What are the steps for performing a Haeney (horizontal mattress) suture?

Horizontal Mattress Suture Technique

The horizontal mattress suture is performed by first entering the skin 4-8mm from the wound edge, passing through the dermis to exit on the opposite side at the same distance, then re-entering 4-8mm lateral to the exit point and passing back across to exit near the original entry point, creating a rectangular pattern that provides excellent wound eversion and tension distribution. 1

Step-by-Step Technique

Initial Needle Entry and First Pass

• Enter the needle perpendicular to the skin surface, 4-8mm from the wound edge (distance varies based on wound tension and tissue thickness) 1
• Pass the needle through the full thickness of the dermis, exiting on the opposite wound edge at the same distance from the edge 1
• Ensure the needle path is at uniform depth to maintain consistent tissue approximation 2

Return Pass (Second Bite)

• Re-enter the skin 4-8mm lateral to your exit point, maintaining the same distance from the wound edge 1
• Pass back across the wound, exiting 4-8mm lateral to your original entry point 1
• This creates a rectangular configuration with the suture running parallel to the wound edge on both sides 1

Knot Tying and Tension Management

• Tie the knot with appropriate tension to achieve wound edge eversion without strangulation 2, 1
• The suture should bring wound edges together under tension when needed, particularly useful for wounds requiring closure over distance 1
• Avoid excessive tightness that can compromise tissue perfusion and lead to necrosis 3

Key Technical Considerations

Wound Eversion Achievement

• The horizontal mattress inherently promotes excellent wound edge eversion, which is critical for optimal healing and cosmetic outcomes 2, 1
• This technique significantly reduces wound dehiscence compared to simple interrupted sutures (demonstrated in oral surgery with p=0.017) 4

Cosmetic Applications

• Running horizontal mattress sutures produce superior cosmetic results compared to simple running sutures on facial wounds, with 25 of 47 patients showing better outcomes at 6 months versus only 5 showing worse results 5
• The final scar appears smoother and flatter than traditional simple running sutures 5

Suture Material Selection

• Use 5-0 or 6-0 monofilament non-absorbable sutures (nylon or polypropylene) for facial applications 3
• For body locations, 4-0 or 5-0 monofilament sutures are appropriate 3
• Monofilament reduces bacterial seeding and infection risk 3

Critical Pitfalls to Avoid

Railroad Track Scarring

• Horizontal mattress sutures can produce surface scarring or "railroad marks" if left in place too long 1
• Remove facial sutures after 5-7 days to minimize this complication 3, 1
• For body locations, removal at 7-10 days is appropriate 6

Tissue Strangulation

• Long scleral passes increase vector forces for wound edge re-approximation, but excessive tension causes tissue ischemia 7
• The suture should achieve approximation without blanching of tissue 3

Wound Assessment Before Closure

• Ensure adequate debridement and absence of active infection 3
• Facial wounds can be closed up to 24 hours post-injury due to excellent vascular supply 3
• Most body locations should be closed within 12-24 hours 3

Advantages Over Alternative Techniques

• Provides superior wound eversion compared to simple interrupted sutures 2, 1
• Distributes tension more evenly along wound edges than interrupted techniques 2
• More effective at preventing wound dehiscence than simple interrupted sutures 4
• Can be performed as running technique for faster closure with excellent cosmetic results 5
• Particularly useful for closing wounds under tension or over distance 1