This technique is very useful for wounds under marked tension, especially for large defects on the back and shoulders. Even a deep, gaping wound can be converted into a manageable fusiform defect with a single well-placed fascial plication suture. It can therefore be conceptualized as an alternative to pulley sutures that affords both a decrease in tension across the wound surface (by shifting tension from the dermis to the fascia) and an increase in the length-to-width ratio of the ellipse.
Indeed, this approach often leads to a more fusiform defect, even when an oval-shaped excision has been performed. Therefore, it may be useful when attempting to keep a defect as short as possible without dog-ear formation. In cases where this approach is anticipated, it may be worthwhile to create a defect with a length-to-width ratio of less than 3 to 1, as is traditionally employed, as that may be sufficient to lead to a tapered ellipse.
A single fascial plication suture may be placed in the center of the wound. This balances the benefit of dead-space minimization and tension relief with the desire to minimize suture material piercing the muscle fascia which may be associated with increased postoperative pain and a theoretical increase in infection rate.
In large wounds under marked tension, a series of spaced fascial plication sutures may be placed as well. Except for the largest wounds, typically no more than three or four sutures are needed to effectively plicate the underlying fascia.
This technique is also useful when large space-occupying lesions, such as cysts or lipomas, have been extirpated. In these cases, placing dermal sutures alone results in significant residual dead space that may be associated with a higher risk of hematoma or seroma formation, as well as subsequent infection. Fascial plication may serve to help minimize this dead space by pulling deeper structures centrally and thereby filling the potential space.