This technique was designed as an alternative to other running dermal techniques that would solve one of their chief drawbacks, the tendency toward differential scar-spread in the center of the wound as a function of the increased tension in this central area.
While originally described as a modification of the buried dermal suture, it may be easily modified as a buried vertical mattress or set-back suture technique as well, with the same principle that suture material is tied in the central portion of the wound.
Like other running dermal techniques, this technique may be used as a modified winch or pulley suture, since the multiple loops help minimize the tension across any one loop and permit closure of wounds under marked tension. Because each throw is not tied off, however, it is important to adequately secure the knot.
Given the theoretical susceptibility to suture material breakage or compromise, this is a technique that is probably best used in a layered fashion, either superficial to previously placed interrupted buried sutures, or deep to a set of more superficially placed buried sutures.
It may be beneficial to place the running sutures closer together toward the center of the wound than at the poles of the incision, as this may foster a more pronounced pulley effect at the center of the wound where the tensile forces are greatest.
Given the concern regarding knot breakage, it may be helpful to attempt to better secure the central (and only) knot. This may be done by paying particularly close attention to knot tying, tying an extra full knot, adding extra throws, or leaving a longer tail than would traditionally be executed. An additional approach is to secure the final knot with the aid of a tacking knot, which may similarly provide extra security.