ROEN0310

20 I I clinical report _ apical microsurgery series trollabletensionbetweentheoperator’sHandBand the beaks of the needle holder in Hand A. Care must always be taken that the tension is only between Hand B and the needle holder in Hand A, so no undesirable tension is exerted on the tissue during the suturing process. The purpose of maintaining some tension is to give the operator a positive tac- tilesensewhiletakinguptheexcesssuturematerial in Hand B. As the suture is drawn through the tissue by Hand B, Hand A is lowered to prevent exerting too much tension on the tissue. The tension on the suture is regulated by the looseness, or tightness, of the loops, which controls the amount of friction for the suture to overcome as it is gathered. Hand B continues gathering as Hand A yields the suture with a descending motion, while still maintaining the desired tension and the beaks of the holder firmly securing the end of the suture. Once the end of the suture is at the desired length relative to the incision, the loops are allowed to slip off the beaks for the initial knot. Then, using the same basic rhythm of movements, the securing and locking knots are placed. It is an alternating rhythm of movementthatisdifficulttodescribeinwriting,but is actually very easy for the beginner microsurgeon to learn. The operator now allows the second surgical assistanttotaketheneedleholderfromHandAand simultaneouslybehandedthemicro-scissorssothat thesuturecanbecutclosetotheknot.Afterthesec- ond assistant has taken the scissors and the suture, theoperatorishandedamicro-forcepstomovethe knotbetweenthepointofinsertionandtheincision gently, helping to prevent plaque build-up over the incision itself (Fig. 9). Note: When moving the knot withthemicro-forceps,itisimportantthattheknot bepushedtoplace,notpulledtoplace.Thisensures the knot’s original integrity is maintained. One of the most common mistakes made in suturing is making the suture too tight. It is better to make the suture a little too loose because if the suture is too tight it causes ischaemia and thus compromisesrapidhealing.Inmakingaslingsuture inasulcularflap,itiseasytobetooaggressivewhen tying the knot, causing the rest of the suture to become too tight. The operator should always re-check the tension over the entire length of the suture before completing the securing knots. Thesuturetensionforthereleasingincisionneeds to be considered differently compared to that used for the rest of the incision. Normally, the releasing incision is not sutured, but if it is, the suture should be looser than the other sutures. It has been shown that epithelial creep, or streaming, occurs rapidly or atarateofabout1mmpersideper24hours.Inother words, a wound whose edges were separated by 2mm would be expected to come together within a 24-hour period. In hundreds of surgeries over the past 12 years, there have only been a few cases in whichthereleasingincisiondidnotcompletelyclose. Of those few that did not close within 24 hours, they didsowithin48hours.Thus,iftheoperatorprefersto suture the releasing incision, it must be sutured loosely (Fig. 10). Another consideration is to suture like tissues to like tissues. Never suture attached gingival tissue to unattached gingival tissue. Should one side of the suture tear out, it will be the attached gingival side. WhenusingtheOMtosuture,theincisioncanbe closed accurately with extremely good approxi- mation. It is because of well-planned and nicely scalloped incisions, atraumatic flap elevation pro- cedures and the very close repositioning of the flap withthin,hair-likesutures(6-0)thatwecanplanon routinely removing sutures in 24 hours (Figs. 3 & 4). Fig. 7_Grasp the needle approximately three-quarters of the distance from the pointed end. Fig. 8_The assistant hands the free end to the operator. roots3_2010 Fig. 7 Fig. 8