The butterfly suture technique is a buried technique designed for wounds under moderate to marked tension. It is best utilized on the trunk and shoulders, where the combination of a thick dermis and the need for marked tension relief make it an occasionally useful approach.

As always, suture material choice depends on preference and location. Though this technique is designed for wounds under significant tension on the trunk it is commonly utilized with a 3-0 suture. While adopting a 2-0 suture material is sometimes useful, especially to avoid bending smaller needles, the knot for this suture is buried in line with the incision and at the base of the dermis and therefore suture material spitting is a risk. Use of an absorbable monofilament (polydioxanone) has been proposed as providing superior outcomes over a braided absorbable suture.

1. 
   

   This technique ideally requires that the wound edges be incised with a reverse bevel, allowing the epidermis to overhang the dermis in the center of the wound.

   
   
2. 
   

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

   
   
3. 
   

   While reflecting back the dermis, the suture needle is inserted into the undersurface of the dermis near the junction of the base of the incised wound edge and the undersurface of the undermined dermis. The needle driver is held like a pencil at 90 degrees to the incised wound edge and the needle may be held on the needle driver at an oblique angle to facilitate suture placement.

   
   
4. 
   

   The first bite is executed by placing gentle pressure on the needle so that it moves laterally and upward, forming a horizontal loop that on cross section resembles the wing of a butterfly. The needle then exits the undersurface of the dermis after following its curvature, in the same plane as its entrance point.

   
   
5. 
   

   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.

   
   
6. 
   

   The second and final bite is executed by inserting the needle into the undersurface of the dermis on the contralateral side, with a backhand technique if desired, and completing a mirror-image loop. The suture material exits directly across from its initial entry point.

   
   
7. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-5 A, 4-5B, 4-5C, 4-5D, 4-5E).