When to Use Horizontal Sutures
Horizontal mattress sutures are primarily recommended for wounds under tension, when wound edges need to be brought together over a distance, and for promoting wound edge eversion to minimize scarring. 1
Indications for Horizontal Mattress Sutures
Horizontal mattress sutures are particularly beneficial in the following situations:
- High-tension wounds: When wound edges must be approximated over a distance 2
- Areas requiring wound edge eversion: To produce less prominent scarring by preventing inversion of wound edges 2
- Corner closures: For angled skin flaps or wounds (corner stitch variation) 2
- Special populations: May be preferred in both young and elderly patients when using absorbable materials like polydioxanone (PDS) 3
Advantages of Horizontal Mattress Sutures
- Provides excellent wound edge eversion
- Distributes tension across a wider area of tissue
- Reduces the risk of wound dehiscence in high-tension areas
- Can be used to close both deep and superficial layers in one technique (subcutaneous loop variation) 4
Limitations and Considerations
- Higher risk of "railroad track" scarring if left in place too long 2
- May cause more tissue strangulation if placed too tightly
- Requires early removal (typically 7-10 days) to minimize scarring 1
- May be associated with increased erythema compared to subcuticular techniques 3
Alternative Approaches
For many routine closures, especially in abdominal surgeries, subcuticular continuous sutures are preferred due to:
- Lower rates of surgical site infections (SSI) 1
- Reduced wound dehiscence compared to interrupted sutures 1
- No need for removal when using absorbable materials 1
- Better cosmetic outcomes in many cases 3
Special Considerations for High-Risk Patients
For patients with factors that may impair wound healing, horizontal mattress sutures may be particularly beneficial:
- Patients with increased tension in the incision
- Preoperative severe malnutrition
- Immunocompromised patients
- Patients with previous fascial defects
- Cases with massive contamination 5
Practical Application
When using horizontal mattress sutures:
- Use appropriate suture material (monofilament often preferred)
- Consider antimicrobial-coated sutures for contaminated wounds 5
- Remove sutures within 7-10 days to minimize scarring 1
- Monitor for signs of infection or tissue strangulation
For optimal outcomes, the choice between horizontal mattress, vertical mattress, or subcuticular sutures should be based on wound characteristics, location, and patient factors that influence healing.