This technique is useful for wounds under marked tension, especially for larger defects on the scalp and forehead. If needed, a galeotomy—relaxing incisions through the galea—may be placed parallel to the long axis of the wound to facilitate even greater tissue movement. Like the fascial plication approach, this can therefore be conceptualized as an alternative to pulley sutures that affords both a decrease in tension across the wound surface (by shifting tension from the dermis to the galea) and an increase in the length to width ratio of the ellipse.
Like the fascial plication technique, this approach often leads to a more fusiform defect, even when an oval-shaped excision has been performed. Therefore, it may be useful when attempting to keep a defect as short as possible without dog-ear formation. In cases where this approach is anticipated, it may be worthwhile to create a defect with a length to width ratio of less than 3 to 1, as is traditionally employed, as that may be sufficient to lead to a tapered ellipse.
If possible, a single galeal imbrication suture may be placed at the center of the wound. This balances the benefit of dead-space minimization and tension relief with the desire to minimize suture material piercing the galea that may be associated with a theoretical increase in infection rate.
In large wounds under marked tension, a series of spaced imbrication sutures may be placed as well. Except for the largest wounds, typically no more than three or four sutures are needed to effectively imbricate the underlying galea.
This technique is also useful when large space-occupying lesions, such as pilar cysts, have been excised from the scalp. In these cases, placing dermal sutures alone results in a significant residual dead space that may be associated with a higher risk of hematoma or seroma formation, as well as subsequent infection. Imbrication may serve to help minimize this dead space by pulling deeper structures centrally and thereby filling the potential space.
A double, or pulley, version of this approach is possible as well, that may be useful when the imbricated tissues are under marked tension. As with any pulley approach, this affords a mechanical advantage and allows the imbricated tissues to be drawn together with greater ease. As an added benefit, this also permits immediate locking of the suture material after the first knot throw, which may obviate the need for an assistant in some cases.