How to Perform a Vertical Mattress Suture [with Video Instructions]

The vertical mattress suture, also known as the far-far-near-near stitch, is your go-to method for secure closures and perfectly everted wound edges. By distributing tension across multiple tissue layers, it keeps wounds aligned and promotes reliable healing.

In this post, you’ll discover when to use vertical mattress sutures, the best materials and tools, step-by-step placement instructions on how to perform a vertical mattress suture. 

What is a Vertical Mattress Suture?

A vertical mattress suture is a percutaneous technique that involves two passes. First, a deep “far” bite placed several millimeters from the wound edge, followed by a shallow “near” bite close to the edge. The suture travels in a vertical plane and mirrors the same pattern on the opposite side of the wound. 

When tied, this configuration naturally everts the edges, keeping them properly aligned and reducing the risk of inversion.

This method is favored because it combines strength with precision. The deep bite distributes tension across the tissue, preventing the suture from cutting through, while the superficial bite ensures accurate epidermal alignment. 

Together, these two layers make vertical mattress sutures especially effective for high-tension wounds where simple interrupted sutures might fail or leave edges inverted.

Indications

• High-tension wounds on extremities, back, or joints where strong holding power is essential
• Areas where wound edges tend to invert naturally, such as concave surfaces or loose skin
• Thick skin requiring both deep tissue approximation and superficial edge control
• Wounds where excellent edge eversion is critical for optimal cosmetic healing
• Scalp lacerations where hemostasis and strong closure matter simultaneously

Contraindications

• Facial wounds where visible suture marks would compromise cosmesis
• Areas with compromised vascular supply where tissue strangulation risk is high
• Very thin or friable skin that may tear with the multiple passes required
• Infected or heavily contaminated wounds where buried suture would harbor bacteria
• Areas requiring subcuticular closure for optimal aesthetic results

Tools & Materials Needed for Vertical Mattress Sutures

Proper equipment selection directly impacts your ability to place vertical mattress sutures effectively. The technique's requirement for both deep and superficial passes through tissue demands specific needle and suture characteristics.

1. Needles

Cutting or reverse-cutting needles are designed to pass easily through tough dermis and fascia without requiring excessive force. 

The 3/8-circle configuration provides a smooth, controlled arc, making it suitable for both deep and superficial tissue passes. 

To ensure proper wound closure, the needle size should be matched to the tissue thickness and is usually larger than those used for simple interrupted sutures.

2. Suture Materials

Non-absorbable monofilament sutures such as nylon or polypropylene are commonly used in high-tension areas where long-term support is needed. 

When suture removal is difficult or only temporary support is required, absorbable materials like polyglactin (Vicryl) are a practical alternative. 

For most body locations, 3-0 or 4-0 sutures provide an appropriate balance of strength and control, with adjustments based on wound size and tension.

In very high-tension areas, such as the back or over joints, larger sutures like 2-0 are typically preferred.

3. Essential Instruments

A needle driver with a secure grip is essential for precise control as the needle passes through multiple tissue planes. 

Toothed forceps help manipulate tissue and maintain proper wound edge alignment during closure. Suture scissors allow for clean, accurate cutting without fraying the material.

To maintain aseptic technique, a sterile drape and properly prepared field should be used throughout the procedure. 

Local anesthetic ensures patient comfort, while an irrigation solution is necessary for thorough wound cleaning before closure. Finally, antiseptic preparation helps reduce the risk of infection in the closed wound.

Patient Preparation and Wound Assessment Before Suturing

Begin by assessing the wound’s depth, contamination, tissue health, and tension. Once evaluated, clean the area thoroughly with sterile saline to remove debris and contaminants. 

After cleaning, administer local anesthesia to ensure the patient remains comfortable throughout the procedure.

Next, decide if vertical mattress sutures suit the wound. They work best for high-tension wounds, edges that tend to invert, or cases needing strong hemostasis.

For superficial, low-tension wounds, simpler techniques like interrupted or subcuticular sutures may give better cosmetic results.

If deep dead space is present, place deep dermal sutures first before using a vertical mattress for the superficial closure.

Finally, leave the stitches in place long enough to allow proper healing before removal.

What are the Differences Between Vertical and Horizontal Mattress Techniques?

Understanding how a vertical mattress differs from its horizontal counterpart helps you choose appropriately for specific clinical situations.

Knowing the differences between vertical and horizontal mattress sutures allows you to select the technique that best meets the wound’s needs. Choosing correctly ensures optimal edge alignment, tension distribution, and overall healing outcomes.

How to Perform Vertical Mattress Sutures

Video by Stanford Surger, “Vertical Mattress Suture”, YouTube.

1. Wash hands, wear gloves, and prepare a sterile field. Assemble needle holder, forceps, scissors, and the suture material. Identify the wound edges and clean the area.
2. Insert the needle about 4–8 mm from the wound edge on one side, pass it through the full thickness of the tissue, and exit the same distance from the wound edge on the opposite side. This is the deep bite that provides wound tension.
3. Reinsert the needle close to the wound edge (1–2 mm from the edge) on the opposite side, pass it superficially through the tissue, and exit near the starting point on the original side. This superficial bite everts the wound edges.
4. Bring the two ends of the suture together and tie a secure surgical knot, ensuring the wound edges are everted but not overly tight.
5. Cut the suture ends to the appropriate length, leaving enough to avoid slippage. Check that the wound edges are well approximated and everted.
6. Place additional vertical mattress sutures along the wound at regular intervals, maintaining even tension and proper spacing.
7. Inspect the wound for proper alignment and tension, clean the area, and provide instructions for aftercare.

Common Mistakes When Performing Vertical Mattress Sutures & How to Avoid Them

Technical errors with vertical mattress sutures often result from misunderstanding the spatial relationships between passes or applying inappropriate tension.

Practice Your Vertical Mattress Suture Technique with Artagia Med's Training Kits

Developing confidence with vertical mattress sutures demands repeated practice with realistic materials. 

The Advanced Suture Practice Kit for Medical Students from Artagia Med delivers comprehensive training through its 35-piece set including practice pads that simulate actual tissue, complete surgical instruments, and varied suture materials. 

Beginners benefit from starting with the Basic Surgical Knot Tying Practice Board Kit, which builds essential knot-tying skills and proper instrument handling. 

As proficiency grows, the Advanced Surgical Knot Tying Board Kit introduces variable tension settings and anatomical markers that prepare you for real clinical challenges. 

Order your training kits today to develop the technical skills that translate directly to confident, competent wound closure in practice.