
mattress suture, a ording the bene ts
o both a vertical and horizontal mat-
tress suture.

257
The Hybrid Mattress Suture
As with most transepidermal tech-
niques, it is important to enter the epi-
dermis at 90 degrees, allowing the needle
to travel slightly laterally away rom the
wound edge be ore ully ollowing the
curvature o the needle when utilizing
this technique.
An advantage o this approach is that
no suture material traverses the incised
wound edge and that the suture similarly
does not cross the sur ace o the wound.
While this may be less than desirable
when attempting to ne-tune epidermal
apposition, it is help ul in minimizing the
risk o unsightly track marks.
As with the vertical mattress tech-
nique, note that the second throw is
placed super cial to the rst, deeper ar-
ar suture, leading to a nested placement
o the suture material. This leads to both
wound eversion as well as wound-edge
approximation.
Drawbacks and Cautions
In practice, this technique does not typi-
cally a ord signi cant bene ts over a
horizontal mattress suture, and like other
mattress approaches it does not typically
permit the same degree o wound-edge
apposition as can be accomplished with
other transepidermal sutures, since the
everting e ect o the suture technique
may even be associated with a small
degree o gaping at the center o the ver-
tical mattress suture. In the event that
deeper sutures were care ully placed, this
may not be a signi cant drawback, since
the wound edges may be well-aligned
rom the placement o these deeper
sutures. I not, or i there is a need or
improved wound-edge apposition even
a ter placing the vertical mattress suture,
additional interrupted sutures may be
help ul.
As with other mattress techniques,
suture removal with this technique may
be more involved than with simple inter-
rupted sutures, particularly i sutures are
le t in situ or an extended period o time
and some o the suture material has been
overgrown by the healing epidermis.
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing a hybrid mattress suture it
is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material, or that constriction may
take place.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complica-
tions, and consideration should be given
to adopting other closure techniques in
the event that sutures will not be able to
be removed in a timely ashion.
References
Hoffman MD, Bielinski KB. Surgical pearl: the hybrid
mattress suture. J Am Acad Dermatol. 1997;36
(5 pt 1):773-774.
Makkar S, Sharma R, Nanda V. Hybrid mattress suture.
Plast Reconstr Surg. 2004;114(7):1971-1973.

258
Technique
1. The ap is brought into place using
buried sutures, allowing the tip to
rest with only minimal tension in its
desired position.
2. The needle is inserted into the distal
edge o the distal non ap section o
skin at 90 degrees with a trajectory
running toward the planned entry
point in the tip.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
place the next throw.
4. The needle is inserted into the distal
portion o the tip at the level o the
superf cial dermis, which should be
the same depth at which it exited in
the prior step. Keeping the needle
running horizontally, parallel with
the skin sur ace, it is rotated through
the dermis o the tip, exiting on the
proximal side o the tip at the same
depth.
5. The needle is then reloaded in a
backhand ashion and inserted into
the dermis o the proximal nontip
section o skin, exiting, parallel to its
initial entry point.
The Tip Stitch
C H A P T E R 5 . 2 2
Synonym
Hal -buried horizontal mattress suture
Video 5-22. Tip stitch
Access to video can be found via

Application
This technique is designed to bring three
ends o tissue together, and is o ten used
in the context o a ap, where it permits
the tip o tissue to be inset. It is also uti-
lized to repair V-shaped lacerations. This
approach may be conceptualized as a
hal -buried horizontal mattress suture.
Since it is used only when attempting to
approximate three segments o skin, it is
a niche technique.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the smallest
gauge suture material appropriate or the
anatomic location should be utilized. On
the ace, where this technique may be used
or ap repairs, a 6-0 or 7-0 monof lament
nonabsorbable suture is appropriate. On
the trunk, extremities, and scalp, a 3-0 or
4-0 nonabsorbable suture material may be
used. Fast-absorbing gut may also be used,
obviating the need or suture removal but
increasing the risk o tissue reactivity.

259
The Tip Stitch
6. The suture material is then gently
tied utilizing an instrument tie. Care
should be taken to minimize tension
on this suture to mitigate the risk
o ap tip necrosis (Figures 5-22A
through 5-22G).
Figure 5-22A. Overview of the tip stitch.
A
Figure 5-22B. The needle is inserted through the
epidermis at 90 degrees on the nontip skin, exiting the
mid-dermis.
B
Figure 5-22C. The needle is then inserted through the
mid-dermis of the tip.
C
Figure 5-22D. View of the needle passing through the
tip. Note that the needle does not pierce the epidermis
of the tip.
D
Figure 5-22E. The needle is then inserted from the
deep dermis through to the outside of the skin on the
contralateral nontip wound edge.
E

260
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-22F. Appearance of the suture prior to tying.
F
Figure 5-22G. Immediate postoperative appearance
immediately after suture tying. Note that the tip is
brought into place in close alignment with the other
wound edges.
G
Tips and Pearls
The tip stitch is very use ul when bring-
ing the tip o a ap into place, and is
used requently in this situation. Impor-
tantly, this technique is designed to gently
approximate the tissues so that the ap
is properly inset in the surrounding skin.
While it bears a technical resemblance to
the hal -buried horizontal mattress, it is
important to appreciate that the tip stitch
is not designed to work under signif cant
tension, as tension across the suture may
lead to necrosis o the delicate and lightly
vascularized tip o the ap.
Placing set-back dermal sutures, imbri-
cation sutures, or suspension sutures prior
to placement o the tip stitch will ensure
that the tip itsel is not under tension
when it is approximated with the sur-
rounding skin.
Drawbacks and Cautions
Flap tip necrosis is the greatest risk with
this technique, since suture material tra-
verses the dermis containing the tip’s vas-
cular supply. This risk may be mitigated
by tying the suture relatively loosely so
that the tip is not overly constricted when
the knot is tied. Additionally, i the bites
o dermis are su f ciently set-back rom
the wound edge, a small bite compris-
ing less than hal o the dermis in the tip
could be taken. This would allow blood
supply to the tip even in the context o
a relatively tight loop running through
the distal ap.
There is sometimes a tendency or the
tip to sit deeper than the surrounding tis-
sues. This may be related to the relative
upward pull on the nontip sections o skin
by the transepidermal sutures.
Finally, while ap tip necrosis is a risk,
studies have suggested that the tip stitch
provides less vascular constriction than
other options, such as placing two verti-
cally oriented sutures at the edges o the
tip or a suture directly through the tip
itsel . Vascular compromise and ensuing
necrosis o the ap tip is always a risk,
even i no sutures are placed through
the tip itsel , and there ore the tip stitch
approach likely provides a reasonable
balance between tissue approximation
and adequate vascular supply.
References
Bechara FG, Al-Muhammadi R, Sand M, et al.
A modi ed corner stitch or xation o f ap tips.
Dermatol Surg. 2007;33(10):1277-1279.
Kandel EF, Bennett RG. The e ect o stitch type
on f ap tip blood f ow. J Am Acad Dermatol.
2001;44(2):265-272.
McQuown SA, Cook TA, Brummett RE, Trachy RE.
Gillies’ corner stitch revisited. Arch Otolaryngol.
1984;110(7):450-453.

261
Technique
1. The ap is brought into place using
buried sutures, allowing the tip to
rest with only minimal tension in its
desired position.
2. The needle is inserted through the
epidermis at 90 degrees starting at
the ar right edge o the distal non ap
section o skin, with a trajectory run-
ning toward the tip. This entry point
through the epidermis should be
approximately 3 mm set-back rom
the epidermal edge, depending on
the thickness o the dermis and the
anticipated degree o tension across
the tip. The needle, and there ore the
suture, should exit in the mid-dermis
on the same portion o non ap skin.
Bite size is dependent on needle size.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
place a suture through the dermis on
the ap tip to the le t o the previ-
ously placed suture.
4. A small amount o suture material
is pulled through and the needle is
inserted into the dermis in the ap
tip, at the same depth as it exited
rom the non ap edge, and the needle
is passed through the dermis on the
ap tip at a uni orm depth ollowing a
trajectory tracing an imaginary circle
The Vertical Mattress
Tip Stitch
C H A P T E R 5 . 2 3
Synonym
Modif ed corner stitch
Video 5-23. Vertical mattress
tip stitch
Access to video can be ound via
SuturingTechniques.com.
Application
This technique, also described as the
modif ed corner stitch, is designed to
bring three ends o tissue together, and
is used in the context o a ap, where
it permits the tip o tissue to be inset.
This can be conceptualized as a vertical
mattress variation o the tip stitch, per-
mitting circum erential tissue advance-
ment while concomitantly encouraging
wound eversion and mitigating the risk
that the tip is set deeper than the sur-
rounding wound edges. Since it is used
only when attempting to approximate
three segments o skin, this is a niche
technique.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate or
the anatomic location should be utilized.
On the ace, where this technique may
be used or ap repairs, a 6-0 suture is
appropriate. On the trunk, extremities
and scalp, a 3-0 or 4-0 suture material may
be used. Monof lament nonabsorbable
suture material is generally appropriate
when utilizing this technique.
A

262
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
around the point where all three seg-
ments o skin will meet. The needle
is then grasped with surgical orceps
and released rom the needle driver.
5. Attention is then shi ted to the proxi-
mal non ap edge o skin, where the
needle is inserted in the mid-dermis
o the incised edge, with the needle
exiting through the epidermis in a
mirror image o step (2).
6. The needle is reinserted through
the epidermis just medial to the exit
point, exiting through the dermis at
the incised wound edge o the non-
ap skin.
7. The needle is then reinserted in the
dermis on the ap in a mirror-image
o the technique utilized in step (4),
running at the same depth o the der-
mis but distal to the suture material
placed in step (4) relative to the ap
tip.
8. The needle is then inserted through
the dermis at the incised wound edge
on the initial edge o non ap skin,
exiting medial and superior to the
original entry point.
9. The suture material is then tied utiliz-
ing an instrument tie (Figures 5-23A
through 5-23H).
Figure 5-23A. Overview o the vertical mattress tip
stitch.
A
Figure 5-23B. The needle is inserted ar rom the
wound edge, exiting at the level o the deep dermis.
B
Figure 5-23C. The needle is then inserted through the
dermis o the tip, moving laterally along the dermis,
without penetrating the epidermis.
C

263
The Vertical Mattress Tip Stitch
D
Figure 5-23D. The needle is then inserted through the
dermis o the nontip skin, exiting ar rom the wound edge.
E
Figure 5-23E. The needle is then inserted closer to
the incised wound edge.
F
Figure 5-23F. The needle is then inserted through the
dermis o the tip, superfcial to its prior arc o passage.
G
Figure 5-23G. The needle is then inserted through the
dermis o the nontip skin, exiting medial to its original
entry point. The suture is then tied.
H
Figure 5-23H. Immediate postoperative appearance.
Tips and Pearls
This technique was developed to solve
a problem encountered with standard
tip stitch techniques—the tendency o
the ap tip to sit deep relative to the
surrounding skin. Some o this problem
may be due to lack o attention to the
importance o uni orm depth when tak-
ing bites through the dermis on all sides,
though more likely it is related to the rela-
tive upward pull on the nontip sections
o skin by the transepidermal sutures in
the standard tip stitch.
The vertical mattress variation o the
tip stitch there ore allows better wound
eversion and less o a tendency toward a
depressed tip than the standard approach.
The tip stitch is very use ul when bring-
ing the tip o a ap into place. Importantly,
this technique is designed to gently
approximate the tissues so that the ap
is properly inset in the surrounding skin.
While it bears a technical resemblance
to the buried purse-string approach, it is
important to appreciate that the tip stitch
is not designed to work under signif cant
tension, as tension across the suture may
lead to necrosis o the delicate and lightly
vascularized tip o the ap.
This is particularly important here,
since the vertical mattress tip stitch places
two loops o suture material through the
tip, increasing the risk o necrosis and
tissue strangulation.

264
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Placing set-back dermal sutures, imbri-
cation sutures, or suspension sutures prior
to placement o the tip stitch will ensure
that the tip itsel is not under tension
when it is approximated with the sur-
rounding skin.
Yet another variation o this technique
entails burying the bite through the sec-
ond non ap wound edge so that the only
percutaneous sutures are in the f rst non-
ap edge o skin. In this case, steps (5) and
(6) are replaced by taking a bite through
the dermis alone be ore beginning the
return course o the suture. This approach
may slightly lessen the chance o in ection
and residual dimpling since the suture
material on that edge does not traverse
the epidermis. This hal -buried approach
is similar to the Allgöwer variation o the
vertical mattress suture.
Drawbacks and Cautions
Flap tip necrosis is the greatest risk with
this technique, since two loops o suture
material traverse the dermis containing
the tip’s vascular supply. This risk may
be mitigated by tying the suture together
relatively loosely so that the tip is not
overly constricted when the knot is tied.
Additionally, i the bites o dermis are su -
f ciently set-back rom the wound edge,
a small bite comprising less than hal o
the dermis in the tip could be taken. This
would allow blood supply to the tip even
in the context o a relatively tight loop
running through the distal ap.
Since this technique entails the place-
ment o two loops o suture through the
ap tip, it may be associated with a higher
rate o necrosis than other variations o
the tip stitch. There ore, unless the better
wound-edge approximation o the verti-
cal mattress placement is needed, it may
be pre erable to adopt other variations
o the tip stitch that do not require the
additional loop o suture through the tip.
Finally, while ap tip necrosis is a risk,
studies have suggested that the tip stitch
provides less vascular constriction than
other options, such as placing two verti-
cally oriented sutures at the edges o the
tip or a suture directly through the tip
itsel . Vascular compromise and ensuing
necrosis o the ap tip is always a risk,
even i no sutures are placed through
the tip itsel , and there ore the tip stitch
approach likely provides a reasonable
balance between tissue approximation
and adequate vascular supply.
References
Bechara FG, Al-Muhammadi R, Sand M, et al.
A modi ed corner stitch or xation o f ap tips.
Dermatol Surg. 2007;33(10):1277-1279.
Kandel EF, Bennett RG. The e ect o stitch type
on f ap tip blood f ow. J Am Acad Dermatol.
2001;44(2):265-272.

265
Technique
1. The ap is brought into place using
buried sutures, allowing the tip to
rest with only minimal tension in or
close to its desired position.
2. Starting approximately 4 mm distal
rom the point where the ap tip will
be inset, the needle is inserted per-
pendicular to the epidermis, approxi-
mately 6 mm distant to the wound
edge.
3. With a uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep
margin than at the sur ace, and the
needle tip exits the skin on the con-
tralateral side. I the needle radius
is too small to complete this arc in
one movement, this f rst step may
be divided into two, with the nee-
dle f rst exiting between the incised
wound edges and then reloaded and
reinserted to exit on the contralateral
side.
4. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping
the needle tip, which can be easily
dulled by repetitive riction against
the surgical orceps.
5. The needle is then reloaded in a
backhand ashion and inserted at
90 degrees perpendicular to the
epidermis approximately 3 mm
rom the w ound edge on the same
The Hybrid Mattress
Tip Stitch
C H A P T E R 5 . 2 4
Synonym
Vertical mattress tip stitch
Video 5-24. Hybrid mattress
tip stitch
Access to video can be found via

Application
This technique is designed to bring
three ends o tissue together, and is
used in the context o a ap or M-plasty,
where it permits the tip o tissue to be
inset. This approach may be conceptu-
alized as a hybrid mattress suture that
encompasses the dermis o the tip o
suture in its near-near step. Since it is
used only when attempting to approxi-
mate three segments o skin, it is a niche
technique.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the smallest
gauge suture material appropriate or the
anatomic location should be utilized. On
the ace, where this technique may be
used or ap repairs, a 6-0 or 7-0 mono-
f lament nonabsorbable suture is appro-
priate. On the trunk, extremities, and
scalp, a 3-0 or 4-0 nonabsorbable suture
material may be used. Fast-absorbing gut
may also be used, obviating the need or
suture removal but increasing the risk o
tissue reactivity.

266
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
side o the incision line as the exit
point, distal rom the exit point
relative to the surgeon so that it is
approximately 2 mm proximal to
the lap tip.
6. The needle is rotated superf cially
through its arc, exiting in the under-
mined space.
7. The needle is then reloaded, again
in a backhand ashion, and a mod-
est bite o the dermis in the ap tip
is taken. The needle moves parallel
to the skin sur ace and does not pen-
etrate the epidermis o the tip.
8. The needle is then again reloaded in a
backhand ashion and is inserted into
the superf cial dermis on the contra-
lateral side, exiting through the epi-
dermis similarly to steps (5) and (6).
9. The suture material is then tied o
gently, with care being taken to
minimize tension across the epider-
mis and avoid overly constricting the
wound edges. Care should be taken
to minimize tension on this suture to
mitigate the risk o ap tip necrosis
(Figures 5-24A through 5-24G).
Figure 5-24A. Overview of the hybrid mattress tip
stitch.
A
Figure 5-24B. The needle is inserted at 90 degrees
to the skin, far from the skin edge and far from the tip,
exiting in the open wound space.
B
Figure 5-24C. The needle is inserted on the contra-
lateral wound edge, exiting far from the incised wound
edge.
C
Figure 5-24D. The needle is then inserted closer to
the skin edge and closer to the tip, exiting in the under-
mined space.
D

267
The Hybrid Mattress Tip Stitch
E
Figure 5-24E. The needle is then passed through the
dermis on the tip; it does not penetrate the epidermis
of the tip, and instead stays at a constant depth in the
dermis.
F
Figure 5-24F. The needle is then inserted from the
underside of the dermis, exiting the epidermis close
to the wound edge. The suture material is then tied,
securing the tip in place.
G
Figure 5-24G. Immediate postoperative view.
Tips and Pearls
The hybrid mattress tip stitch is very use-
ul when bringing the tip o an M-plasty
into position. Importantly, as with the
standard tip stitch, this technique is
designed to gently approximate the tis-
sues so that the ap is properly inset
in the surrounding skin. While it bears
a technical resemblance to the hybrid
mattress, it is important to appreciate
that the hybrid mattress tip stitch is not
designed to work under signif cant ten-
sion, as tension across the suture may
lead to necrosis o the delicate and lightly
vascularized tip o the ap.
As with the tip stitch, placing set-back
dermal sutures, imbrication sutures, or
suspension sutures prior to placement o
the tip stitch will ensure that the tip itsel
is not under tension when it is approxi-
mated with the surrounding skin.
Note that the near-near step incorporat-
ing the ap tip bite is taken just proximal
to the tip o the ap, while the initial ar-
ar bite is taken distal to the ap tip. The
sling-like e ect o this approach orces
the tip into place, securing it in its desired
position.
The vertical mattress component o this
approach helps mitigate the risk o ap
tip inversion, an occasional drawback o
the standard tip stitch technique.
Drawbacks and Cautions
As with all tip stitch techniques, ap
tip necrosis is the greatest risk with this
technique, since suture material traverses
the dermis containing the tip’s vascular
supply. This risk may be mitigated by
tying the suture relatively loosely so that
the tip is not overly constricted when the
knot is tied. Additionally, i the bites o
dermis are su f ciently set-back rom the
wound edge, a small bite comprising less
than hal o the dermis in the tip could be
taken. This would allow blood supply to

268
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
the tip even in the context o a relatively
tight loop running through the distal ap.
Finally, while ap tip necrosis is a risk,
studies have suggested that the tip stitch
provides less vascular constriction than
other options, such as placing two verti-
cally oriented sutures at the edges o the
tip or a suture directly through the tip
itsel . Vascular compromise and ensuing
necrosis o the ap tip is always a risk,
even i no sutures are placed through
the tip itsel , and there ore the tip stitch
approach likely provides a reasonable
balance between tissue approximation
and adequate vascular supply.
References
Kandel EF, Bennett RG. The e ect o stitch type
on f ap tip blood f ow. J Am Acad Dermatol.
2001;44(2):265-272.
Starr J. Surgical pearl: the vertical mattress tip stitch.
J Am Acad Dermatol. 2001;44(3):523-524.

269
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
8-12 mm distant to the wound edge.
2. With a uid motion o the wrist, the
needle is rotated through the dermis,
and the needle tip exits between the
incised wound edges.
3. The needle is then reloaded and rein-
serted rom the underside o the der-
mis on the contralateral wound edge,
exiting approximately 4 mm rom the
wound edge. The exit point is just dis-
tal (relative to the surgeon) rom the
entry point on the original side.
4. The needle is then reloaded and
inserted at 90 degrees perpendicu-
lar to the epidermis approximately
4 mm rom the wound edge on the
contralateral side o the incision line
(the original entry side).
5. With a uid motion o the wrist, the
needle is rotated through the dermis,
and the needle tip exits between the
incised wound edges.
6. The needle is then reloaded and rein-
serted rom the underside o the der-
mis on the contralateral wound edge,
exiting approximately 8-12 mm rom
the wound edge. The exit point is
just proximal (relative to the surgeon)
rom the entry point.
7. The suture material is then tied o
(Figures 5-25A through 5-25G).
The Pulley Suture
C H A P T E R 5 . 2 5
Video 5-25. Pulley suture
Access to video can be found via

Application
The pulley suture technique relies on
the pulley e ect o multiple loops o
suture to permit the closure o wounds
under even signif cant tension. Since
this approach may lead to marked ten-
sion across the wound sur ace, it is typi-
cally used in scalp reduction surgery or
other areas where the f nal cosmesis is
less critical. This approach may also be
used as a temporary technique to better
approximate w ound edges and allow
deep sutures to be placed expeditiously,
a ter which the pulley sutures may be
removed.
Suture Material Choice
Suture choice is dependent in large
part on location, though because this
technique is expressly designed or
w ounds under marked tension, a 3-0
nonabsorbable suture w orks w ell on
the scalp and back, though w hen the
area is under particularly marked ten-
sion a 2-0 nonabsorbable suture may
be help ul.

270
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-25A. Overview of the pulley suture.
A
Figure 5-25B. The needle is inserted through the skin,
far from the wound edge, exiting the underside of the
dermis in the undermined wound space.
B
Figure 5-25C. The needle is then inserted on the
contralateral wound edge, distal to its exit point along
the length of the wound, exiting near to the incised
wound edge.
C
Figure 5-25D. The needle is then inserted directly
across from its exit point, again near to the wound
edge.
D
Figure 5-25E. The needle is then inserted again from
the underside of the dermis, exiting far from the wound
edge directly across from its original entry point.
E
Figure 5-25F. Appearance after placement of the pul-
ley suture prior to tying.
F

271
The Pulley Suture
Figure 5-25G. Postoperative appearance after tying
the knot.
G
Tips and Pearls
This is a use ul technique or select
wounds, as it permits the wound edges
to come together even under marked
tension. Since the sutures are transepi-
dermal, however, it may also be associ-
ated with signif cant cross-hatching or
residual suture track marks i they are le t
in place or any amount o time. There-
ore, one requently used approach is to
use pulley sutures on a temporary basis
intraoperatively to permit placement o
other sutures; once the other sutures have
been placed, the pulley sutures may be
removed be ore the end o the procedure.
I pulley sutures are le t in place, they
should probably be removed in a timely
ashion, and certainly should be le t in
place or no longer than 1 week.
The two loops o suture are slightly
o set rom each other, as the suture tra-
verses the incised wound edge on an
oblique angle, which helps lessen the
risk o tissue necrosis and tear-through.
This technique may be used to prepare
the wound or placement o a buried
pulley suture, such as the pulley set-back
dermal suture. As long as undermining
has been carried out e ectively, utilizing
a pulley technique with a thicker gauge
suture material should allow or e ective
closure o all but the tightest wounds.
In areas under extreme tension, a three-
loop variation o this approach is pos-
sible as well, allowing or an even more
dramatic pulley e ect.
A double variation o this approach, the
tandem pulley stitch, has been recently
described as well.
Drawbacks and Cautions
The greatest drawbacks o this approach
are the possible residual track marks
and w ound spread that may be seen
when w ounds under marked tension
are closed. This technique may elicit an
increased risk o track marks, necrosis,
and other complications when compared
with techniques that do not entail suture
material traversing the scar line, such
as buried pulley techniques. There ore,
sutures should be removed as early as
possible (ideally intraoperatively) to
minimize these complications, and con-
sideration should be given to adopting
other closure techniques in the event
that sutures will not be removed in a
timely ashion.
Suture removal with this technique
may be more involved than with simple
interrupted sutures; the inner loop is gen-
erally easier to cut at the time o suture
removal, though i sutures are le t in place
or an extended period o time they may
have a tendency to be overgrown by the
surrounding epidermis.
References
Field LM. Closure of wounds under tension with
the pulley suture. J Dermatol Surg Oncol.
1993;19(2):173-174.
Hitzig GS, Sadick NS. The pulley suture. Utilization
in scalp reduction surgery. J Dermatol Surg Oncol.
1992;18(3):220-222.
Lee CH, Wang T. A novel suture technique for high-
tension wound closure: the tandem pulley
stitch. Dermatol Surg. 2015;41:975-6.
Snow NS. Closure of wounds under tension with
the pulley suture. J Dermatol Surg Oncol.
1993;19(2):174.

272
Technique
1. The wound edges are broadly
undermined.
2. With the tail o the suture material
resting between the surgeon and
the ar end o the wound, the needle
is inserted through the epidermis
on the ar edge o the wound with
a trajectory running parallel to the
incision. The entry point in the epi-
dermis should be approximately
3-6 mm set-back rom the epidermal
edge, depending on the thickness
o the dermis and the anticipated
degree o tension across the closure.
The needle, and there ore the suture,
should pass through the deep dermis
into the undermined space at a uni-
orm depth.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
repeat the previous step to the le t o
the previously placed suture.
4. A small amount o suture material
is pulled through and the needle is
inserted into the dermis to the le t o
the previously placed suture, and the
same movement is repeated.
5. The same technique is repeated
moving stepwise around the entire
wound until the needle exits close to
The Purse-String Suture
C H A P T E R 5 . 2 6
Video 5-26. Purse-string suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is designed to either
shrink the size o a de ect or obviate it
entirely, depending on the degree o ten-
sion and the size o the de ect. It is a niche
technique, since the purse-string e ect
tends to lead to a slight puckering in the
surrounding skin, a eature that may be
acceptable (and will likely resolve with
time) on areas such as the orearms and
back but is less desirable in cosmetically
sensitive locations such as the ace. The
running nature o the technique means
that compromise at any point in the
course o suture placement may result
in wound dehiscence, though or this
reason a larger gauge suture material is
generally utilized.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the smallest
gauge suture material appropriate or the
anatomic location should be utilized. On
the back and shoulders, 2-0 or 3-0 non-
absorbable suture material is e ective,
and on the extremities and scalp, a 3-0
or 4-0 absorbable suture material may be
used. Since the technique requires easy
pull through o suture material, monof la-
ment nonabsorbable suture is generally
pre erable.

273
The Purse-String Suture
the original entry point at the ar end
o the wound. Once the point closest
to the surgeon is reached, it may be
more com ortable to shi t to a back-
hand technique.
6. Once the desired number o throws
has been placed, the suture material is
then pulled taut, leading to complete
or partial closure o the wound, and
tied utilizing an instrument tie. Alter-
natively, a hand tie may be used i
desired (Figures 5-26A through 5-26G).
Figure 5-26A. Overview o the purse-string suture
technique.
A
Figure 5-26B. Initiation o the purse-string suture
technique. Note the needle enters at 90 degrees and
ollows a course parallel to the wound.
B
Figure 5-26C. Completion o the frst throw o the
purse-string suture. Note that the suture continues to
ollow the curvature o the wound edge.
C
Figure 5-26D. Beginning o the second throw o the
purse-string suture. Again, the suture continues to ol-
low the curvature o the wound edge.
D
Figure 5-26E. Completion o the second throw.
E

274
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-26F. The purse-string suture now encircles
the entire wound. Note the intentionally large bites
taken or demonstration purposes.
F
Figure 5-26G. The completed purse-string closure.
Note the stellate appearance o the wound, which is
more pronounced when repairing areas with a thicker
dermis or when taking larger bites.
G
Tips and Pearls
This technique is designed as an e f -
cient method o wound area reduction. In
many cases, placing a purse-string suture
can e ect complete wound closure, and
it there ore represents an alternative to a
layered repair o a usi orm incision. That
said, a recent randomized controlled trial
demonstrated that purse-string closures
do not result in appreciably improved
scarring over secondary intention healing.
It has been suggested that some de ects
on the back and extremities, particularly
in elderly patients with loose skin, are
better closed with a purse-string approach
than with a traditional linear closure, since
linear closures o ten heal with a residual
scar and require a signif cantly longer exci-
sion line, while the puckering that may be
present immediately postoperatively with
purse-string closures is likely to resolve
with time. That said, in the right hands
linear closures on the trunk and extremi-
ties o ten heal with subtle scarring, even
when wounds are closed under tension.
On a pragmatic level, this approach is
generally utilized when either a patient is
unwilling to undergo a traditional linear
closure or when their comorbidities make
the additional length o the incision or a
linear closure an unrealistic option.
As with linear running dermal tech-
niques, this technique may be used as a
modif ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the knot.
A monof lament suture is generally
used to permit easy pull through as well
as straight orward suture removal.
The purse-string technique may also be
used to e ect hemostasis in the case o
an oozing wound. For wounds in highly
vascular areas, such as the scalp, a purse-
string suture may be per ormed distant
rom the wound edge; small vessels will be
captured within the ring o the purse-string
suture and compressed when the suture
material is tightened, leading to improved
hemostasis. A double ring o purse-string
sutures may be used as well to take even
better advantage o this hemostatic e ect.
Tying a purse-string closure under sig-
nif cant tension may be challenging, as
suture material tends to slip a ter the f rst
knot throw. Utilizing hemostats to secure
the suture ends in position during suture
lockdown may help mitigate this problem.
Drawbacks and Cautions
As with other transepidermal approaches,
this technique may leave suture marks,
and since this suture is generally tied
under marked tension, and is le t in place

275
The Purse-String Suture
or an extended period o time to per-
mit the wound edges to f rmly realign,
this problem may be more pronounced
with this technique than with other tran-
sepidermal approaches. There ore, i the
purse-string approach is to be utilized
at all, it may be pre erable to adopt the
buried subcuticular approach.
The pucker e ect o this closure resolves
rapidly in atrophic skin, though it can per-
sist in other areas; patients should realize
that some degree o residual puckering
toward the center o the wound is to be
expected. As with the buried purse-string
approach, this technique may be used to
help recreate the nipple-areola complex i
ull reconstruction is not desired and the
nipple is lost to a local tumor.
Since the entire closure is held by a single
knot, this approach may be associated with
a higher rate o wound dehiscence, as knot
ailure or ailure in the suture material at any
point leads to an immediate loss o tension
on the closure. Given the concern regarding
knot breakage, it may be help ul to attempt
to better secure the knot. This may be done
by paying particularly close attention to
knot tying, tying an extra ull knot, adding
extra throws, or leaving a longer tail than
would traditionally be executed.
This approach provides less wound
eversion than vertically oriented
approaches such as the set-back der-
mal or buried vertical mattress sutures.
There ore, consideration should be given
to adding additional superf cially placed
everting sutures, such as the vertical
mattress suture, in order to mitigate this
problem. Since this approach is generally
adopted when the surgeon has accepted
that the cosmetic outcome may be less
than ideal, it may be reasonable to use
this approach as a solitary closure.
References
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
The cuticular purse string suture: a modif ed
purse string suture or the partial closure o
round postoperative wounds. Int J Dermatol.
2007;46(7):746-753.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The
purse-string suture revisited: a use ul technique
or the closure o cutaneous surgical wounds.
Int J Dermatol. 2007;46(4):341-347.
Field LM. Inadvertant and undesirable sequelae o
the stellate purse-string closure. Dermatol Surg.
2000;26(10):982.
Greenbaum SS, Radonich M. Closing skin de ects
with purse-string suture. Plast Reconstr Surg.
1998;101(6):1749-1751.
Harrington AC, Montemarano A, Welch M,
Farley M. Variations o the pursestring suture
in skin cancer reconstruction. Dermatol Surg.
1999;25(4):277-281.
Ho man A, Lander J, Lee PK. Modi ica-
tion o the purse-string closure or large
de ects o the extremities. Dermatol Surg.
2008;34(2):243-245.
Joo J, Custis T, Armstrong AW, et al. Purse-string
suture vs second intention healing: results o a
randomized, blind clinical trial. JAMA Dermatol.
2015;151:265-70.
Ku BS, Kwon OE, Kim DC, et al. A case o erosive
adenomatosis o nipple treated with total exci-
sion using purse-string suture. Dermatol Surg.
2006;32(8):1093-1096.
Maher IA, Fosko S, Alam M. Experience vs
experiments with the purse-string clo-
sure: unexpected results. JAMA Dermatol.
2015;151:259-60.
Marquart JD, Lawrence N. The purse-string lock-
down. Dermatol Surg. 2009;35:853-5.
Patel KK, Tel er MR, Southee R. A “round block”
purse-string suture in acial reconstruction a ter
operations or skin cancer surgery. Br J Oral
Maxillofac Surg. 2003;41(3):151-156.
Peled IJ, Zagher U, Wexler MR. Purse-string suture
or reduction and closure o skin de ects. Ann
Plast Surg. 1985;14(5):465-469.
Randle HW. Modif ed purse string suture closure.
Dermatol Surg. 2004;30 (2 pt 1):237.
Romiti R, Randle HW. Complete closure by purse-
string suture a ter Mohs micrographic sur-
gery on thin, sun-damaged skin. Dermatol Surg.
2002;28(11):1070-1072.
Spencer JM, Malerich SA, Moon SD. A regional
survey o purse-string sutures or partial and
complete closure o Mohs surgical de ects.
Dermatol Surg. 2014;40(6):679-685.
Teitelbaum S. The purse-string suture. Plast Reconstr
Surg. 1998;101(6):1748-1749.
Zhu JW, Wu XJ, Lu ZF, Cai SQ, Zheng M. Purse-
string suture or round and oval de ects: a use ul
technique in dermatologic surgery. J Cutan Med
Surg. 2012;16(1):11-17.

276
contralateral side at an equal distance
rom the wound edge by simply ol-
lowing the curvature o the needle.
2. With a uid motion o the wrist, the
needle is rotated through the dermis,
and the needle tip exits the skin on
the contralateral side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping
the needle tip, which can be easily
dulled by repetitive riction against
the surgical orceps.
4. The loose tail o suture material may
be secured in place with the aid o a
hemostat.
5. Starting
proximal
to
the
prior
throw relative to the surgeon, steps
(1) through (3) are then repeated
sequentially until the desired number
o throws is placed.
6. The leading edge o suture is then
tied to the loose end where the
hemostat was placed (Figures 5-27A
through 5-27H).
Tips and Pearls
This is a multiple pulley tissue expan-
sion technique that relies on the multiple
throws o suture to minimize tension
and secure the wound edges in position.
A ter securing the winch stitch, it may
be tightened intermittently by pulling
on the suture material with a skin hook,
permitting even greater mechanical skin
creep.
The Winch Stitch
C H A P T E R 5 . 2 7
Video 5-27. Winch stitch
Access to video can be found via

Application
This is a niche intraoperative tissue
expansion approach. When closing
wounds under marked tension, buried
or transepidermal pulley sutures may be
insu f cient to permit closure. Placing a
temporary winch stitch, in order to take
advantage o mechanical tissue creep,
aids in closing these select de ects. The
suture is removed intraoperatively, a ter
other tension-relieving sutures have been
placed.
Suture Material Choice
Since this is a temporary suture, choice o
suture material is guided more by resil-
ience and resistance to breakage than by
any concern regarding permanent track
marks. There ore, a 2-0 or 3-0 monof la-
ment nonabsorbable suture is generally
appropriate in most areas where this
technique would be used, such as the
trunk and scalp.
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately one-
hal the radius o the needle distant
to the wound edge. This will allow
the needle to exit the wound on the

277
The Winch Stitch
A
Figure 5-27A. Overview of the winch stitch.
B
Figure 5-27B. The needle is inserted at 90 degrees
through the epidermis close to one pole of the wound.
C
Figure 5-27C. The needle is then inserted on the con-
tralateral side, exiting through the skin.
D
Figure 5-27D. Moving along the wound edge, the
needle is again inserted through the skin at 90 degrees.
E
Figure 5-27E. The needle is then inserted on the con-
tralateral wound edge. This pattern continues along the
length of the wound.
F
Figure 5-27F. Appearance after placing a series of
sutures along the length of the wound.

278
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
G
Figure 5-27G. The two ends of the suture are then
tied together over the top of the wound.
H
Figure 5-27H. A skin hook may be used to pull up on
the tied loop of suture, further tightening the line of
sutures.
This technique is not an actual closure
technique; that is, the sutures are not le t
in place to permit tension reduction or
wound-edge apposition, but rather to
allow placement o the actual tension
relieving sutures that may not be easily
placed in extreme high-tension closures.
The individual bites should be large
enough to minimize suture material
tear-through; otherwise, wounds under
extreme tension, especially those with
a relatively atrophic dermis, may not
support the suture material which could
simply tear through the riable skin,
leading to additional de ects and associ-
ated cosmetic compromise.
Drawbacks and Cautions
Depending on the degree o tension and
the thickness and resilience o the dermis,
this technique may lead to some epider-
mal and dermal damage that may not be
desirable. There ore, care should be taken
to use this approach only when abso-
lutely needed. The risk o necrosis, while
mitigated by the act that these sutures
are only le t in place temporarily, is still
a possibility, and even in the absence o
true tissue necrosis the trauma o crush
injury to the delicate dermal vasculature
is a possible risk as well.
Although this approach is designed
to take advantage o mechanical tissue
creep, it is not a dynamic suture tech-
nique, since the ends o the suture mate-
rial are tied together. There ore, the suture
material may be pulled with a skin hook
every ew minutes to take advantage o
tissue creep but are not secured in the
new position, since the suture was tied
a ter its initial placement.
As with any suturing technique, knowl-
edge o the relevant anatomy is critical and
it is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material. For example, the needle
may pierce a vessel leading to increased
bleeding.
Given the possible problems associated
with this approach, a double or pulley
buried suture is pre erable or e ecting
closure in high-tension areas when ea-
sible. This technique remains a use ul
adjunct, however, in cases o extreme
tension where mechanical tissue creep
may be relied on to add laxity to a very
tight closure.
Reference
Casparian JM, Monheit GD. Surgical pearl: the
winch stitch-a multiple pulley suture. J Am
Acad Dermatol. 2001;44(1):114-116.

279
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
one-hal the radius o the needle
distant to the wound edge. This will
allow the needle to exit the wound
on the contralateral side at an equal
distance rom the wound edge by
simply ollowing the curvature o
the needle.
2. With a uid motion o the wrist, the
needle is rotated through the dermis,
and the needle tip exits the skin on
the contralateral side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping
the needle tip, which can be easily
dulled by repetitive riction against
the surgical orceps.
4. The loose tail o suture material is
secured in place with the aid o a
hemostat.
5. Starting
proximal
to
the
prior
throw relative to the surgeon, steps
(1) through (3) are then repeated
sequentially until the desired number
o throws is placed.
6. The leading edge o suture is then
pulled taut and secured in place with
a hemostat.
7. A ter allowing time or tissue creep to
occur, one hemostat is gently pulled,
The Dynamic Winch Stitch
C H A P T E R 5 . 2 8
Synonym
Modif ed winch stitch
Video 5-28. Dynamic winch
stitch
Access to video can be found via

Application
Like the standard winch stitch, this is
a niche intraoperative tissue expansion
approach. When closing wounds under
marked tension, buried or transepider-
mal pulley sutures may be insu f cient
to permit closure. Placing a temporary
winch stitch, in order to take advantage
o mechanical tissue creep, aids in clos-
ing these select de ects. The suture is
removed intraoperatively, a ter other
tension-relieving sutures have been
placed.
Suture Material Choice
Since this is a temporary suture, choice o
suture material is guided more by resil-
ience and resistance to breakage than by
any concern regarding permanent track
marks. There ore, a 2-0 or 3-0 monof la-
ment nonabsorbable suture is generally
appropriate in most areas where this
technique would be used, such as the
trunk and scalp.

280
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
increasing tension across the sutures
and bringing the wound edges closer
together. At maximal pull, an addi-
tional hemostat is then placed at the
junction o the skin and the suture
material, securing the suture material
in position. The hemostat that was
pulled is then removed. This step is
repeated until the desired degree o
tension relie has been accomplished.
8. Once permanent sutures are placed,
the hemostats are removed and
the suture material is pulled out
(Figures 5-28A through 5-28H).
Figure 5-28A. Overview of the dynamic winch
technique.
A
Figure 5-28B. The needle is inserted perpendicular to
the skin and exits on the contralateral side.
B
Figure 5-28C. This procedure is repeated sequentially
until several large, deep bites are taken, in the fashion
of a simple running suture.
C
Figure 5-28D. Both the leading and trailing end of
suture are grasped with needle drivers or hemostats,
placing tension along the suture material and gen-
tly pulling the wound edges together with a pulley
technique.
D
Figure 5-28E. With one end of the suture securely
grasped by a needle driver, the other end is pulled taut,
and a needle driver or hemostat is placed on the suture
where it exits the skin.
E

281
The Dynamic Winch Stitch
Figure 5-28F. The other needle driver or hemostat is
then pulled laterally, tightening the suture.
F
Figure 5-28G. A third needle driver is then placed on
the suture at the junction of the suture and the skin,
again securing the now tighter suture in place.
G
Figure 5-28H. This procedure is then sequentially
repeated until all the slack has been removed from
the suture material and the wound edges are well
approximated. This will allow for placement of a perma-
nent suture across the now temporarily approximated
wound edges.
H
Tips and Pearls
This is a multiple pulley tissue expan-
sion technique that relies on the mul-
tiple throw s o suture to minimize
tension and secure the w ound edges
in position.
This technique is not an actual closure
technique; that is, the sutures are not le t
in place to permit tension reduction or
wound-edge apposition, but rather to
allow placement o the actual tension
relieving sutures that may not be easily
placed in extreme high-tension closures.
The individual bites should be large
enough to minimize suture material
tear-through; otherwise, wounds under
extreme tension, especially those with
a relatively atrophic dermis, may not
support the suture material which could
simply tear through the riable skin, lead-
ing to additional de ects and associated
cosmetic compromise.
Drawbacks and Cautions
Depending on the degree o tension and
the thickness and resilience o the dermis,
this technique may lead to some epider-
mal and dermal damage that may not be
desirable. There ore, care should be taken
to use this approach only when abso-
lutely needed. The risk o necrosis, while
mitigated by the act that these sutures
are only le t in place temporarily, is still
a possibility, and even in the absence o
true tissue necrosis the trauma o crush
injury to the delicate dermal vasculature
is a possible risk as well.
With any suturing technique, knowl-
edge o the relevant anatomy is criti-
cal and it is important to recall that the
structures deep to the epidermis may
be compromised by the passage o the
needle and suture material. For example,
the needle may pierce a vessel leading to
increased bleeding.

282
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Given the possible problems associ-
ated w ith this approach, a double or
pulley buried suture is pre erable or
e ecting closure in high-tension areas
when easible. This technique remains
a use ul adjunct, however, in cases o
extreme tension where mechanical tissue
creep may be relied on to add laxity to
a very tight closure.
Reference
Casparian JM, Rodewald EJ, Monheit GD. The
“modified” winch stitch. Dermatol Surg.
2001;27(10):891-894.

283
3. The needle body is grasped with
surgical orceps in the le t hand and
reloaded onto the needle driver.
4. The needle is then inserted perpen-
dicular to the skin on the contralat-
eral side o the wound edge, 2 mm
distant rom the wound edge.
5. The needle is again rotated super -
cially through its arc, exiting 8 mm
rom the incised wound edge.
6. The suture material is then tied o
gently, with care being taken to
minimize tension across the epi-
dermis and avoid overly constrict-
ing the wound edges (Figures 5-29A
through 5-29G).
The Lembert Suture
C H A P T E R 5 . 2 9
Video 5-29. Lembert suture
Access to video can be found via

Application
This is a niche technique designed to
encourage wound-edge inversion, and
is use ul primarily to recreate a natural
crease. It may be used to recreate the
alar creases as well as to better de ne the
helical rim, and may also be use ul when
recreating the mental crease.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Generally, this suture is
used on the ace and ears, and there ore
a 6-0 or 7-0 mono lament suture may
be best, though ast-absorbing gut may
be used to obviate the need or suture
removal.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
8 mm distant to the wound edge.
2. With a f uid motion o the wrist, the
needle is rotated super cially through
the dermis, and the needle tip exits
the skin 2 mm distant rom the
wound edge on the ipsilateral side.
Figure 5-29A. Overview of the Lembert suture.
A