The Fourth Incision A cosmetic Autopsy Incision Technique Amarjyoti Patowary, MD Presented by Pablo E. Baquero Diego Insignares Maria Camila Ramon

INDEX Main purpose Introduction Conventional methods in practice The fourth incision Steps of incision: Exposure of the Posterior Aspect Anterior Aspect Closing of the incisions Discussion

MAIN PURPOSE Describe few modifications in the autopsy incisions For opening the thorax and abdomen and also proper visualization of the neck structures Incisions and stitches are kept hidden

INTRODUCTION Medicolegal autopsy Careful and meticulous examination The law and justice Parents and guardians Relatives & personal experience Maximum possible exposure. Less stitches from the front.

Conventional Methods in Practice The I-shaped incision Symphysis menti Symphysis pubis Neck exposure is not adequate

Conventional Methods in Practice The Y-shaped incision Point close to the acromion process Shymphysis pubis. Xiphoid process Difficult visualization of the neck structures The stitches in the front of the neck are abstent

Conventional Methods in Practice The modified Y shaped incision Behind the ears Midclavicular point bilaterally Over the clavicle Suprasternal notch Symphysis pubis Visualization the neck is achieved The stitch marks in the front of the neck remain exposed

Conventional Methods in Practice The back of the neck, chest and abdomen is not visualized Distinguish between postmortem staining and the bruises Spinal cord back incision Seepage from the abdominal cavity

THE FOURTH INCISION Some modification in the present autopsy technique Maximum possible exposure of the wall circumference of the body Stitches in the front are not visualized as such

Steps of incision

Exposure of the posterior aspect Positioning the body Prone position Neck flexed

Exposure of the posterior aspect Incision on the back 1 2 ¿? 1. From the mastoid-mastoid in each side, in coronal plane through vertex 2. Incision is extended to the acromion process-trapezium border

Exposure of the posterior aspect 3 3 3. Curved incision bilaterally from the acromion extended up to the iliac crest

Reflection of the Posterior Flap Head Neck Chest Abdomen back 1 2 Posterior flap of the scalp is reflected up to the occiput and anteriorly up to frontal ridge To the superior border of sacrum The whole flap of the skin is reflected up to the superior border of the sacrum

Portrait of Abraham Lincoln 1974. Salvador Dali. Figueras museum We should see beyond the skin, we need find some bruises that are not commonly visualized Portrait of Abraham Lincoln 1974. Salvador Dali. Figueras museum

Exposure of the Anterior aspect Positioning the body After completion of the examination of the posterior aspect, the flap of the skin is reflected back and the body is turned back to the supine position Supine position Keep the neck in extended position

Exposure of the Anterior aspect Incision in the Front 2 1 1 Curved incision from acromion process trough the mid axillary line Another incision is made from the mid axillary line on the iliac crest to the Symphysis pubis

Exposure of the Anterior aspect 3 3 Whole of front of the nech chest and abdomen is exposed 3. The skin is reflected superiorly and the flap is reflected up

Exposure of the Anterior aspect Opening the abdominal cavity 1 2 Paramedial incision is made on the rectus near the symphysis pubis Extended upward to the xiphoid process

Exposure of the Anterior aspect Opening the thorax 1 2 Then the sternum is removed Separating the diaphragm the wall of thorax and abdomen can be examined

Closing of the incision 2 1 The sternum is replaced back Abdomen is closed by stitching the rectus Flap of the skin is replaced back

Discussion

Disadvantage for the author CONVENTIONAL METHOD FOURTH INCISION Posterior part is not visualized Posterior part is completely visualized Difficulty detecting any injury in the back * Complete visualization of the wall circumference of the “body” Difficulty to distinguish postmortem staining bruises Any injury can clearly be visualized Stitches on the front Some stitches, not in front, can be kept hidden Abdomen and thorax is closed in single layer, seepage is frequent Abdomen is closed in two layers, the change of seepage is almost nil Is not designed for the relatives Cosmetic technique for relatives Disadvantage for the author It Consume more time than conventional method

The importance of this technique No injuries are seen Then with this techniques the bruises appear

Benefits of the technique

Thanks for your attention…

The Anatomy Lesson of Dr. Nicolaes Tulp. 1632 Rembrandt