This is a niche technique used for closure, hemostasis, and epidermal approximation of select wounds. It may be conceptualized as a simple running suture that is performed without an anchoring knot and that, when the terminus is reached, travels in the opposite direction toward the original wound apex. While it demonstrates an elegant and symmetrical postoperative appearance, it also entails the placement of a greater number of transepidermal sutures while providing little extra in terms of functional benefit, and therefore is used only infrequently.

As with all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Suture choice will depend largely on anatomic location and the goal of suture placement. The cross stitch may be utilized either to aid in wound-edge approximation or to help with hemostasis. In the latter case, slightly thicker suture material may be utilized.

On the face, a 6-0 or 7-0 monofilament suture may be used for epidermal approximation. Indeed, 5-0 or 6-0 monofilament may be used on the extremities as well, though 4-0 monofilament suture may be utilized in areas under moderate tension where the goal of suture placement is relieving tension and hemostasis as well as epidermal approximation.

1. 
   

   The needle is inserted perpendicular to the 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.

   
   
2. 
   

   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.

   
   
3. 
   

   The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

   
   
4. 
   

   A tail of free suture material is then left, and no knot is tied. A hemostat may be used to clamp the tail of the suture to avoid the risk of pulling it through during the subsequent steps.

   
   
5. 
   

   Starting proximal to the prior knot relative to the surgeon, steps (1) through (3) are then repeated sequentially and the needle is advanced along the course of the wound until the contralateral apex is reached.

   
   
6. 
   

   Once the apex is reached, steps (1) through (3) are then repeated heading in the contralateral direction, again advancing along the wound, but now with entry and exit points crossing the previously placed line of sutures, forming an X appearance.

   
   
7. 
   

   Once the apex is reached, the leading end of the suture is tied to the tail end of the suture using an instrument tie (Figures 5-37A, 5-37B, 5-37C, 5-37D, 5-37E, 5-37F, 5-37G).