Introduction

New York City, a global hub of medical innovation, has just released the top 10 list of classic incisions. These incisions are the backbone of various surgical procedures, from the most common surgeries to complex plastic and reconstructive operations. In this article, we will delve deep into each of these classic incisions, understanding their anatomical basis, surgical applications, and benefits.

1. Surgical Incisions: An Overview

A surgical incision is a cut made through the skin and soft tissue to facilitate an operation or procedure. The goal is to make the incision as small and unobtrusive as possible, ensuring safe and timely operating conditions and aiding in the patient's recovery. Surgical incisions are planned based on the expected extent of exposure needed for the specific operation.

Anatomy of Surgical Incisions

Incisions can be categorized based on the body region they are made in:

• Head and Neck: Wilde's incision, a post - aural incision used for a variant mastoiditis drainage, was named after Sir William Wilde. This incision is significant in ear - related surgeries.
• Chest:
  • Median sternotomy is the primary incision used for cardiac procedures. It extends from the sternal notch to the xiphoid process, and the sternum is divided to provide access to the heart.
  • Thoracotomy involves a division of the ribs from the side of the chest, used for various thoracic surgeries.
• Abdomen and Pelvis: There are numerous incisions in this region, each with its own specific use:
  • Midline incision or midline laparotomy is the most common incision for laparotomy. It follows the linea alba and is favored in diagnostic laparotomy as it allows wide access to most of the abdominal cavity. The upper midline incision extends from the xiphoid process to the umbilicus, while the lower midline incision is limited by the umbilicus superiorly and the pubic symphysis inferiorly.
  • Pfannenstiel incision is a lower transverse incision made in the lower segment of the uterus below the umbilicus and just above the pubic symphysis. It is commonly used in caesarian section and for abdominal hysterectomy for benign disease.
  • Chevron incision is a cut made on the abdomen below the rib cage, starting under the mid - axillary line on the right side and continuing across to the opposite side to provide access to the liver.
• Eye: Radial keratotomy is used in eye surgery, where corneal microincisions are made to flatten the cornea and correct myopia.

2. Top 10 Classic Incisions

1. Median Sternotomy

As mentioned earlier, median sternotomy is crucial for cardiac procedures. It provides direct access to the heart and major blood vessels in the chest. The sternum is divided, and a finochietto retractor is used to keep the incision open. Surgeons use this incision for operations such as coronary artery bypass grafting (CABG), heart valve replacements, and congenital heart defect repairs. The recovery from median sternotomy can be challenging as it involves the division of the sternum, but with proper post - operative care, patients can regain their normal function.

2. Kocher's Incision

An oblique incision made in the right upper quadrant of the abdomen, Kocher's incision is classically used for open cholecystectomy (removal of the gallbladder). It is also appropriate for certain operations on the liver, gallbladder, and biliary tract. Named after Emil Theodor Kocher, this incision allows surgeons to access the gallbladder and related structures with relative ease. The oblique nature of the incision follows the natural orientation of the muscles in the area, which can aid in the healing process.

3. McBurney's/Gridiron Incision

Described in 1894 by McBurney, this oblique incision is made in the right lower quadrant of the abdomen at McBurney's point. It is the standard incision for appendectomy. The incision is placed perpendicular to the spinoumbilical line at the junction of the lateral one - third and medial two - thirds of the spino - umbilical line. This orientation allows the external oblique muscle of the abdomen to be split in the direction of its fibers, decreasing healing times and scar tissue formation. It generally results in good cosmetic outcomes, especially when a subcuticular suture is used to close the skin.

4. Pfannenstiel Incision

This lower transverse incision is very popular in gynecological and obstetric surgeries. In a caesarian section, it provides access to the uterus while leaving a relatively low - lying scar that can be easily hidden by clothing. For abdominal hysterectomy for benign disease, it also offers good exposure and cosmetic benefits. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically.

5. Chevron Incision

The chevron incision is made on the abdomen below the rib cage. It provides wide access to the liver and is used in procedures where extensive exposure of the liver is required, such as liver resections. The average length of the incision is approximately 24 to 30 inches, which can be a disadvantage in terms of recovery time and potential for complications. However, it is necessary when dealing with large or complex liver pathologies.

6. Lanz Incision

A variation of the traditional McBurney's incision, the Lanz incision is made at the same point along the transverse plane. It is deemed cosmetically better and is typically used to perform an open appendectomy. Some surgeons advocate making the incision approximately 2 cm below the umbilicus centered on the mid - clavicular - midinguinal line, while others use McBurney's point to center the incision.

7. Maylard Incision

A variation of the Pfannenstiel incision, the Maylard incision involves sectioning the rectus abdominis muscles transversally to permit wider access to the pelvis. It is also called the Mackenrodt incision. This incision is useful in surgeries where extensive pelvic exposure is needed, such as in some gynecological cancer surgeries. However, it is associated with complications such as delayed bleeding from the cut edges of the rectus muscles and the deep epigastric vessels.

8. Radial Keratotomy (Eye)

In eye surgery, radial keratotomy was once a popular method for correcting myopia. It involves making corneal microincisions to flatten the cornea. By changing the shape of the cornea, light can be focused properly on the retina, improving vision. However, with the advancement of refractive surgery techniques such as LASIK, the use of radial keratotomy has decreased. But it still holds historical significance in the field of eye surgery.

9. Transaxillary Incision (Breast Augmentation)

In breast augmentation surgeries, the transaxillary incision is made in the armpit. This technique hides the scar well and results in less post - operative pain for patients. Notable surgeons like Dr. Lisa Johnson in 2024 specialized in this technique. It requires a certain level of skill as the surgeon has to insert the breast implant through a relatively small opening in the armpit and position it correctly in the breast.

10. Tummy Tuck Incisions

Tummy tuck, or abdominoplasty, has different incision types depending on the patient's needs:

• Standard Tummy Tuck: A horizontal incision is made from hip to hip to remove excess skin around the lower abdomen. If the abdominal muscles are weakened, they can be tightened and reattached. The belly button may also be repositioned. This is suitable for patients who want to get rid of a moderate amount of excess skin.
• Extended Tummy Tuck: This is usually reserved for massive weight loss patients. The incision extends around the sides to allow access to the lower back and hips. Liposuction may be used to remove stubborn fat, and excess skin is removed. It provides the most dramatic results but is also the most invasive option.
• Mini Tummy Tuck: A short incision is placed just above the pubic area. It focuses on the lower abdomen below the belly button and is ideal for patients who are generally slender but have an unwanted “pooch.” The abdominal muscles can be tightened, and excess skin is removed, but the belly button is not repositioned.

3. Surgical Procedures Associated with Classic Incisions

Plastic Surgery

Plastic surgery has seen a significant rise in demand in recent years. Procedures such as breast augmentation, tummy tuck, and rhinoplasty rely on specific incisions:

• Breast Augmentation: In addition to the transaxillary incision, other incisions used include the inframammary incision (made in the crease where the breast meets the torso) and the peri - areolar incision (around the areola). Each incision has its own advantages and disadvantages in terms of scar visibility, access to the breast tissue, and post - operative results.
• Tummy Tuck: As mentioned earlier, different tummy tuck incisions are chosen based on the amount of excess skin and the patient's overall body condition. Surgeons need to consider factors such as the patient's skin elasticity, medical history, and ability to take time off for recovery when deciding on the appropriate incision.
• Rhinoplasty: Incisions for rhinoplasty can be either external (open rhinoplasty) or internal (closed rhinoplasty). External incisions allow for better visualization of the nasal structures and more precise reshaping, while internal incisions leave no visible scars on the outside of the nose.

General Surgery

General surgery procedures cover a wide range of operations, many of which use the classic incisions we've discussed:

• Cholecystectomy: Kocher's incision is commonly used for open cholecystectomy. In recent years, laparoscopic cholecystectomy, which uses multiple small incisions, has become more popular due to its less invasive nature, shorter recovery time, and smaller scars.
• Appendectomy: McBurney's/Gridiron and Lanz incisions are the go - to incisions for appendectomy. However, laparoscopic appendectomy is also widely performed, especially in less complicated cases.
• Herniorrhaphy: Inguinal incisions are used for inguinal hernia repair. For cosmetic reasons, the skin incision for herniorrhaphy is usually a curvilineal incision along the skin crease in the groin.

Obstetrics and Gynecology

In the field of obstetrics and gynecology, incisions play a crucial role in procedures such as caesarian section and hysterectomy:

• Caesarian Section: The Pfannenstiel incision is the most common incision used for caesarian section. It provides good access to the uterus while leaving a relatively low - lying and less visible scar. However, in some cases, a midline incision may be used if more extensive exposure is required.
• Hysterectomy: Pfannenstiel and midline incisions can be used for abdominal hysterectomy. Laparoscopic and vaginal hysterectomy are also options, which are less invasive and have shorter recovery times.

4. Importance of Incision Selection

The selection of the appropriate incision is a critical decision in any surgical procedure. It can impact the surgical outcome, the patient's recovery, and the cosmetic result:

• Surgical Exposure: The incision must provide adequate access to the surgical site. For example, in a liver resection, a chevron incision may be necessary to expose the entire liver. If the incision is too small, the surgeon may have difficulty performing the procedure, leading to longer operating times and increased risk of complications.
• Recovery Time: Some incisions may result in longer recovery times than others. For instance, a midline laparotomy incision may take longer to heal compared to a laparoscopic incision. Surgeons need to consider the patient's overall health and ability to tolerate the recovery process when choosing an incision.
• Cosmetic Considerations: In plastic and some other surgeries, cosmetic outcome is an important factor. Incisions are chosen to minimize scarring and leave the patient with a more aesthetically pleasing result. For example, the transaxillary incision in breast augmentation hides the scar in the armpit.
• Patient - Specific Factors: Patient - specific factors such as age, body habitus, and medical history also play a role in incision selection. Older patients or those with certain medical conditions may have a slower healing process, and the surgeon may need to choose an incision that is less likely to cause complications.

5. Advancements in Incision Techniques

With the advancement of medical technology, there have been significant improvements in incision techniques:

• Minimally Invasive Surgery: Laparoscopic and robotic - assisted surgeries have become increasingly popular. These techniques use small incisions and specialized instruments, resulting in less pain, shorter hospital stays, and faster recovery times compared to traditional open surgeries. For example, laparoscopic cholecystectomy has largely replaced open cholecystectomy in many cases.
• Endoscopic Surgery: Endoscopic techniques allow surgeons to perform procedures through natural body openings or small incisions using a camera and specialized instruments. In breast augmentation, endoscopic techniques can be used to make smaller incisions and achieve better results.
• Precision and Safety: New surgical tools and imaging technologies have improved the precision and safety of incisions. For example, intraoperative imaging can help surgeons better visualize the surgical site and make more accurate incisions.

6. Risks and Complications Associated with Incisions

All surgical incisions carry some degree of risk and potential complications:

• Infection: Incisions are vulnerable to infection, especially if proper surgical asepsis is not maintained. Signs of infection include redness, swelling, pain, and discharge from the incision site. Antibiotics may be prescribed to prevent or treat infections.
• Bleeding: Bleeding can occur during or after surgery. In some cases, such as with the Maylard incision, there is a risk of delayed bleeding from the cut edges of the muscles and blood vessels. Surgeons take precautions to control bleeding during the procedure and monitor the patient closely post - operatively.
• Scarring: Scarring is a natural part of the healing process. However, some scars may be more prominent or cause problems such as keloid formation. Techniques such as subcuticular sutures can be used to improve the cosmetic appearance of scars.
• Herniation: Incisions in the abdomen can sometimes lead to incisional hernias. This occurs when the abdominal muscles and tissues do not heal properly, allowing organs or tissues to protrude through the weakened area. Risk factors for incisional hernias include obesity, smoking, and poor wound healing.

Conclusion

The top 10 list of classic incisions released in New York City represents the cornerstone of modern surgical practice. These incisions have been refined over time to provide the best possible surgical access, while also considering the patient's recovery and cosmetic outcomes. From cardiac surgery to plastic surgery, each incision plays a vital role in different procedures. As medical technology continues to advance, we can expect further improvements in incision techniques, leading to better surgical results and patient experiences.

If you're considering a surgical procedure, it's important to have a detailed discussion with your surgeon about the incision options available and the potential risks and benefits associated with each. Take the time to research and educate yourself about the procedures and incisions to make an informed decision about your healthcare.