Though it may be conceptualized as a bidirectional subcuticular closure, the extra row of sutures in this technique adds little to wound security, as the entire suture line is secured with a single knot. Therefore, it is not recommended as a solitary closure approach, but rather it is best utilized layered over the top of a deeper suturing technique.
This technique results in leaving a very significant quantity of foreign-body material in the dermis in a continuous fashion—essentially twice as much as the running subcuticular technique. While this may not represent a major problem in areas with a thick dermis such as the back, in other anatomical locations the large quantity of suture that is left in situ may result in concerns regarding infection, foreign-body reaction, and even the potential that the suture material itself could present a physical barrier that would impinge on the ability of the wound to heal appropriately—an iatrogenic eschar phenomenon.
The extra row of subcuticular sutures used in this technique raises further concern regarding the possibility of tissue strangulation along the wound margin that could theoretically be associated with tightly placed subcuticular sutures. It, therefore, should be reserved for areas with an outstanding vascular supply, such as the face.
Removal of long-standing suture entails a theoretical risk that a potential space—albeit a thin and long one—is created on the removal of the suture material. This theoretical risk may be mitigated by utilizing the thinnest possible suture material, and this risk is higher in this approach than in the standard subcuticular suturing technique.
There is sometimes a tendency for the apices of the wound to develop exaggerated dog ears due to the tension vector created when looping and tying the suture material over the gauze bolsters lateral to the apices. Minimizing tension across this suture helps minimize this potential issue.