Half Buried Horizontal Mattress Suturing Demonstration

00:04 What are the most common lacerations you'll see in the elderly with fragile skin is called a flap laceration or flap black.

00:11 And what you're seeing in the picture here is a very common look of that.

00:14 You'll see that the very thin skin has had a laceration to some blunt force trauma. They fall down, go boom.

00:21 And then, we're left with this little piece that needs to come back together, and it may or may not stick back in the proper location.

00:28 Sometimes you'll see a loss of tissue on these also.

00:31 The concern is that this may not be a vitalized flap anymore.

00:34 Sometimes they bleed really well from the base of the wound, but the flap itself is devitalized.

00:38 So one of the things that we want to do is put this together in such a way that we're not damaging it.

00:42 Okay, so we don't want to put a bunch of stitches down this, if it's just a little flap there.

00:46 You can kind of see through the skin.

00:48 I'm not talking about young healthy people that we're doing laceration repair on that look like this.

00:52 With those people, you can put a line of simple interrupters down these.

00:55 Go to the problem in the corner, fix a problem that is just two simple lines.

00:58 Okay, don't work down towards the corner and then have a bunch of weird.

01:01 Go to the problem, fix a problem, or changes directions here.

01:04 And then, you have two simple lines that go right in the middle, and just two quarters, eight, sixteenths, until you're done.

01:09 But I'm talking about the laceration that I'm not so sure it's going to really work out so well.

01:13 This tissue is kind of dusky, and gray, and yucky.

01:16 All you want to do - well, I want to get it in its proper location without causing trauma.

01:20 So one thing you need to do is make an invisible line down here and say this is my line. This line right here, I have to start beneath this line to get up into the tissue.

01:29 So when I'm done, my suture is tied down here and not across this right here.

01:35 Okay, so I recommend you start in a backhand.

01:38 And work from underneath that line, and then get up in - whoops, get up in under that tissue. Okay.

01:47 Again, this is large suture. So, you can see what I'm doing.

01:49 In real life will be much smaller than this.

01:54 This is a half buried horizontal mattress stitch.

01:57 I'm just getting into the lower edge.

01:59 I'm not going all the way through the skin.

02:01 See, I'm just kind of barely getting into it, just so I can hold on.

02:06 Okay, that's all it is.

02:10 And then, I'm going to go right back out, down underneath, and beneath that line.

02:18 Okay, so to recap. I poked in, I got deep, came through the tissue deep, came up into this little lack, little flip tip thing here. Get that flipped up, grab this little chunk of this. Don't go through the skin, it's half buried horizontal mattress.

02:32 This is the half buried portion.

02:34 Okay, and then make sure you get back beneath the line on the tip of this apex.

02:38 Because when we pull these together, they're going to go like this.

02:41 Okay, I don't want to have that happening right on top of the tip of that laceration.

02:46 It doesn't make any sense. I'm putting a big knot there.

02:48 And you don't want to poke in from the inside of this first.

02:50 And then head you're knot be there, because again, where you poke in is where you're knot is.

02:53 So always start off with a little lack, off the flap black, and then work your way back out kind of in a little semi circle.

03:00 Okay, so once, twice.

03:06 Okay. And this one, I'm not doing particularly tight.

03:09 I just want this to get grossly approximated.

03:12 So it's together. And that's it.

03:14 I don't want this moving and that's pretty much as tight as I want to be.

03:18 Okay, so this is not going to be a really tight technique, because I don't want to potentially do vitalize or damage that flap.

03:27 Okay, very commonly, after doing this, you may go into throw some Dermabond on that line there on both sides, or maybe just some steri strips across this just to kind of help support it.

03:36 Okay, that said there's other things, we can do some steri strips on here.

03:39 And we can bolster this to make a little stronger.

03:41 But again, that said, not a lot of reason to worry about that.

03:45 For the most part, just get it in place.

03:47 Let's just see what happens. Give it a couple of days and it'll demarcate if it's going to fall off or not.

03:51 Sometimes the very tip of this is garbage or will just die off.

03:54 Everything else would be fine and it's kind of just gets debrided and they have a small area of granulation instead of a big area. Okay.