The pulley suture technique relies on the pulley effect of multiple loops of suture to permit the closure of wounds under even significant tension. Since this approach may lead to marked tension across the wound surface, it is typically used in scalp reduction surgery or other areas where the final cosmesis is less critical. This approach may also be used as a temporary technique to better approximate wound edges and allow deep sutures to be placed expeditiously, after which the pulley sutures may be removed.

Suture choice is dependent in large part on location, though because this technique is expressly designed for wounds under marked tension, a 3-0 nonabsorbable suture works well on the scalp and back, though when the area is under particularly marked tension a 2-0 nonabsorbable suture may be helpful.

1. 
   

   The needle is inserted perpendicular to the epidermis, approximately 8-12 mm distant to the wound edge.

   
   
2. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits between the incised wound edges.

   
   
3. 
   

   The needle is then reloaded and reinserted from the underside of the dermis on the contralateral wound edge, exiting approximately 4 mm from the wound edge. The exit point is just distal (relative to the surgeon) from the entry point on the original side.

   
   
4. 
   

   The needle is then reloaded and inserted at 90 degrees perpendicular to the epidermis approximately 4 mm from the wound edge on the contralateral side of the incision line (the original entry side).

   
   
5. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits between the incised wound edges.

   
   
6. 
   

   The needle is then reloaded and reinserted from the underside of the dermis on the contralateral wound edge, exiting approximately 8-12 mm from the wound edge. The exit point is just proximal (relative to the surgeon) from the entry point.

   
   
7. 
   

   The suture material is then tied off (Figures 5-25A, 5-25B, 5-25C, 5-25D, 5-25E, 5-25F, 5-25G).