This is a useful technique for select wounds, as it permits the wound edges to come together even under marked tension. Since the sutures are transepidermal, however, it may also be associated with significant cross-hatching or residual suture track marks if they are left in place for any amount of time. Therefore, one frequently used approach is to use pulley sutures on a temporary basis intraoperatively to permit placement of other sutures; once the other sutures have been placed, the pulley sutures may be removed before the end of the procedure.
If pulley sutures are left in place, they should probably be removed in a timely fashion, and certainly should be left in place for no longer than 1 week.
The two loops of suture are slightly offset from each other, as the suture traverses the incised wound edge on an oblique angle, which helps lessen the risk of tissue necrosis and tear-through.
This technique may be used to prepare the wound for placement of a buried pulley suture, such as the pulley set-back dermal suture. As long as undermining has been carried out effectively, utilizing a pulley technique with a thicker gauge suture material should allow for effective closure of all but the tightest wounds.
In areas under extreme tension, a three-loop variation of this approach is possible as well, allowing for an even more dramatic pulley effect.
A double variation of this approach, the tandem pulley stitch, has been recently described as well.