Like the traditional suspension suture, this is a niche technique designed to fix the edge of a defect to a deeper structure, and may also be utilized typically in three situations: (1) When repairing a defect that crosses a natural sulcus, (2) When working near cosmetic subunit boundaries and free margins, to avoid functional challenges such as ectropion and eclabium, as well as cosmetic distortion of sensitive areas such as the lip and eyebrows, and (3) When fixing a flap in place to minimize tension on the distal portion of the flap.

Since the dermal component of the suture is percutaneous, however, it consistently results in immediate postoperative dimpling. The advocates of this technique have suggested that the dimpling resolves spontaneously over time, though unless the technique is truly necessary in order to be able to fix the tissue—which may be the case if it is challenging to insert the needle and needle driver through an undermined tunnel of skin—it would probably be preferable to perform a standard suspension suture in order to minimize the risk of long-term dimpling at the site of percutaneous suture placement.

Suture choice is dependent in large part on location, though this technique is usually utilized on the face. Since the suture is placed percutaneously, absorbable suture is preferred. A 4-0 or 5-0 absorbable suture may be used on the face. While utilizing smaller gauge absorbable suture material is reasonable, it may not provide sufficient tensile strength to adequately and reliably fix the tissue to the periosteum.

1. 
   

   Unlike the traditional suspension suture, visualization of the percutaneous tacking site on the mobile flap of skin is not necessary.

   
   
2. 
   

   The suture needle is inserted at 90 degrees into the underside of the dermis at the point in the undermined flap where fixation to the underlying anchoring point is desired. The needle then pierces through the epidermis.

   
   
3. 
   

   The first bite is completed by either reinserting the needle back through the epidermis with the twist of a wrist or by grasping the needle where it exits the epidermis and reintroducing it directly down through the epidermis so that it exits 2-4 mm away from the entry point.

   
   
4. 
   

   The flap of skin 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 suspension suture. The needle is then blindly inserted through the fat and deeper structures until the bone is reached. A 3-mm bite of the periosteum is then taken, and the needle is brought back through the soft tissues into the open center of the wound.

   
   
5. 
   

   The suture material is then tied utilizing an instrument tie. Hand tying may be utilized as well, which may be useful if the depth of the defect is significant (Figures 4-23A, 4-23B, 4-23C, 4-23D, 4-23E, 4-23F).