This technique is designed for wounds under marked tension, especially those on the scalp and upper forehead. It is a deep tissue support technique, permitting the tension of wound closure to shift from the dermis to the galea or fascia, thereby creating a lower-tension closure that is associated with less scar-spread. Like the fascial plication technique, 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 galea or the undersurface of the deep fat, generally a 3-0 (on the scalp), 4-0, or even 5-0 absorbable suture may be used. Since suture material is left deep to the subcutaneous fat, the incidence of suture abscess formation is vanishingly rare.

1. 
   

   After adequate undermining in the subgaleal (on the scalp and upper forehead) or suprafrontalis (on the lower forehead) plane, and after any lagging fat has been extirpated, the wound edges are reflected back using surgical forceps or hooks.

   
   
2. 
   

   While reflecting back the wound edge, including the galea (or deep fat, as applicable), the suture needle is inserted at 90 degrees into the underside of the deep tissue 4-8 mm distant from the incised wound edge, but medial to the edge of the undermined plane.

   
   
3. 
   

   The first bite is executed by entering the deep tissue and following the curvature of the needle parallel to the wound edge. The suture material may be gently pulled to test that a successful bite of deep tissue 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 4-28A, 4-28B, 4-28C, 4-28D).