This technique is best used in areas under very significant tension. Wounds under marked tension may be challenging to close even with well-placed buried sutures. The double butterfly suture technique relies on the pulley effect of multiple horizontally oriented diagonal loops of suture to permit the closure of wounds under even significant tension. Since the loops are horizontally oriented, a broader bite of dermis is included with each throw, adding to the theoretical robustness of this closure technique.

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 gauge 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 approximately 3 mm set-back from the medial edge of the dermis at the base of the bevel. 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, similarly setback from the incised wound edge.

   
   
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 bite is executed by inserting the needle into the undersurface of the dermis on the contralateral side distal to the exit point, with a backhand technique if desired and the needle still pointing in the same direction as the first throw, and completing a loop that forms an S when viewed along with the first loop.

   
   
7. 
   

   The needle is then reinserted into the contralateral wound edge in line with its exit point, now heading toward the surgeon, in a mirror image of step (6).

   
   
8. 
   

   Finally, the needle is then reinserted into the contralateral side in a mirror image of the first throw (step 4). Thus, the entry point of the first suture loop and the exit point of the last suture loop are directly across from each other on the undersurface of the dermis.

   
   
9. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-20A, 4-20B, 4-20C, 4-20D, 4-20E, 4-20F, 4-20G, 4-20H, 4-20I, 4-20J).