This is a niche technique used for securing bolsters over top of skin grafts. It represents a running suture approach for tying over a bolster dressing, which was traditionally performed with multiple interrupted sutures tying down a bolster dressing.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Generally, a 5-0 or 6-0 nonabsorbable monofilament suture is appropriate, as the suture is not designed to bear significant tension.

1. 
   

   After securing the graft in place, the needle is inserted at the 3 o’clock position, 5-mm lateral to the graft edge perpendicular to the epidermis and tangential to the angle of the graft.

   
   
2. 
   

   With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits 2-3 mm distant from the entry point.

   
   
3. 
   

   The free end of the suture may be secured with a hemostat.

   
   
4. 
   

   The suture is then similarly inserted at the 9 o’clock position relative to the graft, following steps (1) and (2).

   
   
5. 
   

   The suture is then similarly inserted at the 12 o’clock position relative to the graft, following steps (1) and (2).

   
   
6. 
   

   The suture is then similarly inserted at the 6 o’clock position relative to the graft, following steps (1) and (2).

   
   
7. 
   

   The needle is passed around the suture material segment between the 9 o’clock and 12 o’clock position.

   
   
8. 
   

   Nonadherent dressing and gauze are then cut to size and slipped over top of the graft in the desired position by passing them through the approximately 5 o’clock position.

   
   
9. 
   

   The ends of the suture material may be pulled toward the 3 and 9 o’clock positions to tighten. The suture material is then tied off gently over top of the bolster, securing the bolster in place (Figure 5-35A).