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Figure 2: (a) Preoperative defect of the right temporal area following Mohs surgical excision of a Basal cell carcinoma, in a 58-year-old female
with Fitzpatrick II skin type; (b) intraoperative appearance following dog ear excision and closure using the Running-X technique; (c) ten days
postoperatively; (d) six weeks postoperatively; (e) twelve weeks postoperatively

marks. The authors in this report have primarily used Running-X, this technique has provided the authors with
this technique for brow and forehead wound closures. excellent cosmetic results [Figure 2].
Therefore, the sutures were removed at 5 to 7 days from
closure. We do not recommend this suture technique for anatomic
locations with thinner, fragile skin or distorted wound
DISCUSSION edges due to the increased risk of tissue strangulation
and wound dehiscence. We also recommend against
The senior author (Ronald Mancini) has successfully used over tightening this suture in order to avoid tissue
this technique for many years to re-approximate surgical strangulation.
wounds of the brow, forehead and temporal area.
Since the Running-X technique is continuous it allows Despite our positive clinical experience with this
for rapid wound closure. The needle is always thrown technique, further studies are required to further define
in the same direction, reducing the time to reload the the limitations and tissue biomechanics of this technique
needle compared to a running horizontal mattress suture and a prospective study comparing the Running-X suture
which needs to be reloaded in opposing directions with technique with commonly used running and interrupted
each throw. This technique functions as a horizontal suture techniques is necessary before any definitive
mattress specifically at the interval between the far and conclusions can be drawn.
near throws. The horizontal and oblique forces placed
across the wound at these intervals of the technique Financial support and sponsorship
provide excellent skin eversion and precise wound edge Nil.
apposition. The eversion is created in a similar fashion Conflicts of interest
to running horizontal mattress sutures. However, it is There are no conflicts of interest.
superior to the running horizontal mattress because the
“X”s created over the wound edges provide a leveling
force for the epidermal edges. In addition, the Running-X REFERENCES
is excellent for closure of wounds under tension because 1. Adams B, Levy R, Rademaker AE, Goldberg LH, Alam M. Frequency
it provides added strength. A similar suture pattern of use of suturing and repair techniques preferred by dermatologic
has been described for epitendinous suture in tendon surgeons. Dermatol Surg 2006;32:682-9.
repairs, and when compared to a simple running suture, 2. Wong NL. Review of continuous sutures in dermatologic surgery. J
the similar patterned suture provided a 245% increase 3. Dermatol Surg Oncol 1993;19:923-31.
Krunic AL, Weitzul S, Taylor RS. Running combined simple and vertical
[5]
in tensile strength. Since this technique places suture mattress suture: a rapid skin-everting stitch. Dermatol Surg 2005;
strands over the wound, unlike traditional running 31:1325-9.
mattress sutures, these strands can easily be divided at the 4. Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin
time of suture removal with minimal patient discomfort. 5. surgery. Am Fam Physician 1991;44:1625-34.
Kim PT, Aoki M, Tokita F, Ishii S. Tensile strength of cross-stitch
Finally, through a summation of the advantages of the epitenon suture. J Hand Surg Br 1996;21:821-3.

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