SEMINAR

Principles of incision, flap

design and suturing
1

PRESENTED BY-DR.YASHOBANTA BISWAL

GUIDED BY- DR.ASHISH SHARMA

DR.HIMANSHU BHUTANI
 Incision
2

 Incision refers to a fine cut produced surgically by a sharp instrument that

creates an opening into an organ or space in the body.

 Incisions are used to gain surgical access to deeper tissues with minimal
damage to the surrounding vital structures.

 A ‘pen grasp’ is used to hold the scalpel in one hand, while the other hand is
used to firmly hold and stabilise the skin or mucosa.
 Incision
3

 Incision should be made in a single firm continuous stroke of uniform depth to

the full thickness .

 Multiple interrupted strokes can cause tearing of the tissues and hence
excessive scar formation.
 Principles of wound incision
4

 1. The surgical site has to be maintained in a sterile and aseptic technique.

 2. The length and direction of incision:

a.to permit sufficient operating space and optimum exposure.

b. the direction of wound heal naturally is from side-to-side,
not end-to-end
c. the arrangement of tissue fibres in the area to be dissected varies with tissue
type
d. the best cosmetic results when incision is made in the direction of the tissue
fibres
 5

 3. The incision should be placed along the Relaxed Skin Tension

Lines(Langer’s line)

4. Fusiform excision
 a. performed with longitudinal axis running parallel to the Langer’s lines
 b. the length should be 4 times with the width of the defect to produce an
accurate approximation of skin edges without dog ear formation
 6

5. Basic surgical skills of wound incision

 a. marking of important landmarks

 b. application of a gentle traction to the skin to avoid wrinkles
 c. the operator should not direct the incision in an outward direction
 d. a single firm continuous stroke through the subcutaneous fat should be used
with cross hatches with ink or marking pen for accurate wound closure
 e. cuts in different planes should be avoided
 Principles and guidelines for flap designs
7

 1. All surgical instruments used for cutting or incising should be sharp

 and of appropriate size.

 2. While incising the tissues firm, continuous strokes should be used.

 3. Avoid cutting the vital structures like nerve, vessels, etc.

 4. Instruments should be perpendicular to the epithelial tissue. This angle

creates sharp wound edges that heal with minimal scar tissue formation.

 5. Long incisions not only give better access and ease in tissue separation, they
also heal faster.

 6. Avoid horizontal and severely angled vertical incisions:

 8

 7. Avoid incisions over bony eminences:

 8. Incisions should be placed and flaps repositioned over solid bone:

 9. Avoid incisions across major muscle attachments

 10. Tissue retractor must rest on solid bone:

 11. Provide adequate visual and operative access with minimal soft tissue
trauma:

 12. Never split the involved interdental papilla:

 13. Involve the entire mucoperiosteum

 9

 14. The apex of the flap should never be wider than the base. Sides of the flap
should be parallel to each other, or convergent from the base
 10

 15. The length of the flap must not exceed twice the width of the base.

 16. An axial blood supply must be included in the base of the flap.

 17. The base of the flap should not be stretched or twisted excessively since this
will compromise the supplying vessels.
 Intraoral incisions
11

 Intraoral incisions and transoral incisions are made to gain access

predominantly to the dentoalveolar structures as in endodontic surgery, ridge
augmentation, dental implants, sinus lift, extraction of the impacted teeth etc.

 In addition they play an important role in surgical access to various sites like
zygomaticomaxillary buttress, lateral pyriform aperture, mandibular angle
body, symphysis in case of fracture fixation and bone graft harvest.

 Though, intraoral wounds heal uneventfully with minimal scar and

complications, the choice of the flap design is important for good surgical
access and less complications.
 Flap design
12

The factors to be considered are:

 (1) anatomy,
 (2) access needed,
 (3) types of restorations at surgical site,
 (4) width of attached gingiva,
 (5) bone thickness and
 (6) muscle attachment.
 Classification of intraoral surgical flaps
13

 There are two major categories of flap designs depending on the location of the
horizontal component of the incision.

 Further, the flap designs are classified based on geometric terms (triangular,
rectangular and trapezoidal) for easy identification.
 14

1. Sulcular full thickness flaps (full mucoperiosteal flap)

 It involves an intrasulcular horizontal incision along with reflection of the

marginal and interdental gingival tissue as part of the flap.
 15

1. Sulcular full thickness flaps (full mucoperiosteal flap)

 a. Triangular (one vertical releasing incision).

 b. Rectangular (two vertical releasing incisions).

 c. Trapezoidal (broad-based rectangular).

 d. Horizontal (no vertical releasing incision).

 16

2. Mucogingival flaps (limited mucoperiosteal flap)

 It has a submarginal horizontal or horizontally oriented incision and the

marginal or interdental papilla is not included in the flap.

 a. Submarginal curved (semilunar).

 b. Submarginal scalloped rectangular (Luebke− Ochsenbein).
 17

3. Locoregional flaps

 Some local flaps can be used for smaller defects in maxillofacial region as
tongue flap for oral submucous fibrosis and palatal flaps for oroantral fistulae.
 1. Sulcular full thickness flaps
(full mucoperiosteal flap)
18

(a). Triangular flap

 It is created by a horizontal, intrasulcular incision and a vertical releasing

incision.
 19

(a). Triangular flap

 Advantage of this flap design is that it allows good wound healing, resulting
from minimal disruption of the vascularity to the flap tissue and need of
minimal sutures for flap reapproximation.

 Disadvantage is the limited surgical access due to the single vertical releasing
incision.

 Distal relaxing incision provides an additional access in a reflected triangular

flap.
 20

(a). Triangular flap

 It is recommended for posterior teeth as it provides favourable surgical access

and excellent wound healing. Due to the anatomic structures contraindicating
other flap designs, only the triangular flap with mesial vertical incision is
recommended for mandibular posterior teeth.
 21

(b). Rectangular flap

 Rectangular flap is formed by an intrasulcular, horizontal incision and two

vertical releasing incisions.

 It is especially useful for mandibular anterior teeth, multiple teeth and teeth
with long roots like maxillary canines.

 For posterior teeth this flap design is not recommended due to the distal
vertical incision that causes suturing problems due to extremely limited space
in that area.
 22

(b). Rectangular flap

Disadvantages

 1. Difficult reapproximation of the flap margins and wound closure.

 2. Difficult postsurgical stabilisation as only the sutures hold the flap
 tissues in position.
 3. Greater chance for postsurgical flap dislodgment.
 23

(c). Trapezoidal flap

 Trapezoidal flap is similar to the rectangular flap except that the two vertical
releasing incisions intersect the horizontal, intrasulcular incision are at an
obtuse angle.

 A broad-based flap with the vestibular portion wider than the sulcular portion
is obtained by the angled vertical releasing incisions. This flap is desirable
based on the assumption of providing a better blood supply to the flapped
tissues.
 24

(d). Envelope flap (Horizontal flap)

 Envelope flap is also known as horizontal flap and is made by a horizontal,

intrasulcular incision with no vertical releasing incision.
 25

(d). Envelope flap (Horizontal flap)

 Due to the limited surgical access this flap has limited use in periradicular
surgery.

 Its application is limited to repair of cervical defects, root perforations,

resorption, caries etc.
 2. Mucogingival flaps (limited mucoperiosteal flap)
26

(a). Semilunar flap

 This is a horizontal incision with a dip towards the incisal aspect in the centre
of the flap, resembling a half-moon.
 Inadequate visual and operative access but may be utilized for incision and
drainage procedure.
 More often this flap design leaves a noticeable scar.
 27

(b). Submarginal scalloped rectangular (Luebke−Ochsenbein)

 scalloped incision in the middle of the attached gingiva is given.

 The angle of the incision in relation to the cortical plate is 45 degree because
this angle provides the widest cut surface, allowing for better adaptation once
the flap is repositioned.
 28

(b). Submarginal scalloped rectangular (Luebke−Ochsenbein)

 Mesial or mesiodistal vertical releasing incisions permit adequate access to the

surgical site without violating the integrity of the attached gingiva around the
tooth or crown.

 The vertical incision of the mucogingival flap should be parallel.

 The junction where the horizontal scalloped incision in the attached gingiva
meets the vertical incision should be rounded to promote smoother and faster
healing.
 29

(b). Submarginal scalloped rectangular (Luebke−Ochsenbein)

 Advantages
I. The marginal or interdental gingiva are not involved
II. It does not expose the crestal bone.

Disadvantages
III. Excessive bleeding
IV. Possibility of flap shrinkage,
V. Delayed healing and scar formation
 Flap reflection
30

 It is a process of separating the soft tissues (gingiva, mucosa and periosteum)

from the surface of the alveolar bone.

 This process must begin in the vertical incision a few millimetres apical to the
junction of the horizontal and vertical incisions.

 The periosteum and its superficial tissues from the cortical plate are elevated
gently with the help of periosteal elevator.

 The marginal and interdental gingiva is separated from the underlying bone
and the opposing incisional wound edge by directing the elevator coronally
without applying a dissectional force.
 Flap reflection
31

 This approach is referred to as undermining elevation, and it allows all

the reflective forces to be directed to the periosteum and the bone.

 After reflection of the attached gingival tissues, elevation is continued

more apically lifting the alveolar mucosa along with periosteum until
adequate surgical access is obtained.
 Flap retraction
32

Proper flap retraction depends on:

 (1) adequate flap extension and proper mucoperiosteal reflection,

 (2) selection of the appropriate size and shape of the retractor and

 (3) position of the retractor—must act as a passive mechanical barrier

resting on solid bone.
 Suturing Materials and
Techniques
33

Ideal requirements for suture materials

 Should have high tensile strength to hold the wound margins

appropriately till the healing is complete.
 Should not be allergic or cause any tissue inflammation.
 Should have least capillarity to avoid retaining the inflammatory
transudate at the wound.
 Should have good knot stability.
 Should be easily sterilised.
 Should be visible in the surgical field.
 Should be affordable.
 34

Classification

Sutures can be classified into three groups

1. Natural and synthetic

2. Absorbable and non-absorbable
3. Monofilament and multifilament.
 35

Classification
 36

Absorbable suture
 These are suture materials that are digested or hydrolysed by the enzymes
present in the body or by other mechanism.

• Natural
• Synthetic
 37

Non-absorbable suture

 These materials cannot be metabolised by the body’s natural mechanism,

therefore they should be removed by the surgeon at the end of healing

• Natural
• Metallic
• Synthetic
 38

I. Monofilament

 This consists of single strand of suture material.

Advantages

• Monofilament sutures are more smooth and strong.

• They do not allow any bacteria to survive.

Disadvantages

• Monofilament sutures cannot be handled well like multifilament sutures.

• Monofilament sutures have to be handled properly and delicately without any
damage to the strand during surgical procedures to avoid any breakage
postoperatively.
 39

II. Multifilament

 This consists of several filaments twisted or braided together, can be coated to

allow smooth movement into tissues.
 40

II. Multifilament

 Multifilament sutures are generally easier to handle and to tie than

monofilament sutures, but they can harbour bacteria and are not suitable in the
presence of contamination and infection.
 Absorbable suture materials
41

Natural absorbable suture materials

Catgut

Types:

• Plain gut
• Chromic gut
 42

Catgut

 Made of collagen harvested from submucosal layer of the small intestine of

sheep and the serosal layer of cattle small intestine (cattle intima).

 Gut that is soaked in chromic acid salts will usually have a delayed absorption
time and a reduction in tissue reactivity compared with untreated catgut.

 Gut usually retains its strength for 2–3 weeks.

 Catgut undergoes resorption by proteolysis (proteolytic enzymes).

 Synthetic absorbable materials
43

Polyglycolic acid (dexon)

 This polymer of glycolic acid, introduced in 1970, was the first synthetic
absorbable suture material to become available.

 excellent tensile strength and knot stability.

 In addition it has delayed absorption and diminished tissue reactivity

compared to catgut.

 The absorption of polyglycolic acid is by hydrolysis

 44

Polyglactin 910 (vicryl)

 introduced in 1974
 This suture is a co-polymer of lactide and glycolide, polyglactin 910,
manufactured with a coating of polyglactin 370 and calcium stearate.
 This lubricant coating provides vicryl its excellent handling and smooth tie
down properties.
 Vicryl is degraded by hydrolysis
 Vicryl is braided and comes in either a clear undyed or violet-dyed form.
 45

Polydioxanone (PDS)
 Polydioxanone is a polymer made from paradioxanone.
 PDS can be useful in situations where extended wound tensile strength is
required.
 Polydioxanone is hydrolysed more slowly than other synthetic absorbables.
(180 days)

Disadvantage
 M0re intrinsic stiffness
 46

Polytrimethylene carbonate (maxon)

 This synthetic monofilament is the newest absorbable material prepared from

polyglyconate, a co-polymer of glycolic acid and trimethylene carbonate.

 It was developed to combine the excellent tensile strength knot stability of

Polydiaxone with improved handling properties.

 cost of Maxon is more than Vicryl or Dexon, its improved strength and
handling characteristics make it the absorbable suture material of choice.
 Non-absorbable suture materials
47

Natural non-absorbable suture materials

Silk

 Silk is created from natural protein filaments spun by the silkworm larva as it
builds a cocoon.
 it has the lowest tensile strength of any material tested.
 It elicits more inflammatory reaction than any other suture except catgut.
 It should be avoided in areas prone to infection .
 48

Linen
 Linen is a cellulose material made from flax.
 It is twisted to form a fibre to make a suture.
 Tissue reaction is similar to silk and the material has good knot stability.
 It is very extensively used for tying pedicles and as ligatures.
 It has excellent knotting properties.
 49

Synthetic non-absorbable suture materials

Nylon
 It is a synthetic polyamide polymer fibre and was the first synthetic suture
material.
 Nylon is the most widely used nonabsorbable suture in cutaneous surgery as a
monofilament .
 It is popular because of its high tensile strength, excellent elastic properties,
minimal tissue reactivity and low cost.
 The main disadvantage to using nylon is its prominent memory which
subsequently leads to an increased number of knot throws (three to four) to
hold a given stitch in place.
 50

Polypropylene (prolene, surgilene)

 It is a plastic suture formed by the polymerisation of propylene by means of a
catalyst.
 Prolene is an extremely inert suture whose tissue reactivity and tensile strength
are comparable to that of nylon.
 It has a very smooth surface with low adherence to tissue which is ideal for a
subcuticular intra-dermal suture because it tends to slide out smoothly at the
time of suture removal.
 Prolene is especially noted for its plasticity. When swelling occurs, this suture
will stretch to accommodate the wound
 51

Braided polyesters (mersilene, dacron)

 Braided polyesters were manufactured to provide the same high tensile

strength and low tissue reactivity as the mono filaments, but with improved
qualities in handling and knot security.
 Polyester sutures are either coated or uncoated.
 Needles
52

 There are basically two shapes of needles

 i. Straight
 ii. Curved
 53

Straight needles

Types
 Round bodied
 Taper cut

Curved needles

 The curvatures come in various types such as 1/4, 3/8, 1/2 and 5/8
 54

Curved needles

Types
 1. Round bodied
 2. Taper cut
 3. Conventional cutting
 4. Reverse cutting
 55

Another type of classification

1. Eyed needles
2. Eyeless (swaged) needles
 56

Advantages of eyeless needles

 1. it cause minimal trauma to the tissue during suturing
 2. No need of prior sterilisation, since it is supplied as a pre-sterilised pack.
 3. Disposable after single use, hence hygienic and no issues of loss of sharpness.
 4. Sharp tip helps in precise and efficient completion of suturing.
 5. Less time consuming when compared to eyed needle,
 6. No issue of accidental unthreading of the needle during surgery.
 Principles of suturing
57

 • The needle should be grasped with the help of needle holders at

approximately 3/4th of its distance from the tip of the needle.

 • The needle should pierce the tissue perpendicular to its surface, as piercing
the tissue obliquely may result in a tear.

 • The curved needles should be passed through the tissues following the
curvature of the needle to prevent tearing of the tissues.

 • The suture should be placed equidistant (2–3 mm) from the incision line. The
depth of penetration should also be equal on both sides of the line.
 Principles of suturing
58

 • The needle should be passed from mobile tissue to the fixed tissue.

 • The needle should pass from the thinner to the thicker side.

 • The needle should pass through the deeper to the superficial side.

 • The distance from the incision point to the needle penetration should be less
than the depth to which the needle penetrates into the tissues in order to cause
eversion of wound margin when the suture is tied.

 • The suture should not be tied so tightly that it results in blanching of the
tissues. The suture should just approximate the wound margins.

 • The knot should not be placed over the wound margins.

 Principles of suturing
59

 • Each suture should be placed 3–4 mm apart.

 • When length of tissue on one side of wound is longer than the other, suturing
would result in dog ear formation. In order to eliminate this, the excessive
tissue should be undermined and an incision at approximately 30 degree to the
original incision is directed at the undermined tissue. The extra tissue is pulled
over the incision, the appropriate amount is excised and the wound is closed
Suture methods
60
61
62
63
64
65
66
67
 68

Types of knots
 I. Square knot, half hitch knot or single knot
 II. Granny knot
 III. Reef knot
 IV. Triple throw knot
 V. Surgeon’s knot
 69

 1. Square knot

 Single loop formed by a clockwise or counter clockwise throw of one thread

over the other.
 70

Granny knot
 A single loop formed by two throws, both in same direction (clockwise or
counter clockwise). It has more holding power than a square knot.
 71

Reef knot
(rif = fold, knot used to gather a ship’s sail to reef in a strong wind)
 Loop formed by two throws first clockwise and secondly counter clockwise or
vice-versa.
 72

Triple throw knot:

 As the name says, 3 throws; first two similar to reef knot as a clockwise and
counter clockwise throw followed by a third throw similar to the second.
 This is more reliable and standard method in surgery.
 73

surgeon’s knot

 It is a square knot with an extra throw (two clockwise followed by one

anticlockwise).
Mechanical Wound Closure Devices
74
 75

Ligating Clips

 These can be resorbable or nonresorbable.

 Ligating clips are made from stainless steel, tantalum or titanium or poly-
dioxanone.
 They are designed for the ligation of tubular structures.
 76

Surgical Staples

 Skin staples are made up of stainless steel, and are placed uniformly to span the
incision line.
 They have minimal tissue reaction.
 Their use is contraindicated when it is not possible to maintain at least 5 mm
distance from the stapled skin to the underlying bone and blood vessels.
 77

Tissue Adhesives

 After tight closure of the subcutaneous tissues, the skin layer can be closed with
the help of tissue adhesive like N-butyl cyanoacrylate, which on tissue contact
polymerizes into a hard substance that keeps the wound margins together.
 78

Dermabond Topical Skin Adhesive

 It is a 2-Octyl cyanoacrylate with a long carbon side chain structure that is
combined with plasticizers – non toxic, flexible, transparent bond.
 It has three dimensional strength
 It sets within three minutes and offers sutureless skin approximation.
 It provides a waterproof clear dressing resulting in excellent cosmetic result.
 79

Thank you