The central drawback of this approach is that, as with all running techniques, the integrity of the entire suture line rests on two knots. Moreover, suture material compromise at any point may lead to a complete loss of the integrity of the line of sutures. Since this technique is designed for low-tension environments, however, and the locked loops of suture may hold in place due to pressure from the skin against the suture, this problem is less pronounced with this technique than with many other running approaches.
In order to avoid wound-edge necrosis, it is important not to be over-zealous with tightening the locking loops of suture. While it may be tempting to pull each loop tight to maximize the hemostatic effect of this approach, this should be avoided. This is particularly important as postoperative edema may lead the sutures to be even tighter after time has passed, increasing the risk of tissue strangulation.
Since all loops of suture are placed in succession, this technique does not permit the same degree of fine-tuning of epidermal approximation as a simple interrupted suture. This must be weighed against the benefit of the increased speed of placement of a line of running locking sutures versus interrupted suture placement, where each throw is secured with its own set of three or more knots.
While this technique may help minimize some of the potential risk of track marks associated with running techniques—the differential pull across different areas of the wound—overly tight throws may actually increase this risk, since the locked loops lead to a secondary row of sure material running parallel to the incision line.
With any suturing technique, knowledge of the relevant anatomy is critical. When placing running locking sutures it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material.
Similarly, particularly if the throws are locked relatively tightly, structures deep to the defect may be constricted. This can lead to necrosis due to vascular compromise or even, theoretically, superficial nerve damage; again, this risk may be mitigated by maintaining some laxity in the locked suture throws.
This technique may elicit an increased risk of track marks, necrosis, inflammation, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, sutures should be removed as early as possible to minimize these complications, and consideration should be given to adopting other closure techniques in the event that sutures will not be able to be removed in a timely fashion.