This is a niche technique used for reducing the appearance of dog ears, or standing cones, at the ends of elliptical excisions or local flaps. While dog-ear minimization is generally accomplished by excising lesions with fusiform incisions, this often extends the length of the wound significantly, which is undesirable. This technique was designed as an approach to mitigate the raised dog-ear appearance of the standing cone while concomitantly avoiding unnecessarily extending the length of the wound.

Suture choice is dependent in large part on location. Since this technique is designed to bite the deep dermis and the underlying fascia or periosteum, the surgeon may choose to utilize a larger gauge suture than would be used for an equivalently placed buried suture. On the back and extremities, a 2-0, 3-0 or 4-0 absorbable suture material may be used, and on the face and other areas under minimal tension a 4-0 or 5-0 absorbable suture is adequate.

1. 
   

   The apex of the wound where the incipient dog ear is anticipated is widely undermined. The wound edge at this apex is reflected back using surgical forceps or hooks, and adequate visualization of the underside of the dermis is required.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 4-6 mm distant from the apex.

   
   
3. 
   

   The first bite is executed by traversing the dermis following the curvature of the needle and allowing the needle to exit farther from the incised wound edge. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle exits approximately 8-mm distant from the incised edge, though this depends on the size of the standing cone that is being smoothed. Keeping the loose end of suture between the surgeon and the patient, the dermis is released.

   
   
4. 
   

   The standing cone may be gently pulled by the suture material so that the location of the first bite directly overlies the planned fixation point. This permits the surgeon to double-check the final position of the suture. The needle is then blindly inserted through the fat and deeper structures until bone is reached. A 3-mm bite of the periosteum or fascia is then taken, and the needle is brought back up through the soft tissues into the open center of the wound.

   
   
5. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-30A, 4-30B, 4-30C, 4-30D).