This technique works best when the standing cone is fixed to a truly immobile tissue, such as the periosteum. Therefore, this approach is of particular utility on the forehead and other areas over bony prominences. On the trunk and extremities, where no truly fixed underlying anchoring point is present, the standing cone can be fixed to the muscle fascia. Though this does not lead to as dramatic a degree of downward pull as when the dog ear is fixed to the periosteum, it does have a positive impact on the height of the standing cone.
In some locations, such as convexities over the forehead, even defects repaired with a 4:1 ellipse may still display residual standing cones at the apices; therefore, this approach may be used as an adjunct in such cases as well.
This technique can be conceptualized as a suspension suture for the standing cone, where the dog ear is anchored downward to prevent the residual focal elevation that will otherwise be seen in such cases. Since no additional tissue is excised, this technique will occasionally lead to a rippling effect in the areas where it is utilized, though this is generally preferable to the dramatic bump that would otherwise be present when dog ears are left behind.
Some experience is helpful in deciding what degree of residual standing cone appearance is acceptable; wounds on the lower legs, for example, often heal well and residual standing cones may smooth out spontaneously, likely due to the tension over bony prominences; conversely, standing cones over cheeks and other areas with abundant soft tissue often resolve only minimally over time, and therefore leaving significant dog ears in these locations should be assiduously avoided if possible.
In some cases, instead of taking a single bite from the undersurface of the dermis it may be more effective to take two bites, as if a set-back dermal suture were being taken from the imaginary line splitting the standing cone. These two bites are then anchored to a central anchoring point deep to the theoretical midpoint of the standing cone.
This approach, when used in concert with a technique such as the fascial plication suture that leads a round or oval defect to appear more fusiform, may permit closure of wounds with significantly less standing cone removal, leading to shorter—and therefore more cosmetically appealing—scars.