This technique is a workhorse approach that is widely utilized by dermatologists and plastic surgeons. It is best used in areas under mild to moderate tension, and is a highly effective approach that may be utilized on the face, as well as the extremities and trunk.

Because of the need to shift planes and the fact that the needle travels in the papillary dermis, this technique may not be particularly well suited to areas with atrophic skin.

Suture choice is dependent in large part on location, though since suture material traverses the papillary dermis and the incised wound edge, 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 theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material. This needs to be weighed against the benefit of utilizing a larger CP-2 needle, which will almost never bend even in the thickest dermis, and the benefit of adopting the 2-0 suture material, which is less likely to snap under tension or fail during tension-bearing activities, leading to attendant dehiscence. 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.

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 and final bite is executed by inserting the needle into the incised wound edge at the level of the reticular dermis. It then angles upwards 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 (Figures 4-3A, 4-3B, 4-3C, 4-3D, 4-3E, 4-3F, 4-3G, 4-3H).