This approach is best used in areas under mild to moderate tension, as it is a running technique that allows rapid placement of multiple buried suture throws. It may be utilized in a variety of anatomic locations, including the face, neck, and extremities. While it may be utilized on the trunk, interrupted set-back sutures are generally more appropriate in this location.
Since it is a running technique, it may be associated with a higher risk of dehiscence, as interruption of the suture material in any point in its course would lead to loss of effectiveness of the entire suture line. Therefore, it is often used in concert with other sutures techniques rather than as a sole closure approach.
Suture choice is dependent in large part on location. Though this technique is designed to bite the deep dermis and remain buried well below the wound surface, the surgeon may choose to utilize a larger gauge suture than would be used for an equivalently placed running simple or running buried vertical mattress suture.
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. While this approach should probably not be routinely utilized on the back, using a 2-0 absorbable suture on the back with this technique results in only vanishingly rare complications, since the thicker suture remains largely on the underside of the dermis, and suture spitting is an uncommon occurrence.
Braided suture material will allow for better locking of the suture in place, though it will also impede the surgeon’s ability to pull suture material through multiple loops, and therefore adequate suture material should be pulled through with each loop. Monofilament absorbable suture material will pull through more easily, though the lower coefficient of friction means that it will easily slide back through the wound and it will therefore not lock in place until tied.
The wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is required.
While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 2-6 mm distant from the incised wound edge.
The first bite is executed by traversing the dermis following the curvature of the needle and allowing the needle to exit closer to the incised wound edge. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle does not, however, exit through the incised wound edge, but rather 1-4 mm distant from the incised edge. The size of this first bite is based on the size of the needle, the thickness of the dermis, and the need for and tolerance of eversion.
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 reflected back in a similar fashion as on the first side, assuring complete visualization of the underside of the dermis.
The second bite is executed by inserting the needle into the underside of the dermis 1-6 mm distant from the incised wound edge. Again, this bite should be executed by following the curvature of the needle and avoiding catching the undersurface of the epidermis that could result in epidermal dimpling. It then exits further distal to the wound edge, approximately 2-6 mm distant from the wound edge. This should mirror the first bite taken on the contralateral side of the wound.
A knot is tied using an instrument tie to secure the suture in place. The tail end of the suture is cut with minimal to no tail, and the needle, now attached to suture material that is securely anchored in the dermis, is reloaded.
Steps (1) through (5) may then be repeated in pairs, moving toward the surgeon, but without tying additional knots with each throw.
Once the end of the wound is reached, the suture material is tied utilizing an instrument or hand tie (Figures 4-12A, 4-12B, 4-12C, 4-12D, 4-12E, 4-12F, 4-12G). 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.
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