🎥 Video: A Suture Technique for High Tensioned Wounds

Do you find it challenging to close a high tensioned wound and need a suture technique to help minimize scarring? We’ve all been there.  If you are finding that as you are placing your deep sutures and you are just not quite getting the wound edge eversion you like because of its pronounced tension, and you would like a little help…well, the best technique to help achieve that is the - Horizontal Interrupted Mattress (HIM) technique. 

🎥 Watch VIDEO here to see how to perform it with quick tips to be mindful of!

The picture on the left shows an excision I marked to treat a BCC on the left posterior shoulder.  This wound is moderately tensioned. As I was deciding how to close this wound, I was mindful of the fact that this was a highly “functional” anatomic area. He was an active patient, and I was anticipating this patient would be using his arm, inadvertently pulling on his surgery site, despite the wound care instructions recommending him not to. 

So with this thought process, the HIM technique was a good option because I did not want the risk of the wound dehiscing (technique shown in middle picture).  The option of placing interrupted sutures, compared to a running suture, always provides better wound support just in case one knot decides to unravel.

I also like the option of using the HIM because it helps achieve a more pronounced wound edge eversion. Eversion is necessary to help minimize scarring. Notice in the middle picture how it gives that raised ridge look?  When the wound stretches, pulls, and contracts with time, this raised ridge acts like I buffer to help minimize the risk of developing a widened scar line, leaving a finer scar.  

This technique can be used at any anatomic location that needs more eversion after placement of subcuticular sutures.  Examples of wounds that may need more eversion will include delicate places on the face - like the forehead, temple area, and cheeks.   

Non-cosmetic places (e.g. extremities, trunk) may be more challenging to execute due to thicker skin and these areas, more often than not, have more tension.  However, you can see in this example, I was able to apply this technique successfully and the patient healed well.

Take a look at how he healed 7 weeks postoperatively with a finer, less perceptible scar (right pic).

So if your answer is “Yes!”, I actually do need help closing a higher tensioned wound, despite after placing my deeps, then remember this game changer technique to close the wound - the Horizontal Interrupted Mattress (HIM).

Just to wrap it up, here is summary of when to apply this technique, pros, and cons -

APPLICATION -

  • Can be used for atrophic skin as the broader anchoring bites minimizes tissue tear  
  • Can be used as a secondary technique to help with wound edge eversion
  • Can be used for higher tensioned wounds

PROS

  • Can help indirectly ligate a small leaking vessel
  • No suture material is traversing the incised wound edge minimizing track marks
  • 4 point anchoring bites help distribute tension on the wound more evenly
  • Allows better wound edge eversion

CONS

  • Wound edge approximation more difficult to achieve in higher tensioned wounds with thicker skin

EMPOWER YOURSELF WITH THE RIGHT SKILLS

I hope this case study helps give you more insight to better prepare you for the next time you deal with a higher tensioned wound. 

Coming soon, my advanced suturing course for the dermatology NP/PA is opening up for a short amount of time for enrollment. If you want to dive deeper and learn how to master your suturing skills, sign up for the WAITLIST .

It is my mission to empower our community and help you feel more confident in your technique!

Serving with GRATITUDE,

Theresa Talens DNP, FNP-C

P.U.L.S.E. Dermatology & Procedures, Inc.

Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.