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One of the chief advantages of this technique is its ease of execution; since the suture follows the arc of the needle on the undersurface of the dermis there is no need to change planes, effect a heart-shaped suture placement, or guarantee that the suture exit point is precisely at the inside edge of the lower dermis, as may be needed with the pulley buried vertical mattress suture.
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Accurate suture placement is predicated on having a sufficiently undermined plane, since the entire suture loop lays on the undersurface of the dermis. Therefore, broad undermining is a prerequisite for utilizing this technique, since the first throw of the needle begins 2-6 mm distant from the incised wound edge.
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This technique is useful when there is significant tension across the wound, and a single set-back dermal suture may not hold the edges together. 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.
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This technique is also very useful when the surgeon needs the first throw of the knot to securely hold the wound edges together, as this technique is able to effectively lock the suture in position after only a single throw. This obviates the need for an assistant's constant presence in these instances, and permits precise placement of the suture and knot to allow for precise epidermal approximation.
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It is critical to keep the suture material deep to the loops of suture when using this technique, as this is the mechanism by which the suture locks in place after the first throw. As long as the surgeon conceptualizes this approach as placing a standard set-back dermal suture followed by a second standard set-back dermal suture closer to the surgeon, this technique can be very simple to learn and is easily reproducible.
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As always, the choice of suture material is largely based on the individual surgeon's preference. Braided absorbable suture material has the advantage of locking more reliably than monofilament, though monofilament suture allows for easier pull through and therefore may better facilitate the pulley effect of the double loop of suture material.
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In areas under extreme tension, a three-loop variation of this approach is possible as well, allowing for an even more dramatic pulley effect. This benefit must be weighed against the added retained suture material that would be associated with the additional loop.