This approach may be conceptualized as a hybrid between a vertical mattress suture, a simple interrupted suture, and a pulley suture. Like the vertical mattress suture, this technique leads to pronounced wound-edge eversion. Like the simple interrupted suture, this approach affords excellent wound-edge approximation. And like the pulley suture, the multiple loops lead to a reduction in needed tension across the suture material.
As with most transepidermal techniques, it is important to enter the epidermis at 90 degrees, following the curvature of the needle when utilizing this technique. This will allow for maximal wound eversion and accurate wound-edge approximation.
As with the simple interrupted suture, care should be taken to avoid skimming the needle superficially beneath the epidermis. This results from failing to enter the skin at a perpendicular angle and to follow the curvature of the needle. This may result in wound inversion as the tension vector of the shallow bite pulls the wound edges outward and down.
Note that the second throw is placed superficial to the first, deeper far-far suture, leading to a nested placement of the suture material. This leads to both wound eversion as well as wound-edge approximation, and the final loop of suture material traversing the incised wound edge permits the wound edges to be precisely matched.
Before forming the final locking loop, it is helpful to pull through the bulk of the suture material, leaving only a modest tail and a small residual loop. This will help reduce the risk of the suture material tangling during pull through.