Criss-cross tie-over tacking suture, three point suspension suture

Like the tie-over suture, this technique is useful when attempting to recreate a natural sulcus when the defect lies parallel to the sulcus. It may be conceived as a hybrid between the traditional suspension suture and the tie-over suture, as it entails combining a buried vertical mattress suture with an anchoring suture that attaches to deeper structures, but rather than separately executing a buried vertical mattress suture and a tie-over suture these two steps are combined into one. Since its application is limited to areas where the buried vertical mattress suture directly overlies the natural sulcus, this represents a niche technique.

This technique is generally utilized on the face, and therefore the smallest gauge suture material with appropriate tensile strength should be utilized. Generally, a 4-0 or 5-0 absorbable suture material provides adequate security when anchoring to the periosteum. Nonabsorbable material could theoretically be utilized, and may provide a longer-lasting depressive effect on the tissue, but this benefit is likely outweighed by the increased risk of foreign-body reaction and suture material extrusion.

1. 
   

   The wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is desirable.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 4 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by following the needle initially at 90 degrees to the underside of the dermis and then, critically, changing direction by twisting the needle driver so that the needle exits in the incised wound edge. This allows the apex of the bite to remain in the papillary dermis while the needle exits in the incised wound edge at the level of the reticular dermis.

   
   
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 reflected back in a similar fashion as on the first side.

   
   
5. 
   

   The second bite is executed by inserting the needle into the incised wound edge at the level of the reticular dermis. It then angles upward and laterally so that the apex of the needle is at the level of the papillary dermis. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   The suture material is then tied utilizing an instrument tie, but importantly the suture material is not cut, thus leaving a long tail.

   
   
7. 
   

   Once the buried vertical mattress suture has been completed, starting from the side of the tied buried vertical mattress suture where the long tail is present, the needle is blindly inserted through the fat and deeper structures until the bone is reached. A 3-mm bite of the periosteum is then taken, and the needle is brought back up through the soft tissues into the open center of the wound on the contralateral side of the buried vertical mattress suture and lifted above the buried vertical mattress suture.

   
   
8. 
   

   The suture material is then tied to the loose tail over the buried vertical mattress suture using an instrument tie, anchoring down the buried vertical mattress suture (Figures 4-25A, 4-25B, 4-25C, 4-25D, 4-25E).