Atlas of Primary Care Procedures, 1st Edition



Vertical Mattress Suture Placement

The vertical mattress suture is unsurpassed in its ability to evert skin wound edges. The vertical mattress suture is commonly employed where wound edges tend to invert, such as on the posterior neck, behind the ear, in the groin, in the inframammary crease, or within concave body surfaces. Because lax skin may also invert, the vertical mattress stitch has been advocated for closure on the dorsum of the hand and over the elbow.

The vertical mattress suture incorporates a large amount of tissue within the passage of the suture loops and provides good tensile strength in closing wound edges over a distance. The vertical mattress suture can be used as the anchoring stitch when moving a skin flap or at the center of a large wound. The suture also can accomplish deep and superficial closure with a single suture. The vertical mattress suture can provide deeper wound support in situations when buried subcutaneous closure is not advisable (e.g., facial skin flaps). Early removal of vertical mattress sutures is advocated, especially if nearby simple interrupted sutures can remain in place for the normal duration.

A major drawback to the routine use of vertical mattress sutures on cosmetically important areas is the development of crosshatch marks (i.e., railroad marks or Frankenstein marks) from the suture loops on the skin surface. After placement of a vertical mattress suture, the natural process of wound inflammation and scar retraction pulls the externalized loops inward. The resulting pressure necrosis and scarring is worsened if the vertical mattress suture is tied too tightly or if a large-caliber suture (3-0 or 4-0 USP) material is used.

A variation of the vertical mattress suture, known as the shorthand technique or near-near/far-far technique, has been advocated by some physicians. The variation places the near-near pass of suture first, allowing the clinician to pull up the suture strings to elevate the skin for placement of the far-far loop. The variation is advocated because it can be placed more rapidly than the classic technique. Unfortunately, the skin can tear when lifting the skin after the initial pass. This tendency for wound edge tearing causes some clinicians to pass the near-near loop deeper and wider, diminishing some of the eversion benefit of the standard vertical mattress technique. Only the classic technique is demonstrated in this chapter.



  • Closure of wounds that tend to invert (e.g., back of the neck, groin, inframammary crease, behind the ear)
  • Closure of lax skin (e.g., dorsum of the hand, over the elbow)
  • Anchoring stitch when moving a skin flap




The far-far pass is made with the suture needle entering and exiting the anesthetized skin 4 to 8 mm from the wound edge (Figure 1A). The suture needle should pass vertically through the skin surface. The far-far suture must be placed at the same distance and the same depth from the wound edge (Figure 1B).


(1) The far-far pass is made with the suture needle entering and exiting the anesthetized skin 4 to 8 mm from the wound edge.

PITFALL: Pass the suture needle symmetrically through the tissue. Asymmetric bites through the wound edge cause one edge to be higher than the other. The creation of a shelf, with one wound edge higher, produces cosmetically inferior scars that are prominent because they cast a shadow.

Place the needle backwards in the needle driver. The near-near pass is made shallow, within 1 to 2 mm of the wound edge, using a backhand pass. The near-near pass should be within the dermis.


(2) Place the needle backwards in the needle driver.



Tie the suture snugly but gently (Figure 3A). Tight sutures produce crosshatch marks (Figure 3B).


(3) Tie the suture snugly but gently.

PITFALL: Novice physicians often tie the suture tightly to produce additional eversion. Avoid this temptation, because it results in increased wound scarring.

The vertical mattress suture can act as the anchoring suture when moving a skin flap into place.


(4) The vertical mattress suture can act as the anchoring suture when moving a skin flap into place.




The mattress suture closures are considered a variation of single-layered closure, and the codes 12001–12021 apply for wound repair.Chapter 14 lists the codes for simple skin suture placement.


The standard instruments used for office surgery are also used for mattress suture closure (see Appendix A). Suggested suture removal times are listed in Appendix C, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H.


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