Atlas of Primary Care Procedures, 1st Edition



Horizontal Mattress Suture Placement

The horizontal mattress suture is an everting suture technique that allows for separated wound edges to be approximated. The horizontal mattress suture spreads the closure tension along the wound edge by incorporating a large amount of tissue within the passage of the suture thread. The technique is commonly employed for pulling wound edges over a distance or as the initial suture to anchor two wound edges (e.g., holding a skin flap in place).

Thin skin tends to tear with placement of simple, interrupted sutures. The horizontal mattress suture is effective in the closure of fragile, elderly skin or the skin of individuals receiving chronic steroid therapy. The horizontal mattress suture technique also is effective in closing defects of thin skin on the eyelid and the finger and toe web spaces. Control of bleeding is another advantage of this suture. Hemostasis develops when a large amount of tissue is incorporated within the passage of a suture. The technique can produce effective bleeding control on vascular tissues such as the scalp.

Certain skin defects tend to have the skin edges roll inward. Inversion of the wound edge can retard healing and promote wound complications. The horizontal mattress suture produces strong everting forces on the wound edge and can prevent inversion in susceptible wounds in the intergluteal cleft, groin, or posterior neck.

After placement of horizontal mattress sutures, the loops of suture thread that remain above the skin surface can compress the skin and produce pressure necrosis and scarring. This scarring potential limits the use of the horizontal mattress sutures on the face. Pressure injury commonly develops when the sutures are tied too tightly. Bolsters are compressible cushions placed within the extracutaneous loops of suture to prevent pressure injury to the skin. Some of the commonly used materials in bolsters include plastic tubing, cardboard, and gauze.

Skin compression injury can be reduced by early removal of horizontal mattress sutures. Some authorities recommend removal in 3 to 5 days, with the surrounding interrupted sutures left in place longer. Early suture removal is especially valuable when the horizontal mattress technique is employed in cosmetically important body locations such as the head and neck.



  • Closure of thin or atrophic skin (e.g., elderly skin, eyelids, individuals on chronic steroid therapy)
  • Eversion of skin defects prone to inversion (e.g., posterior neck, groin, intergluteal skin defects)
  • Closure of bleeding scalp wounds
  • Closure of web space skin defects (e.g., finger or toe web spaces)




The suture needle is passed from the right side of the wound to the left side of the wound (Figure 1A). The entry and exit sites of the wound generally are 4 to 8 mm from the wound edge. Do not tie the suture! The needle is placed backward in the needle driver (Figure 1B), and then the suture is passed back from the left side to the right side (Figure 1C). The second pass of the suture is 4 to 8 mm down the wound edge (Figure 1D).


(1) The horizontal mattress suture.



The horizontal mattress suture is tied, producing skin edge eversion (Figure 2A). Tying the suture tightly produces extra eversion (Figure 2B).


(2) Avoid the temptation to tie the horizontal mattress suture tightly, because tight knots often produce skin pressure necrosis.

PITFALL: Although the added eversion may appear beneficial at the time of wound closure, tight knots often produce skin pressure necrosis. Avoid the temptation to tie the horizontal mattress suture tightly.

Bolsters can cushion the skin from the pressure produced by the extracutaneous loops of a horizontal mattress suture. Gauze is used in these bolsters.


(3) Use bolsters to cushion the skin from the pressure produced by the extracutaneous loops of a horizontal mattress suture.



Multiple horizontal mattress sutures are used to close a finger web wound (Figures 4A and 4B).


(4) Use multiple horizontal mattress sutures to close a finger web wound.

This wound in the groin is prone to inversion (Figure 5A). The horizontal mattress suture can effectively evert the edges (Figure 5B).


(5) Closure of skin defects prone to inversion.




The mattress suture closures are considered a variation of single-layered closure, and the codes 12001–12021 apply for wound repair.Chapter 14 provides a list of these codes.


The standard instruments used for office surgery are also used for mattress suture closure (see Appendix A). 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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