This is a niche technique useful for reducing the size of a defect prior to flap or graft repair in wounds under marked tension. It is most commonly employed on the scalp, trunk, and extremities, though its use has been described elsewhere as well. It should probably be avoided on the face, where possible anatomical distortion, as well as the long-term fibrotic bands from the placement of these sutures, are undesirable. Of note, this technique does not entirely close a defect; instead, it serves to pull the wound edges closer together, reducing the size of the defect prior to definitive closure.

Suture choice is dependent in large part on location. Since this technique is designed to hold a fair amount of tension, generally a 3-0 or 2-0 absorbable suture is appropriate. As a large amount of suture material will remain relatively superficially in the bed of the wound, longer-lasting absorbable suture material (such as polydioxanone) should probably be avoided.

1. 
   

   The desired axis of partial wound closure is visualized, and the wound edge on one side of the desired axis is reflected back using surgical forceps or hooks. 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 7-9 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by traversing the dermis following the curvature of the needle and allowing the needle to exit closer to the incised wound edge. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle does not, however, exit through the incised wound edge, but rather 5 mm distant from the incised edge. The size of this first bite is based on the size of the needle and the thickness of the dermis.

   
   
4. 
   

   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, assuring complete visualization of the underside of the dermis.

   
   
5. 
   

   The second bite is executed by inserting the needle into the underside of the dermis 5 mm distant from the incised wound edge. Again, this bite should be performed by following the curvature of the needle and avoiding catching the undersurface of the epidermis that could result in epidermal dimpling. It then exits further distal to the wound edge, approximately 6-9 mm distant from the wound edge. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   The suture material is then pulled centrally, reducing the size of the open wound, and the suture material is tied utilizing an instrument tie. Hand tying may be utilized as well. The use of an assistant to hold the wound edges in place as far medially as possible may be helpful (Figures 4-29A, 4-29B, 4-29C, 4-29D, 4-29E.