LETTERS AND COMMUNICATIONS

5. Becker RC. Aspirin and the prevention of venous thromboembolism. N Scott Fosko, MD
Engl J Med 2012;366:2028–30.
Department of Dermatology
Anna Lyubchik, BA Mayo Clinic
Stony Brook University School of Medicine St. Louis, Missouri
Department of Dermatology
Stony Brook, New York
Jordan Slutsky, MD
Department of Dermatology
Kyle Xu, MD Stony Brook University School of Medicine
Division of Plastic and Reconstructive Surgery Stony Brook, New York
Department of Surgery
Saint Louis University School of Medicine The authors have indicated no significant interest with
St. Louis, Missouri commercial supporters.

The Buried Half Horizontal, Half Vertical Mattress Suture: A Novel Technique for Wound Edges of
Unequal Lengths

Wound edges in dermatologic surgery are often
unequal in length, and they may result from crescentic
excision or repair of a Mohs micrographic surgery
defect. A novel suture technique combining a buried
half horizontal and half vertical mattress, which the
authors abbreviate: “Hovert,” is primarily used to
reduce length discrepancy, distribute tension evenly
along the length of the wound, and preempt the need
for standing cone excision.
Method
of the longer wound edge with minimal tension as one
closes from one end to the other.
This technique is best performed using a Precision-3 (P-3)
needle. The smaller bite of the needle (approximately 5–
10 mm) avoids excessive bunching of skin. The P-3 needle
is clamped below the shank, so only half of the full cur-
vature passes through the tissue. In addition, one can pull
the suture ends less tightly before tying to avoid over-
correction of the longer edge. However, even if bunching
is noted, the experience of the authors suggests that this

The Hovert can close any curvilinear wound or defect

with unequal wound edges. Starting on the longer
wound edge, a buried suture is placed horizontally in
the deep dermis following the arc of the needle (Figure
1). On the opposite and shorter side, the needle is
placed in the same dermal plane, but the needle is
oriented vertically and positioned at the midpoint of
where the horizontal suture would meet the opposing
wound edge. The suture is tied at the lower end of the
half vertical mattress and buried, approximating the
longer wound edge to the shorter wound edge.

This technique is repeated along the wound edge in an

interrupted fashion. The Hovert is best initiated at one
Figure 1. Schematic illustration of the buried half hori-
of the lateral apices of the excision (Figure 2) rather zontal and halfvertical mattress suture prior to tying
than in the middle, permitting progressive shortening a surgeon’s knot.

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 LETTERS AND COMMUNICATIONS
Figure 2. Two-dimensional model for length reduction in
a buried half horizontal and half vertical mattress suture, in
which D1 = initial horizontal bite diameter and D2 = tied
horizontal suture diameter. Assuming the suture is
inelastic and the dermal skin is pliable, but not com-
pressible, then the area enclosed by the suture within
both figures is the same. Using the formula for the area
of a circle, Area = pr2, we can derive the following:
1/2 p(D1/2)2 = p(D2/2)2, D2 = 0.707 D1.
will settle down over time. Transepidermal sutures may
be placed to correct any step-offs, and a specific tech-
nique, the “running pleated” suture, has been described.1
Although the Hovert is useful in most locations, it is less
optimal for areas of thin dermis (periorbital) and highly
sebaceous tissue (nasal). The former because the suture
will be forced too superficially, and the latter because any
suture in the sebaceous plane would be too inflammatory
and lead to possible dehiscence.
Discussion
Unequal wound edge lengths need to be equalized to
avoid contour deformities from standing cones.
Reported solutions include the “rule of halves”2
(RoH) and the “running pleated”1 suturing methods
Figure 3. Preoperative photograph of crescentic defect with
the superior edge (9 cm) longer than the inferior edge (6 cm).
1392 DERMATOLOGIC SURGERY
© 2016 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Figure 4. Crescentic defect repaired with the buried half
horizontal and half vertical mattress suture. (A) An imme-
diately postoperative photograph with a final wound
length of 6 cm. (B) A 3-month postoperative photograph
with a final wound length of 6 cm. Note the eversion
without evidence of ischemic necrosis.
to avoid standing cone excisions. Not mutually
exclusive of the above, the Hovert is a buried suture
technique that progressively reduces the length of the
longer wound edge and distributes tension evenly.
In a theoretical 2-dimensional mathematical model,
assuming the dermal skin is noncompressible and the
suture is inelastic, a minimum reduction of 29% on the
buried horizontal mattress edge is visualized in Figure 2.
The initial bite is depicted to enclose a semicircle of
dermal skin, and after tying the knot, the encircled skin
is deformed into its equilibratory form of a full circle of
the same area, whereby the outward pressure exerted
by the dermis on the suture would be equal at every
point of the circle’s perimeter. This model is an under-
estimation of the length reduction because the dermal
skin is variably elastic and compressible, and may shift
3 dimensionally, thus resulting in a smaller full circle
and even greater length reduction after knot tying.
Vascular compromise is not an issue with the Hovert
because the horizontal suture is on the wound edge with
the greater length and vascular surface area.
Starting the Hovert at a wound apex allows for a more
effective method of suturing in regards to managing
tension and maintaining suture integrity. Suture place-
ment in the RoH begins at the middle of the defect, which
corresponds to the widest gap and the area of greatest
tension. Closing a wound first at the area of maximal
tension can result in wound edge misalignment,
 LETTERS AND COMMUNICATIONS

excessive tissue stretch, tearing, and vascular compro-
mise. In contrast, the Hovert suture permits the initiation
at the lateral edge, which is the point of lowest tension.
Each subsequent Hovert continues in a setting of low
tension because the defect is progressively closed.
In terms of suture integrity, the issue of working space
is relevant. In order to enter deep and exit superficially
in a vertical mattress, one must maneuver the needle
through the space from the bottom of the wound
defect to the top (vertical space) and the gap between
cone excision. The hybrid technique combines the
benefits of a vertical and horizontal buried mattress,
permitting hemostasis, firm closure, and even dis-
tribution of tension. Moreover, this method is
adaptable and can be used in conjunction with other
epidermal closure techniques.
References
1. Kouba D, Miller S. “Running pleated” suture technique opposes wound
edges of unequal lengths. Dermatol Surg 2006;32:411–4.

the 2 wound edges at the surface (horizontal space). 2. Weisberg N, Nehal K, Zide B. Dog ears: a review. Dermatol Surg 2004;
26:363–70.
Placing 2-sided vertical mattresses in the RoH pro-
gressively tightens and constricts the working space
Wesley Wu, MD
horizontally and vertically on both sides of the defect,
Department of Dermatology
thereby inhibiting optimal placement of subsequent
Baylor College of Medicine
sutures. Conversely, the Hovert requires more of
Houston, Texas
a horizontal working space than a vertical space. With
a progressively narrow horizontal space, the hori-
zontal suture may be adjusted using less of the needle’s Arianne Chavez-Frazier, MD
curvature via choking down from the shank, and final Park Avenue Dermatology
sutures are as well placed as preceding ones. Orange Park, Florida

In the senior author’s experience (T.N.), the Hovert Michael Migden, MD

method is easier, faster, and more effective. Sutures are Department of Dermatology
tied in low tension, and there is no struggle to The University of Texas MD Anderson Cancer Center
maneuver the needle in the cramped quarters of Houston, Texas
a shrinking working space. Figures 3 and 4 demon-
strate long-term integrity of the shortened scar line. Tri Nguyen, MD
Texas Surgical Dermatology
Conclusion Houston, Texas

The Hovert is an efficient method for reducing The authors have indicated no significant interest with
wound length discrepancy and the need for standing commercial supporters.

Tricks and Tips for Manual Dermabrasion

Manual dermabrasion with sterile sandpaper
is a commonly used cosmetic surgery procedure1
to treat acne scars, or scars from accidents or
previous surgery, 2 as well as fine facial
wrinkles.
Compared to tool-operated dermabrasion, this tech-
nique offers a variety of advantages, including limited
cost and minimal set up. However, sandpaper
dermabrasion requires sterilization which limits the
application of the procedure as an office treatment.
We would like to suggest a new, simple relia-
ble, inexpensive manual dermabrasion
technique performed with a presterilized scratch
pad (Figure 1).

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