This technique is designed for areas under tension, though it may be used in any anatomic location. As such, utilizing a sufficiently robust needle may be very helpful in mitigating the risk of needle bending that can be seen when attempting to place the needle in the thick dermis of the back.
As with the buried vertical mattress approach, 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, though the needle is oriented parallel to the incised wound edge, and on a diagonal relative to the vertical axis, as opposed to the perpendicular approach utilized with the buried vertical mattress.
As with most approaches, the apex of the needle's pass should be in the papillary dermis or deeper; if the needle courses too superficially, dimpling may occur. This technique is unique in that it incorporates a large segment of dermis along the axis of the wound, theoretically increasing the robustness of each suture placement, and that it has the needle move on an upward and outward diagonal from the wound edge, facilitating wound eversion as well.
Proponents of this technique have advocated the use of a long-lasting nonabsorbable monofilament suture material, polydioxanone, since it retains its strength for an extended period of time and is therefore particularly amenable to use in high-tension closures.
Like the buried horizontal mattress suture, an advantage of this approach is the relatively generous section of dermis included in each suture. In areas of atrophy, the broader bite of dermis included in each suture may help mitigate the risk of tearing through the atrophic dermis that may be encountered when utilizing vertically oriented buried sutures in these circumstances.
An additional benefit of this approach is that since each completed suture is oriented horizontally, less individual sutures need to be placed to cover a given length of the wound.