ROEN0310

I 19 clinical report _ apical microsurgery series I roots3_2010 holder, with the needle properly positioned in the beaks, so the sutures can be easily and accurately placed. All suturing is accomplished using 6-0 black monofilament nylon (Supramid, S. Jackson). Some microsurgeonsuse8-0andeven10-0sutures.Inmy opinion,the6-0iseasytouse,doesnottearthrough the tissue as readily and the results are no different to those obtained with thinner sutures, which are technique demanding. Keep in mind that the su- tures will be removed in 24 hours, so it really is a mute point as to whether the suture is 6-0, 8-0 or 10-0. The results achieved with 6-0 suture seem to be well suited to apical microsurgery. The black silk suture, traditionally used in surgery, is a detriment to the rapid healing we are trying to achieve. Not onlydoesbacterialplaqueaccumulatemorereadily on braided versus monofilament, but the braiding also acts as a wick for the migration of bacteria into the wound. This can result in an increased inflam- matory response and compromised healing. The type of needle used depends on the type of flap to be sutured. For the Ochsenbein-Luebke Flap, a 3/8 circle, taper point needle (TPN; Supramid, S. Jackson) is used. The TPN is far superior to the reverse cutting needle (RCN) because there is no tendency to cut or tear the flap edges. Additionally, it is easier to guide a TPN to the desired point of exit in the attached tissue than it is to guide a RCN. TPNs are easier to use when suturing this type of flap. One of the nicest things about using this flap design is the ability to see the healing taking place easily (Figs. 2–6). Forthesulcularflap,a3/8circleRCNisused.This needle is used because the larger size facilitates passing it through the contacts when doing a sling suture.Theslingormattresssutureisroutinelyused to save time on closure, rather than for individual buccal to lingual sutures. On many occasions, the TPNisalsousedtosuturetheattachedgingivalarea of the flap at the coronal aspect of the releasing incision. While the scope assistant holds the retractor in place, the second assistant uses a small Castroviejo needle holder, ensuring that the beaks of the holder are grasping the needle approximately three-quar- ters of the distance from the pointed end to where the suture is attached to the needle. The second assistant must pay special attention to keeping the beaks of the holder away from either end of the needle, as these are the areas of its greatest weak- nessandcanbeinadvertentlybentorbroken(Fig.7). Theneedleistobefirmlygraspedperpendicularlyto the beaks of the holder. This allows the operator more definite control and a better feel of the needle during the suturing process. The second assistant passes the needle holder to the operator’s working hand (Hand A). The operator begins the suturing process by inserting the needle through both sides of the incision. Once the needle has been inserted completely through both sides of the incision, the needle is grasped between the thumb and index finger of the opposite hand (Hand B). While the operator is doing this, the second assistantholdstheendofthesuturesoitwillnotin- advertentlybepulledthroughthetissues.Theoper- ator proceeds to make the three loose loops around thebeaksoftheneedleholdertostartthefirstknot. While the operator is making these initial loops, the second surgical assistant places the end of the suture within the operator’s visual field. The opera- tor should be able to grasp the end of the suture easily in the beaks of the needle holder. The second assistant ensures that the end of the suture is within the operator’s field of vision by looking into a monitor that has been placed within her line of vision (Fig. 8). The loops around the beaks of the needle holder create sufficient friction for a con- Fig. 5_Two weeks post-op: note scar from ten-year-old prior apical surgery. Fig. 6_Six months post-op: nothing can be seen but the old scar. Fig. 5 Fig. 6