This technique is designed for wounds under marked tension, especially those on the back and shoulders. It is a deep technique, permitting the tension of wound closure to shift from the dermis to the fascia, concomitantly creating a lower-tension closure which is associated with less scar spread. In addition to tension reduction, this approach also leads to an increase in the apparent length to width ratio of an excised ellipse and improved dead-space minimization.

Suture choice is dependent in large part on location. As this technique is designed to bite the fascia, generally a larger-gauge suture can be utilized. Therefore, for the back and shoulders a 2-0 or 3-0 absorbable suture may be used. Since suture material traverses the fascia, the incidence of suture abscess formation is vanishingly rare. If this technique is used on the scalp or forehead, a 4-0 absorbable suture may be used.

1. 
   

   The wound edges are reflected back to permit visualization of the deep bed of the wound. In deep excisions, such as those performed for melanoma or large cysts, the muscle fascia may be directly visible. Otherwise, visualizing the subcutaneous fat is appropriate as well.

   
   
2. 
   

   The suture needle is inserted at 90 degrees through the deep fat 2-4 mm medial to the lateral undermined edge of the wound.

   
   
3. 
   

   The first bite is executed by entering the fascia and following the curvature of the needle. The suture material may be gently pulled to test that a successful bite of fascia has been taken.

   
   
4. 
   

   Keeping the loose end of suture between the surgeon and the patient, attention is then shifted to the opposite side of the wound. The second bite is executed by repeating the procedure on the contralateral side.

   
   
5. 
   

   The suture material is then tied utilizing an instrument tie. Hand tying may be utilized as well, particularly if the wound is deep and the instruments cannot be easily inserted to complete the tie (Figures 4-26A, 4-26B, 4-26C, 4-26D, 4-26E, 4-26F, 4-26G).