Epidermal dimpling will occasionally 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.
Since this pulley approach leaves an extra single loop of suture material in the skin, 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.
There is also a theoretical concern that the extra loop of suture could lead to some wound-edge necrosis, particularly if it is oriented in an oblique fashion, though this is not usually seen in practice. Finally, since the additional loop of suture material is located on the side of the first bite, the pulley effect may not be as pronounced as in other pulley techniques, since there is no back-and-forth pulley effect between the two sides of the wound.