This technique may be conceptualized as a buried vertical mattress suture with an additional bite, or as a 1½ loop buried vertical mattress pulley suture. It is therefore slightly faster to execute than the pulley buried vertical mattress, since this technique saves one needle throw. That said, since there is one less loop of suture, the pulley effect may similarly be less pronounced, though this needs to be weighed against the theoretical benefit of less retained suture material in this technique than in a double buried vertical mattress suture.
This technique requires some practice to master, though once mastered it is straightforward to execute. The first bite may be finessed by first reflecting the wound edge back sharply during needle insertion and then returning the edge medially after the apex has been reached. This approach helps lead the needle in the correct course without an exaggerated change in direction with the needle driver.
The apex of the needle should be in the papillary dermis; if the needle courses too superficially, dimpling may occur. This technique is useful when there is significant tension across the wound, and a single buried vertical mattress suture may not hold the edges together.
This technique is also very useful when the surgeon needs the first throw of the knot to securely hold the wound edges together, as this technique is able to effectively lock the suture in position after only a single throw. This obviates the need for an assistant’s constant presence in these instances, and permits precise placement of the suture and knot to allow for precise epidermal approximation.
It is critical to keep the suture material deep to the loops of suture when using this technique, as this is the mechanism by which the suture locks in place after the first throw. As long as the surgeon conceptualizes this approach as placing a standard buried vertical mattress suture followed by a second half vertical mattress suture slightly deeper, this technique can be very simple to learn and is easily reproducible.
The extra throw may also be completed with an oblique or near-horizontal orientation, since it is very important that this extra throw bite sufficient dermis to support the tension of the wound. The extra throw may also be executed as a single set-back dermal suture, though doing so may lead to some discrepancy in the depth of the wound edges, necessitating the placement of depth-correcting epidermal sutures.