Find these structures:
Humerus
Crest of greater tubercle
Pectoral girdle
Clavicle
Scapula
Coracoid process
Spine of scapula
Acromion
Superior angle
Medial border
Inferior angle
Sternum
Manubrium
Suprasternal notch (Jugular notch)
Sternal angle
Body
Xiphoid process
Ribs
Intercostal space
Costal margin (Costal arch)
Cranium
Occipital bone
External occipital protuberance
Superior nuchal line
Temporal bone
Mastoid process
Vertebrae
Spinous process
Vertebra prominens (C7)
Sacrum
Dorsal surface
Coccyx
Ilium
Iliac crest
Palpate from the donor’s suprasternal notch to the xiphoid process. Make a median incision along this line.
Note: The median incision is unlikely to jeopardize any deep structures (e.g. muscles or neurovasculature), but take caution when performing transverse/oblique incisions not to cut muscle.
Area One
Superior Incision: Incise from the suprasternal notch. Continue laterally along the clavicle to the acromioclavicular joint.
Inferior Incision: Incise from the sternal angle (where rib 2 articulates with the sternum), and extend laterally to the midaxillary line
Note: The 2nd rib is the most superior palpable rib. The sternal angle is at the level of the 2nd costal cartilage.
Area Two
Inferior Incision: Incise from the 5th intercostal space (or more inferiorly to encompass the entirety of the breast), and laterally to the midaxillary line.
Area Three
Inferior Incision: Incise from the xiphoid process, following the costal margin, inferolaterally to the midaxillary line.
Note: Subcutaneous tissue (hypodermis, superficial fascia) separates the skin from muscles and often contains neurovasculature (nerve, artery, vein, and lymphatics). Depending on the dissection, you may be asked to either remove the skin (‘skinning’), or remove both the skin and subcutaneous tissue.
Note: When removing large areas of superficial tissues, it may be helpful to create an incision in the reflected skin and subcutaneous tissue through which a finger or tool can be inserted (‘button hole’) to facilitate removal of superficial tissues.
Remove the skin and subcutaneous tissue from Area One. Work from the midline laterally. Once reflected, the superior portion of pectoralis major m. should be visible.
Note: Upon removal of the skin and subcutaneous tissue, anterior and lateral cutaneous neurovascular bundles may be seen leaving the muscle and entering the subcutaneous tissue.
Note: Be careful to not damage the cephalic v. within the deltopectoral triangle, superolateral to pectoralis major m.
Note: The deltopectoral triangle is bounded superolaterally by the deltoid m., superomedially by the clavicle, and inferiorly by the pectoralis major m.
Make an encircling cut around the nipple and areola down to, but not through pectoralis major m., and leave in situ for future reference. Remove the subcutaneous tissue to further expose the pectoralis major m.
Note: The nipple is typically located at the 4th intercostal space. This landmark can help in orientation for future dissections.
Remove the skin and subcutaneous tissue in Area Three. The external oblique m. and aponeurosis and the rectus sheath will be deep. A small portion of the serratus anterior m. should be visible laterally.
Find these structures:
Pectoralis major m.
Serratus anterior m.
Long thoracic n.
Cephalic v.
Deltopectoral triangle
Clavipectoral fascia
Note: Muscles are covered with investing fascia that is relatively opaque and firmly attached to the muscle. The thickness of this layer varies in different parts of the body.
Note: To reflect muscle, cut a portion of a muscle, and fold it back on itself to reveal deep structures. Reflection may be completed by severing the proximal or distal attachments, or by cutting through the belly of the muscle, as specified. Use blunt dissection methods to further reflect the cut muscle.
Pectoralis major m.:
*[ ] indicate source of the nerve or artery*
Serratus anterior m.:
Note: The cephalic v. drains lateral components of the superficial upper limb into the axillary v.
Pectoralis minor m.
Lateral pectoral n.
Medial pectoral n.
Thoraco-acromial a. (pectoral brs.)
Thoraco-acromial v.
Note: Neurovasculature lies immediately deep to the clavicular head of pectoralis major m.
Pectoralis minor m.:
Note: The medial pectoral n. innervates both the pectoralis major and minor mm. It typically pierces the pectoralis minor m., which can be helpful for differentiating between the 2 nerves. The medial pectoral n. may emerge as two branches (either through or inferolateral to pectoralis minor m.).
Note: The lateral pectoral n. only innervates the pectoralis major m. and is typically located superomedial to the medial pectoral n. If you find the names confusing, keep in mind they reflect the origins of these nerves from the brachial plexus, not their anatomical relationships in this region.
Note: There are numerous branches of the thoraco-acromial a.: acromial, clavicular, deltoid, and pectoral branches. The pectoral branches serve and are found deep to pectoralis major and minor mm.
Find these structures:
Medial pectoral n.
Thoraco-acromial a. (pectoral brs.)
Clavipectoral fascia
Note: Four main structures pierce the clavipectoral fascia superior to pectoralis minor m.: cephalic v., lateral pectoral n., and thoraco-acromial aa. and vv.
Note: To help prevent mold issues, be mindful of the plastic shroud and muslin on the table. Do NOT allow these to fall on the ground. If these elements contact the ground, throw them away, and ask for replacements.
Note: The skin of the back of the neck is difficult to remove, because of its curvature and thickness of skin. Place a wooden block under the sternum to flex the neck.
The most superior incision extends from the external occipital protuberance of the occipital bone to the mastoid process of the temporal bone. Continue this incision inferiorly to the base of the neck.
A second incision should extend laterally to the acromioclavicular joint.
All other incisions should extend laterally to either the posterior axillary, or the midaxillary lines.
Find these structures:
Thoracolumbar aponeurosis (fascia)
Trapezius m.
Accessory n. (CN XI)
Transverse cervical a.
Transverse cervical v.
Trapezius m.:
Note: The posterior layer of the thoracolumbar aponeurosis (fascia) is visible in this view. The three layers (anterior, middle, and posterior) of the aponeurosis cover deep back muscles and the trunk.
a.) Incise along proximal attachments of the trapezius m. (spinous processes of the vertebrae and the ligamentum nuchae). Lift the trapezius m. off of the deep neck muscles.
b.) Sever the scapular (distal) attachments of the trapezius m. (spine of the scapula and acromion); maintain the distal attachment to clavicle.
c.) Reflect the trapezius m. toward the clavicle.
Note: In close proximity to the accessory n. are branches of the ventral primary rami (VPR) of cervical nn. 3 & 4 (C3 & C4) that provides sensory (proprioceptive) innervation to the trapezius m. This complex of nerves is often referred to as the subtrapezial plexus of nerves.
Find these structures:
Latissimus dorsi m.
Thoracodorsal n.
Thoracodorsal a.
Thoracodorsal v.
Latissimus dorsi m.:
Note: Use blunt dissection techniques to reflect this muscle, and be careful to not reflect or damage the deeper musculature: serratus anterior mm. and serratus posterior inferior mm. Pay special attention to the direction of muscle fibers.
Note: The thoracodorsal neurovascular bundle is visible near the axilla and deep to the latissimus dorsi m.
Find these structures:
Levator scapulae m.
Rhomboid minor m.
Rhomboid major m.
Levator scapulae m.:
Note: The rhomboid muscles are often difficult to distinguish from one another or may be fused. Typically, the dorsal scapular a. & v. emerge between these muscles. Rhomboid minor m. is superior to the rhomboid major m.
Rhomboid minor m.:
Rhomboid major m.: