anatomy, followed by key stitches.
One-sample t-tests Conclusions
showed that the importance given to these video elements
were statistically significantly different than a hypothetical
average of random rankings (Figure 1).
Video-recording procedures were most frequently per-
formed for educational purposes or conference presenta-
tions (40/44). Social media (8/44) and patient care (7/44)
were among the least common reasons.
Discussion
This study suggests that videography is infrequently used by
ACMS members to record dermatologic procedures. This is
in stark contrast to the high numbers of dermatologic
surgeons who perform photography.1 Using the opinions of
practicing ACMS surgeons, we propose inclusion of critical
elements of procedural technique for clinical videography to
support its wider practice.
Videography is distinctly superior to photography for
Mohs surgery given the dynamic and 3-dimensional nature
of the procedure. Videography during Mohs has also
demonstrated benefit regarding patient education and
satisfaction,2 evaluation of resident surgical skills,3,4 and
postsurgical wound care intervention.5 Despite their utility,
videos which contain elementary surgical details—such as
achieving hemostasis—may be unnecessarily long and
detract from other important educational topics.
Using the above gathered data and our clinical experi-
ence at OHSU, we propose a standardized approach and
methodology for video-recording surgical reconstruction
procedures. In the attached online video, we highlight the
top 4-ranked videography elements (skin marking and
repair design, primary and secondary flap motion, under-
mining and elevating repair in correct depth with respect to
underlying anatomy, and key stitches) in order of clinical
and educational importance as perceived by practicing
ACMS surgeons (See Video 1, Supplemental Digital
Content 1, http://links.lww.com/DSS/A438). We hypothe-
size that standardization of video presentations will
highlight desired criteria, reduce barriers to videography
in clinical practice, improve educational outcomes, and
support accurate patient expectations of cosmetic outcome.
We acknowledge the inherent limitations surrounding
this study’s sample size and response rate. Furthermore,
only fellowship-trained Mohs surgeons were surveyed,
limiting external validity among other dermatologists and
dermatologic surgeons.
How We Do It: The Subcutaneous Inverted Looped Horizontal Mattress Stitch:
A Novel and Efficient Design for High-Tension Dermal Closures
I n cutaneous surgery, tissue eversion, precise approxi-
mation of epidermal edges, and minimization of tension
on the wound are important factors in achieving both
proper healing and optimal cosmesis of sutured defects. For
716 DERMATOLOGIC SURGERY • May 2021 • Volume 47 • Number 5
© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Among ACMS surgeons surveyed, video recording of
dermatologic procedures was uncommon and considerably
less prevalent than clinical photography. We propose a
standardized approach highlighting the top-ranked videog-
raphy elements as perceived by ACMS surgeons to
standardize surgical video presentations.
Acknowledgments
This publication was made possible with support from the Knight
Cancer Institute Biostatistics Shared Resource at Oregon Health
and Science University (NCI Cancer Center Support Grant P30
CA069533).
References
1. Rimoin L, Haberle S, DeLong Aspey L, Grant-Kels JM, et al. Informed
consent, use, and storage of digital photography among Mohs sur-
geons in the United States. Dermatol Surg 2016;42:305–9.
2. Newsom E, Lee E, Rossi A, Dusza S, et al. Modernizing the Mohs
surgery consultation: instituting a video module for improved patient
education and satisfaction. Dermatol Surg 2018;44:778–84.
3. Alam M, Nodzenski M, Yoo S, Poon E, et al. Objective structured
assessment of technical skills in elliptical excision repair of senior
dermatology residents: a multirater, blinded study of operating room
video recordings. JAMA Dermatol 2014;150:608–12.
4. Liu KJ, Tkachenko E, Waldman A, Boskovski MT, et al. A video-based,
flipped classroom, simulation curriculum for dermatologic surgery: a pro-
spective, multi-institution study. JAAD 2019;81:1271–6.
5. Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video
modules for delivery of informed consent and wound care education in the
Mohs Surgery Unit. Semin Cutan Med Surg 2008;27:89–93.
Erika L. Hagstrom, MD, MA*
Dylan Haynes, BS*
Emile Latour, MS*
Justin J. Leitenberger, MD*
*All authors are affiliated with the
Department of Dermatology
Oregon Health and Science University
Portland, Oregon
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article on the
journal’s Web site (www.dermatologicsurgery.org).
The authors have indicated no significant interest with
commercial supporters.
these reasons, a layered skin closure approach is often used,
and the proper placement of buried absorbable dermal su-
tures is a key step in promoting wound edge approximation,
eliminating dead space, and off-loading tension from the
www.dermatologicsurgery.org
 epidermal layer.1 For direct closure of extremely wide de-
fects or smaller defects located in high-tension areas (e.g.,
the scalp, back, anterior chest, or shins), placement of the
initial dermal stitches can be especially challenging.
For decades, reconstructive surgeons have developed and
modified a variety of deep suturing techniques specifically
designed for high-tension cutaneous tissue. Commonly used
techniques include the following: buried vertical mattress,
double butterfly, buried pulley, and subcutaneous inverted
cross mattress.2–5 Here, we aim to introduce and describe
the utility of the subcutaneous inverted looped horizontal
mattress (SILHM), a novel buried design that combines the
benefits of tension distribution along the wound edges of a
horizontal mattress with the mechanical advantage of
pulley stitches. To the authors’ knowledge, this suture
design has not been previously described in the literature.
Technique
The lesion of concern is completely excised, and its free
edges are undermined in the subcutaneous plane to free
them for approximation. The SILHM stitch, then, is
described as follows (diagrammatically in Figure 1 and
clinically in Figure 3).
Step 1
Complete a full traditional intradermal stitch, starting in the
infradermal plane, 3 to 5 mm lateral to the wound edge
(Figure 1A).
Step 2
Have an assistant hold the loose end of the thread
perpendicular to the wound and loop the needle around
Figure 1. Step-by-step illustration of the subcutaneous inverted
looped horizontal mattress stitch. (A) Completion of a first in-
tradermal stitch. (B) Looping of the needle around the loose
thread followed by advancement along the wound edge to begin
a second intradermal stitch on the same side of the wound. (C)
Completion of the second intradermal stitch. (D) Knot tying deep,
in the center of the 2 placed sutures with the loose ends of the
suture creating a moving pulley.
Communications
© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
the thread; then, advance along the wound edge to re-enter
the infradermal plane on the same side of the wound to
begin a second, full intradermal stitch (Figure 1B, C).
Step 3
Retrieve the loose end of the thread and tie a knot in the
center between the 2 intradermal stitches (Figure 1D).
When the traditional percutaneous horizontal mattress
design is inverted and buried within the dermal layer, the
resulting suture trajectory becomes analogous to 2 consec-
utive intradermal stitches arranged in series (Figure 2). Such a
suture, without a central interlocking step, does not
effectively approximate opposing wound edges, nor does it
incur a significant mechanical advantage. A key step of the
proposed SILHM design is the looping of the needle around
the loose end (Figure 1B) of the thread after the first
intradermal stitch but before the second. Tying the 2 loose
ends of the thread in the center of the suture creates an
interlocked loop and transforms the SILHM design into a
horizontally oriented pulley stitch, with the centrally located
loop functioning as a moving pulley (Figure 1D, 2 and 3J). As
the knot is tied, the wound edges are pulled together from the
center, while opposing tension vectors within the interlocked
loop prevent the knot from coming loose (Figure 3K).
Discussion
When compared with simple interrupted subcutaneous
stiches, the SILHM stitch—like other buried mattress suture
designs5—recruits a greater amount of tissue per length of
thread used and knot tied and more efficiently approximates
wound edges. When compared with simple interrupted
subcutaneous stitches, the SILHM stitch—like other buried
pulley stitches3–5—offers mechanical advantage and requires
significantly less input force to overcome the opposing tissue
tension during the approximation of wound edges.
The SILHM stitch is technically straightforward and can
be readily performed by any cutaneous surgeon, regardless
of experience. It is well-suited for areas of moderate to high
tension but especially well-suited for areas of extremely high
tension, where it offers several advantages over other buried
suture designs. Securing a tight knot with the initial buried
stitches of other suture designs is challenging because of the
likelihood of knot slippage and wound reopening between
Figure 2. Schematic illustration of the traditional, inverted sub-
cutaneous and looped horizontal mattress suture trajectories.
The looping results in a moving pulley (shown in blue).
www.dermatologicsurgery.org 717
 Figure 3. Series of photographs depicting the
implementation of the SILHM stitch on a
high-tension surgical wound located on the
anterior shin. (A, B) Completion of first in-
tradermal stitch. (C) Needle looped around
the loose end suspended by an assisting
hand. (D) Needle re-enters the infradermal
plane on the same edge of the wound, di-
rectly lateral to the last exit point. (E) Creation
of deep central pulley as needle exits the
superficial dermis on the superior edge of the
wound. (F) Completion of the final in-
tradermal stitch as the needle re-enters the
opposite, inferior edge of the wound at the
level of the superficial dermis, and (G) exits
on the infradermal plane. (H–K) Surgeon re-
trieves both ends of the suture and applies
tension resulting in facile approximation of
the 2 skin edges without separation due to
the deep moving pulley created from the
central loop. The suture is subsequently tied
resulting in secure deep knot placement in
between the 2 placed sutures. (L) High-ten-
sion wound closure achieved with a single
central SILHM stitch and 6 additional simple
intradermal interrupted stitches (Note: gauze
and prolene suture used only for visualization
purposes).

throws. This often requires the use of assisting hands, References

clamping devices, or temporary stitches, which can reduce 1. Weitzul S, Taylor RS. Suture techniques and other closure mate-
the efficiency of closure. The built-in looped interlocking rials. In: Robinson JK, Hanke CW, Senglemann RD, Siegel DM,
editors. Surgery of the Skin. New York, NY: Elseveir; 2005; pp.
design of the SILHM, however, keeps the knot in position
225–44.
because it is being tightened and immediately incorporates 2. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg
any input of approximating force into the system, even Oncol 1989;15:17–9.
before a second and securing knot throw (Figure 3H–K). 3. Breuninger H. Double butterfly suture for high tension: abroadly an-
Once the knot is tightened and secured around the central chored, horizontal, buried interrupted suture. Dermatol Surg 2000;26:
loop, tension vectors around the knot are distributed among 215–8.
4 opposing directions, which is an arrangement that further 4. Giandoni MB, Grabski WJ. Surgical pearl: the dermal buried pulley
suture. J Am Acad Dermatol 1994;30:1012–3.
contributes to knot stability. Thus, the SILHM stitch
5. Yag-Howard C. Novel surgical approach to subcutaneous closure: the
virtually eliminates the need for temporary assisting subcutaneous inverted cross mattress stitch (SICM Stitch). Dermatol
techniques or repeated attempts due to knot slippage. Surg 2011;10:1503–5.
Because the risk of knot slippage is minimized, the
suture’s coefficient of friction and tissue grip are less of a
Denise N. Clark, MSc*
concern. Therefore, the surgeon may safely use a mono- Gerard M. Guillot, III, PhD†
filament absorbable material such as polydioxanone suture, Ally-Khan Somani, MD, PhD*
which slides easily through tissue and is associated with *Division of Dermatologic Surgery
prolonged time to absorption, maximal tensile strength, and and Cutaneous Oncology
low tissue reactivity.1 Because the looped design always Department of Dermatology
places the secured knot deeply between the 2 approximated Indiana University School of Medicine
wound edges, effectively burying it in the center of the Indianapolis, Indiana
suture, the risk of inflammation and foreign body reaction is †Center for Medical Education
further minimized. Finally, in the senior author’s experi- Indiana University School of Medicine
ence, the SILHM stitch is also an excellent option for dermal Muncie, Indiana
closures in spaces with relatively little room to maneuver,
such as small, tight scalp defects and delicate flaps, allowing The authors have indicated no significant interest with
one to place 2 sutures with a single knot. commercial supporters.

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© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.