What are common mistakes made with vertical mattress suturing and how can they be avoided?

Common Mistakes in Vertical Mattress Suturing

The most critical mistake with vertical mattress suturing is applying excessive tension, which causes tissue blanching, ischemia, and ultimately necrosis, along with prominent "railroad track" scarring if sutures are left in place too long.

Key Technical Errors and Prevention

Excessive Tension and Tissue Strangulation

• Tying sutures too tightly causes tissue blanching and compromises perfusion, leading to wound edge necrosis and poor healing outcomes 1
• The suture should achieve approximation without visible blanching of tissue—if the tissue turns white, the tension is excessive 1
• Hypereversion of wound edges occurs when vertical mattress sutures are tied too tightly, creating an unnatural wound contour 2

Railroad Track Scarring

• Leaving vertical mattress sutures in place beyond 5-7 days for facial wounds or 7-10 days for body locations causes permanent "railroad marks" from the external suture bites 1, 3
• Early suture removal is essential to limit surface scarring damage 3
• The American Academy of Dermatology recommends facial suture removal after 5-7 days specifically to minimize this complication 1

Improper Suture Material Selection

• Using multifilament sutures increases bacterial seeding and infection risk—monofilament sutures (5-0 or 6-0 for face, 4-0 or 5-0 for body) should be preferred 1
• Monofilament sutures cause less tissue drag and reduce infection rates compared to braided materials 4

Inadequate Wound Assessment Before Closure

• Attempting closure without adequate debridement or in the presence of active infection leads to wound complications 1
• Failing to recognize appropriate timing windows: facial wounds can be closed up to 24 hours post-injury due to excellent vascular supply, but most body locations should be closed within 12-24 hours 1

Technical Execution Pitfalls

Bite Depth and Placement Errors

• Taking excessively deep passes through tissue layers risks nerve entrapment and compression 4
• Placing sutures over soft tissue alone rather than ensuring bony support (when applicable) can lead to tissue distortion and nerve compression 4
• Long scleral passes increase vector forces and can compromise wound edge re-approximation 1

Suture Removal Difficulties

• The classic vertical mattress technique creates multiple externalized loops that make removal more uncomfortable for patients and time-consuming for staff 2
• Difficulty grasping externalized loops during removal is a recognized disadvantage of traditional vertical mattress technique 2

Alternative Approaches to Consider

Modified Techniques for Better Outcomes

• The modified buried vertical mattress suture produces less hypertrophic scar/keloid formation (2% vs 16%) and less wound spread (6% vs 24%) compared to conventional techniques 5
• Running combined simple and vertical mattress sutures prevent both inversion and hypereversion while reducing procedure time 2
• The shorthand vertical mattress technique provides equivalent wound eversion in half the time of classic technique without compromising results 6