This is a niche technique designed for wounds with an atrophic dermis, where standard suturing techniques result in significant tissue tear through due to atrophic skin. By placing adhesive strips on the skin surrounding the wound, the skin’s resistance to tear through is increased substantially, permitting closures on even very atrophic lower leg and forearm skin.

With this technique, sterile adhesive strips are included on the surgical tray. Other forms of sterile tape or adhesive dressings may be used as well.

On the forearms, 4-0 monofilament nonabsorbable suture may be used, while on the lower legs a 3-0 monofilament suture may be more effective.

1. 
   

   The adhesive strips are placed on the skin surrounding the wound. They should be placed immediately adjacent to the wound margin on dry skin to facilitate adhesiveness.

   
   
2. 
   

   Horizontal mattress sutures are then placed, passing through both the skin and adhesive strips. The needle is inserted perpendicular to the adhesive strip and epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

   
   
3. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side, piercing the skin and adhesive strip.

   
   
4. 
   

   The needle is then reloaded in a backhand fashion and inserted at 90-degrees perpendicular to the epidermis and adhesive strip proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.

   
   
5. 
   

   The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of steps (2) and (3).

   
   
6. 
   

   The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-32A, 5-32B, 5-32C, 5-32D, 5-32E, 5-32F, 5-31G).