This running technique is designed to allow for moderate tension relief while concomitantly permitting easy suture placement in relatively tight spaces. It is best suited to areas with thicker dermis, though it may also be utilized in any body area when deep sutures are placed and where insertion of the full needle is challenging.

Some authors have advocated this technique as a replacement for standard running buried suture approaches, while others prefer to treat it as a niche approach exclusively for areas where other running fully buried approaches are more challenging to execute.

Suture choice is dependent in large part on location. Though suture material travels percutaneously, exiting the epidermis and then reentering, the smallest gauge suture material appropriate for the anatomic location should be utilized. Often absorbable suture material is used to allow for an entirely buried suture line. If reentry is to be attempted through the same hole as suture exit, monofilament suture material may be preferred over the braided alternatives. On the back and shoulders, 2-0 or 3-0 suture material is effective, though theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material, particularly where the material has exited the epidermis entirely. 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.

In addition to utilizing absorbable suture material, nonabsorbable suture material may also be utilized with this technique. In that event, the knots at the beginning and end of the suture line are tied externally, permitting easy suture removal. In such cases, a monofilament would be preferable to permit easy pull through at suture removal, reinsertion of the needle through the same hole, and a more pronounced pulley effect.

1. 
   

   If possible, the wound edge is reflected back using surgical forceps or hooks. In areas under marked tension, or where full visualization is not possible, the needle may be blindly inserted from the undermined space.

   
   
2. 
   

   The suture needle is inserted at a 90-degree angle into the underside of the dermis 4-mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is started by following the needle and traversing from the underside of the dermis in the undermined space and passing entirely through the dermis and exiting the skin.

   
   
4. 
   

   The needle is then reloaded onto the needle driver with a backhanded technique, and inserted through the epidermis either directly through the same hole as the suture followed during exit, or just medial to it. A shallow bite is taken and the needle exits on the margin of the incised wound edge.

   
   
5. 
   

   The needle is then reloaded, again in a backhanded fashion, and it is inserted into the contralateral incised wound edge at the same depth as it exited on the first side. The needle again follows a mirror-image superficial course through the dermis, exiting through the epidermis again approximately 4 mm from the wound edge. Alternatively, this step may be combined with the prior step and the needle can be inserted into the contralateral edge while it is still loaded from the initial pass exiting the incised wound edge.

   
   
6. 
   

   The needle is then loaded in a standard fashion and inserted either through the same hole or just lateral to it, following a deeper course and exiting the undersurface of the dermis into the undermined space.

   
   
7. 
   

   The suture material is then tied, securing the anchoring stitch, and the trailing end is trimmed.

   
   
8. 
   

   Steps (1) through (6) are then repeated sequentially for the desired number of throws, moving proximally toward the surgeon after each set of two sutures.

   
   
9. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-15A, 4-15B, 4-15C, 4-15D, 4-15E, 4-15F, 4-15G, 4-15H, 4-15I, 4-15J). The final anchoring knot is tied by leaving a loop on the penultimate throw, and tying the free end of suture material from the final throw to this loop. The ends of the suture are then trimmed.