Vertical and horizontal mattress stitches

What it is

Mattress stitches pass through the skin twice before being tied, so each stitch holds more tissue than a simple one. The vertical mattress goes far-far, then near-near in the same vertical plane: a wide deep bite across the wound, then a small superficial bite back across close to the edges. The deep pass closes dead space and takes tension; the superficial pass lines up and everts the edges, so it is chosen where edges tend to roll in, such as loose or concave skin. The horizontal mattress crosses the wound, moves along parallel to it, and crosses back on the same side, making a box that spreads tension along the wound; it suits high-tension or fragile skin and helps stop oozing. A half-buried horizontal mattress (corner stitch) brings the tip of a flap into place without strangling its blood supply. Both cause more ischaemia and marks than simple stitches, so they are tied gently and often removed earlier or alternated with simple stitches.

Indications

• Vertical mattress: edges that invert, loose or concave skin, and wounds where eversion is hard to achieve.
• Vertical mattress: deeper wounds where one stitch must close dead space and line up the edges.
• Horizontal mattress: wounds under tension, fragile or thin skin (older adults), and to help control oozing edges.
• Half-buried horizontal (corner) stitch: the tip of a triangular flap or a V-shaped laceration.

Contraindications and precautions

• Same as any closure: no infected wounds, abscesses or retained foreign body; late or heavily contaminated wounds need assessment first.
• Mattress stitches strangle more tissue: avoid them on skin with poor blood supply unless tied loosely, or use the corner stitch.
• They leave more marks; on the face they are used sparingly and removed early.
• Very high tension is better reduced with deep dermal stitches or undermining by an experienced operator, not by tighter mattresses.
• Deep structure injury or complex wounds go to a senior or specialist.

Equipment

• Sterile gloves, drape, antiseptic and local anaesthetic.
• Needle holder, toothed fine forceps and suture scissors.
• Non-absorbable monofilament skin suture sized for the site.
• Irrigation fluid, gauze and dressing; bolsters (small rolls of gauze) may protect fragile skin under a horizontal mattress.

Step by step (and why)

1. Prepare, anaesthetise and irrigate as for any closure — a clean, numb field comes before any stitch choice.
2. Vertical: enter far from the edge and take a deep bite across to the same far point — the far-far pass takes tension and closes depth.
3. Vertical: reverse the needle, re-enter near the edge on the exit side and take a small superficial bite back — near-near lines up and everts.
4. Vertical: keep both passes in one line at right angles to the wound and tie on the starting side — a twisted plane misaligns the edges.
5. Horizontal: cross the wound as for a simple stitch, then move along parallel to the wound on the far side — this sets the box width.
6. Horizontal: re-enter on that side and cross back at the same depth, then tie beside the first entry — level passes avoid a step.
7. Corner stitch: run the horizontal pass through the dermis of the flap tip only, not its skin surface — the tip keeps its blood supply.
8. Tie gently so the edges meet and evert without blanching — mattresses hold more tissue, so tension causes necrosis faster.
9. Alternate with simple stitches where useful and plan earlier removal — this limits marks while keeping the closure secure.

Complications

• Ischaemia and necrosis of the edges, more likely than with simple stitches, especially when tied tight.
• Suture marks (track marks) from the extra skin passes, worse when left in too long.
• Flap tip necrosis if a corner is closed with ordinary stitches through the tip.
• Infection and dehiscence as with any closure.
• Excessive eversion or a ridge if the near-near bite is too deep.

Next step

• Check edge colour after tying; loosen or replace any stitch that blanches the skin.
• Plan removal at the earliest safe time for the site, sometimes removing mattresses before the simple stitches.
• Dress, advise wound care and warning signs, and check tetanus status.
• Call a senior for flaps with doubtful blood supply, high-tension wounds or complex facial repairs.

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Elsewhere in DurgiPedia

• Healing of skin wounds: first and second intention

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Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Wound Closure Techniques (StatPearls (NCBI Bookshelf), 2023).

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