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to 1 cm away from the wound edge deeply into the wound. It is then passed
through the opposite side and reenters the wound parallel to the initial suture. To
avoid “buckling” and to provide some eversion of the wound edges, the skin must
be entered perpendicularly, and the wound must be entered and exited at the same
depth ( Fig. 110.8 ).

FIGURE 110.8 The horizontal mattress stitch is useful for closing the deep layer in shallow
lacerations and in body areas with little subcutaneous tissue. Certain dyed suture materials may
cause a tattooing of the skin if placed in such a shallow position. (From Grisham J. Wound care.
In: Dieckmann RA, Fiser DH, Selbst SM, eds. Illustrated Textbook of Pediatric Emergency &
Critical Care Procedures . St. Louis, MO: Mosby; 1997:678, reprinted with permission.)

The modified horizontal mattress stitch (half-buried) is often used to close a
flap. It is also called the corner stitch. It relieves intrinsic tension and avoids
vascular compromise when approximating the tip of the flap. Using 5-0 or 6-0
sutures, the provider should enter intact skin across from the apex of the flap and
exit the wound just below the subcuticular plane. The needle should be brought to
the tip of the flap, entering and exiting at the subcuticular plane. Then, the needle
is brought across the edge of the flap in the subcuticular plane and the skin is
exited. A knot should be tied in the usual manner and the tip of the flap brought to
the apex of the wound ( Fig. 110.9 ).
Placing the needle in the flap edge first can be done to repair wounds in which
there is ample perfusion to the flap. The edge of the flap can then be moved back