When are horizontal mattress sutures and overlapping sutures used in surgical repairs?

Horizontal Mattress and Overlapping Sutures in Surgical Repairs

Horizontal mattress sutures and overlapping sutures should be used in specific surgical scenarios where tissue approximation, tension management, and functional outcomes are prioritized for optimal patient morbidity and mortality outcomes. 1

Horizontal Mattress Sutures

Indications

• Wound edge compression for hemostasis 2
• Closures under moderate tension 2
• When edge eversion is important 2
• Shallow defects where deep stitches are technically difficult 3
• Facial repairs requiring superior cosmetic outcomes 4

Benefits

• Provides excellent wound-edge approximation and eversion 3
• Creates smoother and flatter scars compared to simple running sutures 4
• Distributes tension more evenly across the wound 1
• Reduces risk of ischemia at individual suture points 5
• Particularly useful in narrow spaces requiring deep stitches 3

Technique Variations

• Fully buried horizontal mattress: Excellent for shallow defects with minimal dead space 3
• Locking horizontal mattress: Facilitates easier suture removal while maintaining hemostasis and eversion 2
• Running horizontal mattress: Provides cosmetically superior results compared to simple running sutures in facial repairs 4

Overlapping Sutures

Indications

• External anal sphincter repairs in obstetrical injuries 1, 6
• Complex tissue approximation requiring layered closure 6
• When structural integrity is critical for functional outcomes 6

Benefits

• Provides stronger structural support in complex repairs 6
• May improve functional outcomes in sphincter repairs 1, 6
• Creates better tissue approximation in certain anatomical locations 6

Specific Clinical Applications

Obstetrical Repairs

• For external anal sphincter repair in 3c perineal tears: Either end-to-end or overlapping technique can be used 6
  • End-to-end technique may utilize PISA (posterior, inferior, superior, anterior) suture placement 6
  • Overlapping sphincteroplasty provides structural support in complex tears 1

Dermatologic Surgery

• For facial Mohs defects: Running horizontal mattress sutures produce significantly more cosmetically pleasing results than simple running sutures 4
  • At 6-month follow-up, horizontal mattress sutures showed superior cosmetic outcomes in 25 out of 47 patients 4

General Surgical Wounds

• For vertical mattress variations: Running combined simple and vertical mattress sutures provide good wound eversion while preventing hypereversion 7
  • This technique is faster to perform and easier to remove than classic vertical mattress sutures 7

Important Considerations

Technique Selection

• For shallow defects requiring minimal dead space closure: Choose fully buried horizontal mattress 3
• For deep defects requiring significant dead space closure: Consider fully buried vertical mattress instead 3
• For facial closures prioritizing cosmesis: Select running horizontal mattress 4

Potential Pitfalls

• Avoid locking sutures in perineal repairs as they can cause excessive tension leading to tissue edema and necrosis 1
• Avoid transcutaneous interrupted suturing on sensitive skin surfaces as it can damage nerve endings and increase pain 1
• Ensure proper tension to prevent ischemia or wound dehiscence 2

Material Selection

• Monophil fiber with atraumatic threading is optimal for continuous sutures 5
• For obstetrical repairs, delayed absorbable sutures such as polyglactin or poliglecaprone are recommended 1, 6

By selecting the appropriate suture technique based on the specific surgical scenario and anatomical location, surgeons can optimize wound healing, minimize complications, and improve both functional and cosmetic outcomes.