3.4

sunken integumentary lips

(1) Point of entry is at each end of the line of closure (2) You can also enter via the nostril for areas that are otherwise difficult to reach.

sunken areas of the hands

(1) The hands are also a neglected area when tissue building (2) There are different points of entry for the various parts of the hand, fingers, back, and sides.

sunken submandibular region

(1) This area right below the jawline is often neglected. As a rule of thumb, if the face and hands require tissue building, this area will most likely need it, too (2) A long needle is required since the point of entry is located behind each angle of the jaw (3) The needle must be long enough to reach the midline below the chin.

Some embalmers feel that tissue building appears more natural than waxing.

(a) Enter the mucous membrane at each end of the line of closure (b) Due to the curvature of the mouth, one point of entry for each lip will not work; extend the needle to the medial lobe (c) Occasionally, the injection of only one lip may correct the separation

types of needles

-Half-curved needle -Double-curved needle (S-shaped) -Circle needle (may have a spring eye) -Loopuyt's needle

desiccated membranes

Desiccated membranes can only be restored by modeling artificial lips or waxing

elderly eyebrow

Hair will angle downward

Beard and Goatee Restoration

If the beard or goatee is large enough, the embalmer may use cement on areas which will be hidden. For the visible margins and for thinner beards and goatees, wax should be employed for attachment (to avoid the noticeable "shiny" appearance that cements can cause.) The attachments are made in a similar procedure to the restoration of sideburns

large prominent moustache

If the moustache is extremely full, the embalmer may wish to use two rows of hair restoration, rather than one. This will provide a fuller moustache

hair restoration: entire head

Most common cause of hair loss (other than normal hair loss) is chemotherapy cancer treatment • Wig is often provided by family • If no wig: • Purchase a wig • Use a scarf or hat • Replace all hair

Bridge stitch (Interrupted suture or temporary suture)

Normally sutured prior to embalming for proper tissue alignment

Bridge stitch (aka Interrupted suture or temporary suture)

Normally used prior to arterial embalming to align tissue (e.g. align a laceration); the tissue will then firm during embalming

pencil line m

Restoration is similar to general discussion, except the hair is trimmed shorter when finished

pencil line moustache

Restoration is similar to general discussion, except the hair is trimmed shorter when finished.

Moustache

The embalmer places a layer of wax on the upper lip. Working laterally to medially, small patches of hair are pushed into the wax. Once all the hair patches are placed, the moustache is trimmed.

suturing

This method is most often employed when the embalmer is attaching large quantities of hair with a hidden point of attachment. The process is to suture several strands of hair together creating a single unit of hair (in a sort of "haystack" appearance.) This unit is then sutured to the skin.

hypodermic tissue building

This procedure is performed AFTER arterial embalming. Otherwise, if it was done before embalming, the vascular/capillary systems would be destroyed and swelling would occur • Injection of special tissue-building liquid into the tissues via hypodermic syringe/needle to restore natural contour • Hypodermic tissue building is performed following arterial embalming: • Disrupt capillary beds • Impede circulation • Possible distortion of features if any swelling occurs during arterial injection

handle bar or wax end moustache

This type of moustache is very difficult to restore and generally is purchased from a supply company. The purchased moustache cemented into place. If restored, longer hair is used and then moustache wax is applied to shape the moustache.

curled moustache

This type requires longer hair which must be directly laterally. Applying a thin layer of wax to your fingers may prove helpful in curling (curving) the moustache

when to trim hairs in eyebrow attachment?

Trim hairs AFTER entire eyebrow is attached

average eyebrow

Usually angles upward and outward toward distal edge

young eyebrow

Usually follows well-defined margin

Loop stitch

a single, noose-like suture, not pulled taut before knotting, which stands from the skin and which anchors restorative materials.

Baseball suture (Sail suture)

a stitch for making two edges just meet worked under and over from the inside outward and used especially in seaming baseball covers and mending tears in sails

tissue builder

a substance used to elevate sunken (emaciated) tissues to normal level by hypodermic injection.

Purse-string suture

a suture made around the circumference of a circular opening or puncture to close it or to hold the margins in position

restoration of the eyebrows

a) Eyebrows are usually restored lateral to medial using a wax attachment b) If both are being restored, restoration should be done simultaneously.

melted wax

a) Few embalmers still utilize this method as it requires the wax to be heated, which is not generally done today b) Similar to the cement method, the embalmer would place strands of hair at the point of attachment and then pour melted wax over the attachment. As the wax cools it solidifies and keeps the hair in place.

cement

a) For replacement of hair in areas where the attachment will not be visible, the embalmer can hold the hair at the point of attachment and apply bonding cement (e.g. rubber cement) over it to hold it in place. Cement is the strongest bond method of attachment b) However, this method is not advisable along visible margins as it leaves a "shiny" finish which can be difficult to cover with cosmetics c) In addition, the hair will lie flat against the skin if glue is used.

Parts of the eyebrow

a) Head - most medial portion (usually has the greatest density) b) Body - main portion which is on both the lateral plane of the forehead and part of the temporal region c) Tail - most lateral portion

Factors influencing the method of attachment

a) Length of hair b) Quantity of hair c) Underlying surface (wax or natural skin) d) Area involved (hidden or visible)

Refer to the text for common points of entry and treatments when tissue building the following types of cases:

a) Sunken eyes (1) Eyeballs that have lost convexity b) Sunken supraorbital areas c) Sunken temples d) Sunken cheeks e) Separated mucous membranes (lips) f) Sunken mucous membranes (lips) g) Sunken integumentary lips h) Sunken sides of the nose i) Sunken forehead j) Sunken submandibular region k) Sunken chin l) Sunken areas of the neck m) Sunken areas on the hands

embedding

a) This method is an old method and is not commonly used today. The process includes the use of a straight needle, which has had half of the eye cut off. Two or three strands of hair are then placed in the half eye and are pressed into the tissue or wax. This is generally done for single stray or straggly hairs. b) It is not used today due to high risk of a needle stick, as the embalmer will press the needle (with the point up - toward embalmer's hand!) into the skin or wax as the hair is embedded. c) In this video, the process of "hair punching" is demonstrated on a silicone mask. While the application is different, the methods are very similar. The artist uses an exacto knife to hold the sharp end of the needle while they cut the eye and while they embed (or "punch") the hair into the scalp. Obviously, you would not insert the needle as far as they do in this video (because you would hit the skull.) The process is the same, however, and this video demonstrates the embedding process and how to create the embedding needle.

wax attachment

a) Wax attachment is the process of placing a thin layer of wax on the area to be restored. Using spring forceps, the embalmer forces small tufts of hair into the wax b) This is preferred in areas of thin hair and marginal hairlines. A marginal hairline is the border between areas having hair and areas not having hair.

restoration

a) create eyelash with tape and insert under eyelid (into wax) b) purchase eyelashes from supply company

Restoration of a sideburn should begin:

at the inferior margin and overlap each patch of hair

Intradermal suture (Hidden stitch)

hidden stitch; type of suture used to close incisions in such a manner that the ligature remains entirely under the epidermis

Contour

outline or surface form

Point of entry

place to access to inner positions

Dehydration (Desiccation)

removal of water from a substance. dehydration is generally used to indicate the natural loss of water, and the term desiccation is used when a substance is intentionally caused to lose water as in a desiccator

Solvent

substance to dissolve something (i.e. tissue builder)

straight

tends to be a thin straight line from the head to tail

Gelatinous

texture of jelly

arched

the eyebrow forms an arc from head to tail

Hypodermic tissue building

the injection of special creams or liquids into the tissues through the use of a syringe and needle to restore natural contour.

angled

this is generally a thin eyebrow which is primarily moving superiorly from head to medial portion of the body, and moving inferiorly from body to tail

Hypodermic injection

under the skin

Subcutaneous

under the skin

Alternatives include:

wigs and scarves

Inversion suture (Worm suture; draw suture)

worm suture, draw stitch; a method of sewing an incision along the edges without entering the opening whereby the suture becomes invisible and the line of suture becomes depressed, which lends it ease of concealment by waxing

hair replacement: melted wax

• Antiquated method • Requires wax to be heated (not generally done today) • Similar to the cement method • Place strands of hair at the point of attachment and then pour melted wax over the attachment • Wax cools and solidifies - holds hair in place

hair replacement: embedding

• Antiquated method - not commonly used today • Use of a straight needle with half of the eye cut off • Pass 2 or 3 strands of hair through the half eye and press into tissue or wax • Generally done for single stray or straggly hairs • Not used today due to potential of needle sticks • Pressing the needle "point up" (toward embalmer's hand) as the hair is embedded into the base (skin or tissue)

hair restoration of a sideburn

• Area can be waxed - press hair into wax • Glue hair to area • Implant into skin (instead of wax) • Begin at the inferior margin and overlap each patch of hair as you work superiorly (bottom to top) • Arrange hair in small patches held together with wax or rubber cement • Cement these patches in overlaying pattern (bottom to top)

Lock suture (aka Interlocking suture)

• Creates a tight, leakproof closure • Does leave a VISIBLE RIDGE on the surface of skin • Pass ligature through BOTH sides of the incision • Lock by looping the needle through the ligature

hair replacement entire head

• Done with purchased artificial hair • Glued hair cannot withstand excessive styling • Curl or style before placement • Choose this option if you can complete with minimum handling • May take 6-8 hours • Wig is often the best option • Shave entire head • Mark hairline • Apply glue or double-sided tape • Apply tufts of hair (longer than normal) at outer layer • Continue application inwards (towards top of head) • Gently comb into position • Longer hairs can be applied at hairline • Comb back

hair replacement: cement

• E.g. - Aron Alpha (super adhesive) • For areas where the attachment is not visible • Back of head • Hair is held at the point of attachment and bonding cement placed over it to hold it in place • Strongest bond method of attachment. • Not advisable along visible margins • Leaves a shiny attachment • Difficult to cosmetize • Hair will lie flat against the skin if glue is used.

hair coloring

• For those who have it done on a regular basis • Family may request coloring be done • Family should supply you with the coloring agent normally used by deceased • Use exact name/brand • Not "make it light brown"

hair restoration: eyelashes

• General Characteristics • Hair of an eyelash is thicker than cranial hair • Adjacent hairs have different lengths • Eyelash hairs can cluster in small groups • Restoration • Create eyelash with tape and insert under eyelid (into wax) • Purchase eyelashes from supply company

hair replacement factors

• Goal should be to camouflage the DEMARCATION LINE • Hair sewn to material exposes edge of material • Factors influencing the method of attachment: • Length of hair • Quantity of hair • Underlying surface (wax or natural skin) • Area involved (hidden or visible)

sources of hair

• Hair from the back of the head of the deceased • Camel-hair brush • Generally utilized for smaller treatments (eyelashes) • Wigs or Toupees • Beauty Shop • Mortuary Supply Company

types of needles

• Half-curved • Double curved needle (S - shaped) • Circle needle (may have a spring eye) • Loopuyt's needle

scarves

• Have some hair show on face/head from beneath the scarf • Ends of hair are not seen - attach with cement

parts of the eyebrow:

• Head - most medial portion (usually of greatest density) • Body - main portion • On both the lateral plane of the forehead and part of the temporal region • Tail - most lateral portion

purposes of sutures:

• Hold borders of an incision together • Gather and turn under excess tissue • Hold flaps of skin in position during embalming • Correct distortion from sagging muscles

sutures: purpose

• Hold margin of a deep wound in a fixed position • Form a mesh to anchor wax • Anchor a deep wound filler • Circle and hold the margin of a hole • Serve as an armature (framework) • Attach hair

Beard/Goatee Restoration

• If beard/goatee is large enough • Use cement on areas that will be hidden • Visible margins and thinner beards and goatees • Wax should be employed for attachment • Similar procedure to the restoration of sideburns • Work "bottom to top"

large prominent m

• Might use two rows of hair restoration (rather than one) • Provides a fuller appearance

Baseball suture (aka Sail suture)

• Most commonly used suture • Seals incisions and especially effective on autopsy cases

hair replacement: suturing

• Most often employed when attaching large quantities of hair with a hidden point of attachment • Suture several strands of hair together, creating a single unit of hair • Tie it at the end - "haystack" • Unit is then sutured to the skin

Hair Restoration: Moustache

• Place a layer of wax on upper integumentary lip • Work from lateral to medial • Small patches of hair are pushed into the wax • Hairs should point downward and towards outer corners of mouth • Trim after all hair patches are in place

hair replacement: wax

• Process of placing a thin layer of wax on the area to be restored • Using spring forcep, force small tufts of hair into the wax • Preferred in areas of thin hair and marginal hairlines • Borders between areas having hair and areas not having hair

curled m

• Requires longer hair that must be directed laterally • Thinly waxed fingers to assist in curling (curving) the moustache

hair replacement: eyebrows

• Restoration of eyebrows • Usually restored lateral to medial using a wax attachment • If both are being restored - restoration should be done simultaneously • Place thin layer of wax along supraorbital margin • Take small tuft of hair and insert ends into wax • Fingers or spring forceps

hair restorations-generalizations

• Should be at least 2 inches long • Trimmed after attachment is complete and dry • Hair fibers are not exactly identical • Does not have to match perfectly • Hair can be darkened using an eyebrow pencil • Use lighter color replacement hair and darken after attachment • Using an eyebrow pencil, mark margins of the hairline with dots • Guideline for the restoration • Alternatives include wigs and scarves

N-Suture

• Similar to the purse-string • Used to close holes (e.g. colostomy openings)

three forms of the eyebrow:

• Straight - tends to be a thin straight line from the head to tail • Arched - eyebrow forms an arc from head to tail • Angled - generally a thin eyebrow • Moves superiorly from head to medial portion of the body • Then inferiorly from body to tail.

most common areas hypodermic tissue building

• Temples • Eyes • Cheeks • Lips • Hands • Supraorbital area • Mouth • Neck • Forehead • Chin

hair restoration: general process

• Use hair patches that are slightly longer than needed • Apply thicker hair than needed • Thinning can be accomplished later • Begin at more distant point and move toward the hairline or part • Each hair patch should overlap the attachment of the previous • Trim/shape hair AFTER cement or attachment has completely hardened

accessory chemical

• Used in addition to vascular/cavity fluids • "Tissue builder" - used to elevate sunken tissue

double intradermal (subcutaneous)

• Used to close an incision so it can't be seen • Stronger than single intradermal (as both ends are fixed)

single intradermal (subcutaneous)

• Used to close an incision so it cannot be seen

Whip suture (aka Continuous suture)

• Used to close long incisions • Very similar to Lock suture • Except sutures are further apart (1 - 1.5 inches) • Common to close autopsy incisions • Keeps fluids from leaking during transfer to FH

Purse-string suture

• Used to secure the margins of a hole in position • Most commonly used for a colostomy opening

Handle-bar a.k.a. Waxed-end Moustache

• Very difficult to restore and generally is purchased from a supply company • Purchased moustache is generally cemented into place • If restored, longer hair is used and moustache wax is applied to shape the moustache

Ligature

A thread, cord, or wire used for tying vessels, tissues, or bones.

Hair Preparation without Restoration

A. Any hair which has been uncut should be trimmed B. Hair should be washed C. At the family's direction, hair may be colored D. If needed, hair may be styled to match style worn during life

Three forms of the eyebrow:

-straight -arched -angled

Once you have selected the area in need of treatment, you can begin the process of hypodermic tissue building:

1. Fill syringe with tissue builder. 2. Insert the needle/syringe into the most distant portion of the area to be built up. 3. As you remove the needle, inject tissue builder into area. 4. Use hand on the surface to smooth area and restore the natural contour. 5. Because it turns to a gelatinous substance when it comes into contact with moisture, the tissue builder should, on its own, seal the hole made by the needle. a) Wax may be necessary as the entry point will often turn dark following the injection.

hair restoration general factors

1. Hair for restoration should be at least 2 inches long, it can be trimmed after attachment is complete and dry 2. Hair fibers are not exactly identical, so it need not be perfectly the same color 3. Hair can be darkened using an eyebrow pencil, so it is suggested to use lighter color replacement hair and darken after attachment 4. The margins of the hairline should be marked with a series of dots made by an eyebrow pencil as a guideline for the restoration

Sources of Hair for a Restoration

1. Hair from the back of the head of the deceased 2. Camel-hair brush (generally utilized for eyelashes) 3. Wigs or toupees 4. Beauty shop - though I have not ever asked a hair dresser to save hair for the funeral home 5. Mortuary supply company (e.g. Dodge, ESCO, etc.)

General Characteristics of an Eyelash (a.k.a. Cilia)

1. Hair of an eyelash is thicker than cranial hair 2. Adjacent hairs have different lengths 3. Eyelash hairs can cluster in small groups 4. Restoration

Substances used for Tissue Building

1. Massage cream 2. Colloidal substance

Intradermal suture (aka Hidden stitch)

1. Single intradermal (subcutaneous) 2. Double intradermal (subcutaneous)

Basket-weave suture (aka cross stitch)

1. This suture is essentially a criss-cross pattern of stitches 2. The first series is made going from one side of the wound to the opposite margin and back to the original side 3. The second series of stitches is made at right angles to the first series 4. The distance between stitches depends on the degree of tissue fixation achieved during embalming; pliable tissue requires closer spacing than firmly fixed tissue -Used to form a thread/ligature anchor for wax or mastic compound

Process of Hair Attachment

1. Use hair patches which are slightly longer than needed 2. Apply thicker hair than needed, thinning can be accomplished later 3. Begin at a more distant point and move toward the hairline or part 4 Each hair patch should overlap the attachment of the previous 5. Trim and shape the hair only after the cement or attachment has completely hardened.

purposes of a suture

1. hold borders of an incision together 2. gather and turn under excess tissue 3. hold flaps of skin in position during embalming 4. correct distortion from sagging muscles 5. hold margin of a deep wound in a fixed position 6. form a mesh to anchor wax 7. anchor a deep wound filler 8. circle and hold the margin of a hole 9. serve as an armature 10. attach hair

Anchor

A material or technique employed to secure tissues or restorative materials in a fixed position

Basket-weave suture (Cross stitch)

A network of stitches which cross the borders of a cavity or excision to anchor fillers and to sustain tissues in their proper position

Suture

Act of sewing; also be completed stitch

Inversion suture (aka worm suture or draw stitch)

Also used to close an incision so it can't be seen