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This is an infrequently used technique that is a hybrid between a simple interrupted suture, a mattress suture, and a simple running suture. It is useful when the benefits of interrupted sutures—especially the frequent knot placement leading to a more secure closure—is desired. It may also be used if the wound length is slightly too long for a single simple interrupted suture. This approach entails taking two simple interrupted bites in succession and then tying off the suture, leaving an “x” of suture material over the wound edge. It may be used alone in the context of small wounds under minimal to no tension, such as those formed by a punch biopsy or a traumatic laceration. It may also be used as a secondary layer to aid in the approximation of the epidermis when the dermis has been closed using a dermal or other deep suturing technique. This technique may also be used for vessel ligation and hemostasis, where it is classically referred to as the figure of 8 suture.
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Suture Material Choice
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With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Suture choice will depend largely on anatomic location and the goal of suture placement. This technique is rarely used on the face, but if it is used there a 6-0 or 7-0 monofilament suture may be used for epidermal approximation. On the extremities, a 5-0 monofilament suture may be used if there is minimal tension, and 4-0 monofilament suture can be used in areas under moderate tension where the goal of suture placement is relieving tension or hemostasis as well as epidermal approximation. In select high-tension areas, 3-0 monofilament suture may be utilized as well. When used for hemostasis on the interior of a wound, a 4-0 absorbable suture may be used.
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The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.
With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.
The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps. It is gently grasped and pulled upward with the surgical forceps as the body of the needle is released ...