This technique requires some practice to master, though once mastered it is straightforward to execute. The first bite may be finessed by first reflecting the wound edge back sharply during needle insertion and then returning the edge medially after the apex has been reached. This approach helps lead the needle in the correct course without an exaggerated change in direction with the needle driver.
A similar approach may be utilized by surgeons who favor skin hooks over surgical forceps; here again, the hook may be used to hyper-reflect the skin edge back during the first portion of the first bite and then similarly pull the incised wound edge toward the center of the wound during the second portion of the first bite. This will encourage the needle to follow the desired heart-shaped path without necessitating a dramatic twist of the needle driver as the needle changes course.
The apex of the needle should be in the papillary dermis; if the needle courses too superficially, dimpling may occur. While such dimpling is sometimes almost unavoidable, it remains best to avoid it if possible since: (1) patients may sometimes have some concern regarding the immediate postoperative appearance, and (2) dimpling signifies that the suture material traverses very superficially, raising concern that it could be associated with an increased risk of suture spitting.
This technique is useful when there is significant tension across the wound, and a single buried vertical mattress 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.
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.
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 buried vertical mattress suture followed by a second buried vertical mattress suture closer to the surgeon, this technique can be very simple to learn and is easily reproducible.
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 facilitate the pulley effect of the double loop of suture material.
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.