Like traditional running buried sutures, this is a hybrid technique, combining the tension relief and lack of transepidermal suture placement of a classic buried suture with the rapidity of placement and lack of resilience of a superficial running technique. This is therefore a niche approach, since the running nature of the technique means that compromise at any point in the course of suture placement may result in wound dehiscence. It does afford the advantage of the knot resting in the center of the wound, which may reduce the tendency for the central portions of the wound to gape open. Still, unless truly needed, this approach should not be utilized as a solitary technique for the closure of most wounds.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 suture material is effective, though if there is marked tension across the wound this approach would not be appropriate as the primary closure, and would be used best for its pulley benefits. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate. Since the technique requires easy pull through of suture material, monofilament absorbable suture is probably preferable.

1. 
   

   At the midpoint of the wound, the wound edge is reflected back using surgical forceps or hooks.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 2-mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by following the curvature of the needle and allowing the needle to exit in the incised wound edge. The size of this bite is based on the size of the needle, the thickness of the dermis, and the need for and tolerance of eversion. The needle’s zenith with respect to the wound surface should be between the entry and exit points.

   
   
4. 
   

   Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then gently grasped with the forceps.

   
   
5. 
   

   The second bite is executed by inserting the needle into the incised wound edge at the level of the superficial papillary dermis. This bite should be completed by following the curvature of the needle and avoiding catching the undersurface of the epidermis that could result in epidermal dimpling. It then exits approximately 2-mm distal to the wound edge on the undersurface of the dermis. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   Instead of tying the suture, a tail is left protruding from this first set of sutures and may be secured with a hemostat.

   
   
7. 
   

   Moving superiorly toward the distal pole of the wound, the procedure is then repeated sequentially, repeating steps (2) through (5) while moving distally toward the apex for as many throws as are desired, without placing any additional knots.

   
   
8. 
   

   Once the superior-most set of throws is placed, the needle is passed beneath all of the previously placed sets of sutures until it exits proximal to the starting point at the midpoint of the wound. Only then are the ends of the suture material pulled to effect partial closure of the distal portion of the wound.

   
   
9. 
   

   Starting at the inferior or proximal apex, steps (2) through (5) are then repeated, with the pairs of sutures moving upward toward the center of the wound.

   
   
10. 
    

    Once the desired number of throws have been placed, and the midpoint of the wound has been reached, the suture material is then pulled taut, leading to complete closure of the wound, and tied utilizing an instrument tie (Figures 4-35A, 4-35B, 4-35C, 4-35D, 4-35E, 4-35F, 4-35G, 4-35H, 4-35I, 4-35J).