The pulley buried dermal suture, while seemingly a simple approach, can sometimes be difficult to execute properly. Care should be taken to remain at the correct depth when utilizing this technique, as taking overly superficial bites and not following the course of the needle increases the risk of marked wound inversion.
Since pulley sutures leave two loops of suture material in the skin in lieu of one, this may result in an increased risk of foreign-body reaction, suture spitting, or suture abscess formation. Still, since the bulk of retained suture material is in the knots, rather than in the thrown loops of suture, this theoretical risk may not translate into a real-world problem in most cases.
Unlike the pulley set-back dermal suture, the pulley buried dermal suture leaves suture material traversing the incised wound edge, which may similarly increase the theoretical risk of suture spitting or suture abscess formation, especially since the pulley approach may effectively double the volume of nonknot retained suture material when compared to a standard dermal suture.
As with many buried techniques, epidermal dimpling may occur where the arc of the suture reaches its apex at the dermal-epidermal junction; on the face and areas with thin dermis this should be assiduously avoided. Similarly, areas with sebaceous skin, such as the nose, require meticulous avoidance of dimpling which has the potential to persist. In truncal areas or those with thick dermis, however, a small degree of dimpling will resolve with time as the absorbable sutures are gradually resorbed.
The tendency toward wound inversion with this approach means that superficial sutures are needed more frequently with this technique than with many others, since the transepidermal sutures are utilized in order to effect eversion of the wound edges. Since obviating the need for superficial sutures may be desirable both in terms of patient comfort and convenience and ultimate cosmetic and functional outcome, this should be considered before broadly applying this technique.