The buried tip stitch is very useful when bringing the tip of a flap into place. Importantly, this technique is designed to gently approximate the tissues so that the flap is properly inset in the surrounding skin. While it bears a technical resemblance to the buried purse-string approach, it is important to appreciate that the buried tip stitch is not designed to work under significant tension, as tension across the suture may lead to necrosis of the delicate and lightly vascularized tip of the flap.
Placing set-back dermal sutures, imbrication sutures, or suspension sutures prior to placement of the tip stitch will ensure that the tip itself is not under tension when it is approximated with the surrounding skin.
Depending on patient positioning, the three wound edges may be approximated in any order, so that a backhand approach could be used if desired, or the bite through the flap tip could be executed as the first step in a closure. If this is done, however, the knot will be placed directly adjacent to the tip of the flap, which may not be ideal.
A downside of traditional tip stitch placement is the tendency for the tip to sit deeper than the surrounding tissues. This may be related to the relative upward pull on the nontip sections of skin by the transepidermal sutures in the standard tip stitch. Therefore, the problem of a depressed tip is not generally seen with the buried tip stitch approach, another significant advantage of this technique.