This technique may be used as a modified winch or pulley suture, since the multiple loops help minimize the tension across any one loop and permit closure of wounds under marked tension. Because each throw is not tied off, however, it is important to adequately secure the first and final throws with a well-locked knot.
Like the butterfly suture, this technique is best used with a beveled incision. Indeed, the horizontal orientation of this suture may be conceptualized as a continuous butterfly suture with a backstitch component.
Given the theoretical susceptibility to suture material breakage or compromise, this is a technique that is probably best used in a layered fashion, either superficial to previously placed interrupted buried sutures, or deep to a set of more superficially placed buried sutures.
If braided absorbable suture is used, the added friction between loops may help lock the suture material in place with each throw, but caution should be taken to pull sufficient suture material through with each throw, as this friction may impede the surgeon’s ability to pull suture material through the course of multiple loops. Similarly, if monofilament suture is used it may be easier to pull the additional suture material through but it may make it more difficult to lock the suture in place before tying, and the running suture loops may gape open as the surgeon moves proximally through the different sets of throws.
It may be beneficial to place the running sutures closer together toward the center of the wound than at the poles of the incision, as this may foster a more pronounced pulley effect at the center of the wound where the tensile forces are greatest.
Given the concern regarding knot breakage, it may be helpful to attempt to better secure the first and final knots at the ends of the running series of loops. This may be done by paying particularly close attention to knot tying, tying an extra full knot, adding extra throws, or leaving a longer tail than would traditionally be executed. An additional approach is to secure the final knot with the aid of a tacking knot, which may similarly provide extra security.
This technique calls for horizontally oriented suture loops to be placed with a slight upward tilt at their apex (i.e., when the suture material moves laterally away from the incised edge). This approach, in the context of a beveled incision, leads to a nicely everted wound edge, as is seen with the butterfly suture.