Horizontal Mattress Suture

Horizontal Mattress Suture Tutorial


In this guide, I will be discussing how to place an horizontal mattress stitch, assuming you have already learned how to hold suture instruments, tie surgical knots with instruments, and place simple interrupted stitches.

Although I believe there are few indications for the use of this technique, it can be useful for producing eversion of the wound edges and controlling bleeding of the wound edges. I will provide a step-by-step process for placing the horizontal mattress stitch.

I will also introduce the half-buried horizontal mattress and the three-point stitch, which are used for closing the tips of flaps. Additionally, I will list the required instruments/supplies, such as a needle driver, scissors, a suture on a curved needle, an artificial skin substitute, and a toothed forceps.

For those who want to enhance their learning experience, I recommend our suture practice kit and complete suturing course.

NOTE: This tutorial assumes that you have read and practiced

  1. How to hold suture instruments
  2. How to tie surgical knots with instruments
  3. Simple interrupted suture guide


Let me give you my opinion regarding the use of horizontal mattress stitches – I think there are very few indications for the use of this technique.

The main reason I teach it is to introduce the techniques of the half-buried horizontal mattress and its cousin, what I call the three point stitch for closing the tips of flaps.

Some folks use the horizontal mattress stitch to close wounds in the palm of the hand and I cannot argue with that as this technique will:

  • Produce eversion of the wound edges. 
  • Help control bleeding of the wound edges. 

Why do I not like this suture technique for standard wound closure?

It can leave very bad “track marks” on either side of the wound AND it tends to crush the wound edges -which is why it helps control bleeding from wound edges.


  • Needle driver – aka needle holder
  • Scissors
  • A suture on a curved needle (a larger needle will be easier to learn with). Use a 3-0 or 4-0 suture material.
  • An artificial skin substitute
  • A toothed forceps


If you know how to place a simple interrupted stitch, then the horizontal mattress is DEAD SIMPLE.

Just as the vertical mattress is two simple interrupted stitches stacked one over the other – one going right and the second going left – the horizontal mattress is two simple interrupted stitches placed side by side – one going right and the other going left.  Let me show you. 

First, place a simple interrupted stitch – exactly as you would normally do – needle in and out of the skin perpendicular to the skin surface (So as to get more tissue in the depth than near the surface and therefore EVERT the wound edges.) 

Next, turn the needle around in the driver (Just as you did when placing the second pass of the vertical mattress – so you are now sewing “backhanded”.) 

Then, move down the wound edge about 4-5mm and  place a SECOND INTERRUPTED STITCH (sewing backhanded) – exactly as you placed the first one – ie. a simple interrupted stitch designed to evert the wound edges – but this time sewing backhanded ie. going from left to right.  

At this point it should look like two simple interrupted stitches, one placed going right and the other placed going left, each separated by about 4-5mm. 

Finally, tie a knot and tighten the stitch.  As you tighten the knot LOOK AT THE WOUND EDGES.  Just as the wound edges come together and start to EVERT – STOP TIGHTENING.  If it is too loose the edges won’t come together BUT if it is TOO TIGHT, you start to strangulate the tissues – leading to decreased blood supply to wound edges and poor scar. 

That’s it! It is simple and easy once you know how to do a well-placed simple interrupted stitch.

But remember, the only reason I teach you how to place this stitch is the introduce the half-buried horizontal mattress and the most important – three point stitch – used in closing the tip of a skin flap.

To enhance your learning experience, purchase our suture practice kit and course.


Our suture practice kit is a comprehensive package that contains all the necessary instruments, sutures, an artificial skin pad, an instructional card, and a unique case that allows you to practice at the optimal surgical distance, no matter where you are. Additionally, this kit can be transformed into an advanced first aid kit by attaching an accompanying case.

To ensure that you learn the necessary techniques effectively, we offer seven days of online teaching that covers knot tying, instrument ties, hand ties, simple interrupted, vertical mattress, horizontal mattress, half-buried horizontal mattress, the "three-point" suture, deep suture placement with buried knots, running stitches, and running subcuticular stitches. Each day's lesson also includes several tips to enhance your wound-closing skills. All techniques are demonstrated through video and still images for clarity.


How to Perform a Horizontal Mattress Suture Video

In this video, Dr. Naysmith covers how to perform a horizontal mattress suture stitch. 

Horizontal Mattress Suture Video Transcript 

The horizontal mattress suture. Have a look at this diagrammatically see if you can see what's going on. Just as vertical mattress is essentially two simple interrupted sutures, one stacked upon the other vertically, the horizontal mattress suture is actually two simple interrupted sutures but this time placed side by side in parallel.

So how do we make a horizontal mattress suture? Well it's pretty well dead easy. You place a simple interrupted stitch—your best simple interrupted just as you did for any simple interrupted. This is interrupted number one, we'll call it. You then turn the needle backhand on the needle driver and you come in at 90 degrees and place the second interrupted suture exactly as an interrupted suture. The thing to notice is we move down the wound and the other thing to notice is the distance between the wound edge and the stitch is the same here and here and here. And when we put the final pass through, you guessed it, the distance from the wound edge is the same here.

So we're this far so we're going to tie it. You can see it's just two simple interrupted's one going from right to left and the other going from left to right exactly as you would place a single one just two side by side. Now you do have to turn the needle around and you do have to sew backhand but that's not a big deal.

When we tighten it up this everts the wound edge very nicely.

So the question now comes as to when would I use a horizontal mattress suture, and how would I use it. Let's have a look at it clinically first. We're going to put it in one simple interrupted there it is we turn the needle back hand on the needle driver now same distance from the edge same distance from the edge. You can see we go down the wound and then that distance that distance that distance and that distance all the same. And you can see how well it everts the wound edges it just pops them straight up.

And have a look you'll see there's enough that you can actually see on the edge that you could cut the stitch out from the left hand side of this there it is and you want it that wide.

So the question now is when do I use this thing. Well I have to tell you frankly not very often. This isn't a stitch which is required too often. It is good at wound edge aversion and it's really good at stopping bleeding if you've got a lot of bleeding on the wound edge but you're basically stopping bleeding by crushing the tissue and that's the problem is that when you put this one in it crushes tissue it tends to devascularize them and this leads to increased scarring.

So I guess the real question is if that's what this thing's all about why would you ever bother learning this one well it's because the cousin of the horizontal mattress the half buried horizontal mattress and the three-point suture are absolutely imperative to know and if you know how to place a horizontal mattress suture it's ever so easy to understand the half-buried horizontal mattress suture and the three-point suture as you'll see

so now it's your turn to do this so make your incision in the foam put a simple interrupted stitch in in this case we're going all the way through with one pass and make sure you're a little bit aways from the wind edges then move down the wound

backhand the stitch by back loading it on the needle driver and look here where that much distance that much distance we're going to move down the wound and we're going to be the same distance away from the wound edge when we place this

and when we come out on this side we're going to try and be pretty much the same distance out so we have two simple interrupteds in absolute parallel to each other and we've done it by just moving down the wound a little bit all these distances are the same

then just your standard square knot

and even on the foam you'll see that the wound edges pick up but you'll also see that it crushes that foam in between the loops of the stitch

so the half-buried horizontal mattress suture and the three-point suture both essentially the same things looks kind of like this and this is just a modification of the horizontal mattress

when we look at this it's not difficult to understand why these are important when you see the three-point stitch if you're going to be closing wounds like this seeing trauma or you're going to be doing reconstructive things like this a little limburg flap we need to know how to do this half buried horizontal mattress suture it's absolutely essential that you know this i'll make that point very clear when we come to show you it diagrammatically

this point comes to this point this point comes to this point you'll see how this closes

let's look at an example of exactly how this goes we'll look at that last lady here's a little basal cell skin cancer and we're going to cut it out in the shape of a rhombus which is also called a limburg flap when we come to close it what we do is we rotate that flat from the side of the cheek down and in but the important thing is these corners have to be put in with a half buried horizontal mattress suture if we're going to keep them alive and minimize scarring

so how do we put in the half-buried horizontal mattress let's look at the straightforward half beard horizontal mattress first we pass the needle through the skin and here you select the depth of the penetration you're going and most of the time it's just going to be in the dermis this is a more superficial stitch than most of the stitches that we've been using so whatever depth we come in there we turn the needle now parallel to the wound edge so we run the needle along the dermis at the same depth that it came out of on the first side this is absolutely critical to get right all of these penetrations have to be at the same level when we put the final pass through likewise it has to be at the same level in the dermis that all of the other stitches have passed

if you don't do that you'll get a step deformity so when we tie this up and this comes together what you'll see is that there's only stitch on one side of the wound the other side is being held by that little loop of suture and it's brought together nicely so this is a pretty important one that we would use we don't want to see scar on one side of the wound that sort of thing and this is a much more superficial stitch than anything else we've ever seen

again I have make this point all these penetrations at the same depth from the surface of the skin

so when should you use it well there's really two indications from my point of view one is when there's differing thicknesses of skin being brought together for example if you're moving in a flap from someplace else you can actually adjust the thickness by putting this stitch in and just getting the skin edges to come together nicely the other is where you don't want suture marks on one side of the wound and for me this means uh on the facelift i'll put this stitch in on the hair bearing portion and then pick up the non-hair bearing portion with the buried bit i'll show you an example of this

before I show you the clinical example let's take your turn to practice uh make your incision in the foam come in and here you're gonna come a bit more tangential you're gonna come out in the red we're going to be right in the dermis on this one come through and then

look at the wound edge we're going to be exactly the same depth and we're running parallel to the skin surface here with the needle so we run down a length of the dermis now we backhand the needle and we're going to go in at exactly the same depth on this side that we started with on the first pass and then that second pass on the left side all the same length and we've run down the length of the wound so when we tie this we can actually see the loop of suture so we can take it out so there you go

a little square knot and you'll see it comes together beautifully the skin edges just sort of kiss together and this is a terrific stitch this is one that you really should know it'll help you a lot

so let's have a look at a clinical example of this now the clinical example is going to be a facelift

so here we are in the post regular area I don't want to have a scar on that flap I don't mind having a little in the hair bearing area so i'm going to go through pick up the dermal layer and I run down a length of dermis as you can see i'm going to backhand the needle here come back moving down the wound pop it through the skin

and then when we tie this up you'll see that the skin edges come together with no suture exposed on the flap side of this so there'll be no scar on that side as we move down the wound all of these scars are going to be in the hair bearing area we don't mind that that's not a disaster in any way shape or form so there's limited indications for things you might do but it's really a good trick to have


1 comment

  • David Naysmith

    Thank you for checking out this tutorial on a horizontal mattress suture. Please let me know if you have questions here and I will do my best to answer them.

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