When is a horizontal mattress suture indicated and when is it contraindicated?

When to Use Horizontal Mattress Suture

Horizontal mattress sutures are indicated when you need wound edge eversion, hemostasis, closure under moderate-to-high tension, or when closing wounds over a distance—but they should be removed early (5-7 days for face, 7-10 days for body) to prevent railroad track scarring. 1

Primary Indications

High-Tension Wound Closure

• Horizontal mattress sutures excel in high-tension situations where wound edges must be brought together over a distance 1
• They require significantly more pulling force (mean 8.11 N) compared to pulley sutures (3.46 N), making them mechanically robust for tension-bearing wounds 2
• The technique is particularly useful when standard interrupted sutures would create excessive tension on individual points 3

Wound Edge Eversion

• Horizontal mattress sutures promote excellent wound edge eversion, which is critical for optimal cosmetic outcomes and preventing depressed scars 3, 1
• The eversion effect helps ensure that as the wound contracts during healing, edges remain level rather than inverting 1

Hemostasis

• Use horizontal mattress when wound edge compression is needed to control bleeding 4
• The compression effect of the suture provides superior hemostasis compared to simple interrupted sutures 4

Specific Clinical Applications

Surgical Contexts

• In periodontal surgery: Modified vertical mattress combined with single interrupted sutures (5-0 or 6-0 monofilament non-absorbable) achieve primary closure without tension 5
• In cardiac surgery: Pledgeted horizontal mattress sutures using 0 silk are used for diaphragmatic retraction during minimally invasive mitral valve procedures 5
• In diaphragmatic repair: Non-absorbable mattress sutures (2-0 or 1-0) in two layers are the standard for closing diaphragmatic defects 5

Dermatologic Surgery

• For shallow defects or narrow spaces: The fully buried horizontal mattress variant provides excellent approximation when deep stitches are technically difficult 6
• For angled flaps: The corner stitch (horizontal mattress variation) is specifically indicated for closure of angled skin flaps 1

Critical Contraindications and Caveats

Timing of Removal

• Remove facial horizontal mattress sutures at 5-7 days maximum to prevent railroad track scarring 7
• Remove body location sutures at 7-10 days to balance healing with complication prevention 7
• Early removal is non-negotiable—the primary disadvantage of horizontal mattress is surface scarring if left too long 1

Avoid in These Situations

• Do not use when precise wound edge apposition is the priority—horizontal mattress makes exact edge placement more difficult 4
• Avoid in areas where suture marks are unacceptable unless you can guarantee early removal 1
• Consider alternative techniques for very deep defects requiring dead-space closure—fully buried vertical mattress may be preferable 6

Tension Management Pitfall

• Excessive tension causes tissue ischemia and necrosis—the suture should achieve approximation without blanching 7
• While horizontal mattress tolerates tension well, you must still avoid overtightening 2

Practical Algorithm for Selection

Choose horizontal mattress when:

1. Wound edges are under moderate-to-high tension AND
2. You need eversion or hemostasis AND
3. You can commit to early suture removal (5-10 days depending on location) 1, 7

Choose alternative techniques when:

• Precise edge apposition is critical → use simple interrupted 3
• Avoiding suture marks is paramount → use subcuticular 3
• Minimizing pulling force is needed → use pulley suture 2
• Very deep defects require closure → use buried vertical mattress 6

Technical Considerations

Suture Material Selection

• Use 5-0 or 6-0 monofilament non-absorbable for facial applications to minimize infection risk 7
• Use 4-0 or 5-0 monofilament for body locations 7
• Monofilament reduces bacterial seeding compared to braided sutures 7

Enhanced Technique

• The locking horizontal mattress variant facilitates easier removal and provides better control over wound edge placement while maintaining hemostasis and tensile strength 4
• This modification addresses the traditional difficulty with suture removal 4