This is a niche hybrid technique, combining the tension relief and lack of transepidermal suture placement of a classic buried suture with the rapidity of placement and lack of resilience of a superficial running technique and the locking benefit of a running locked suture. The locking loops of suture add significantly to the volume of retained suture material and also make suture placement more challenging to learn than other techniques.

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, a 3-0 suture material is effective, though if there is marked tension across the wound this approach would not be appropriate as the primary closure. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate.

1. 
   

   The wound edge is reflected back using surgical forceps or hooks.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 2 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by following the curvature of the needle and allowing the needle to exit in the incised wound edge. The needle’s zenith with respect to the wound surface should be between the entry and exit points.

   
   
4. 
   

   Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then gently grasped with the forceps.

   
   
5. 
   

   The second bite is executed by inserting the needle into the incised wound edge at the level of the superficial papillary dermis. This bite should be completed by following the curvature of the needle and avoiding catching the undersurface of the epidermis. It then exits approximately 2 mm distal to the wound edge on the undersurface of the dermis. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   This first anchoring set of sutures is then tied with an instrument tie.

   
   
7. 
   

   Moving proximally toward the surgeon, steps (1) through (5) are then repeated, leaving a loop of suture material created between the anchor suture and the start of this second dermal suture protruding from the wound center.

   
   
8. 
   

   The needle is inserted beneath the loop of suture and then looped again around the loop, creating a secondary loop of suture material.

   
   
9. 
   

   The needle is then pulled through this secondary loop and gently pulled upward, securing the loop in place.

   
   
10. 
    

    The needle is then inserted through the center of the wound underneath the newly formed loop.

    
    
11. 
    

    The procedure is then repeated sequentially, repeating steps (7) through (10) while moving proximally toward the surgeon for as many throws as are desired, without placing any additional knots until the desired number of loops have been placed.

    
    
12. 
    

    The suture material is then tied utilizing an instrument tie. Alternatively, a hand tie may be used if desired (Figures 4-39A, 4-39B, 4-39C, 4-39D, 4-39E, 4-39F, 4-39G, 4-39H, 4-39I, 4-39J, 4-39K).