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

2. 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

3. 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

4. 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.

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

6. 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

7. 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

8. 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

9. 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

10. Steps of incision

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

12. 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

13. Exposure of the posterior aspect3 3
3. Curved incision bilaterally from the acromion extended up to the iliac crest

14. 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

15. 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 Salvador Dali. Figueras museum

16. 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

17. 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

18. Exposure of the Anterior aspect3 3
Whole of front of the nech chest and abdomen is exposed
3. The skin is reflected superiorly and the flap is reflected up

19. 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

20. 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

21. Closing of the incision2 1
The sternum is replaced back
Abdomen is closed by stitching the rectus
Flap of the skin is replaced back

22. Discussion

23. 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

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

25. Benefits of the technique

26. Thanks for your attention…

27. The Anatomy Lesson of Dr. Nicolaes Tulp. 1632 Rembrandt