This technique is designed to either shrink the size of a defect or obviate it entirely, depending on the degree of tension and the size of the defect. It is a niche technique, since the purse-string effect tends to lead to a slight puckering in the surrounding skin, a feature that may be acceptable (and will likely resolve with time) on areas such as the forearms and back but is less desirable in cosmetically sensitive locations such as the face. The running nature of the technique means that compromise at any point in the course of suture placement may result in wound dehiscence, though for this reason a larger gauge suture material is generally utilized.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 nonabsorbable suture material is effective, and on the extremities and scalp, a 3-0 or 4-0 absorbable suture material may be used. Since the technique requires easy pull through of suture material, monofilament nonabsorbable suture is generally preferable.

1. 
   

   The wound edges are broadly undermined.

   
   
2. 
   

   With the tail of the suture material resting between the surgeon and the far end of the wound, the needle is inserted through the epidermis on the far edge of the wound with a trajectory running parallel to the incision. The entry point in the epidermis should be approximately 3-6 mm set-back from the epidermal edge, depending on the thickness of the dermis and the anticipated degree of tension across the closure. The needle, and therefore the suture, should pass through the deep dermis into the undermined space at a uniform depth.

   
   
3. 
   

   The needle is then grasped with the surgical pickups and simultaneously released by the hand holding the needle driver. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to repeat the previous step to the left of the previously placed suture.

   
   
4. 
   

   A small amount of suture material is pulled through and the needle is inserted into the dermis to the left of the previously placed suture, and the same movement is repeated.

   
   
5. 
   

   The same technique is repeated moving stepwise around the entire wound until the needle exits close to the original entry point at the far end of the wound. Once the point closest to the surgeon is reached, it may be more comfortable to shift to a backhand technique.

   
   
6. 
   

   Once the desired number of throws has been placed, the suture material is then pulled taut, leading to complete or partial closure of the wound, and tied utilizing an instrument tie. Alternatively, a hand tie may be used if desired (Figures 5-26A, 5-26B, 5-26C, 5-26D, 5-26E, 5-26F, 5-26G).