Median (Midsagittal) Incision:

• 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.  

Transverse/Oblique Incisions:

• 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.

Photo 2. Procedural: ‘skinning’ 

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.

Photo 3. Procedural: removal of both skin and subcutaneous tissue

2.) Dissection of Area One: 

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.

Photo 4. Procedural: Area One

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.

Photo 5. Cephalic vein and deltopectoral triangle

3.) Dissection of Area Two:

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.

Photo 6. Procedural: nipple and areola

4.) Dissection of Area Three:

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.

Photo 7. Procedural: Area Three

Clean the pectoralis major and serratus anterior mm., and find the cephalic v.

Find these structures:

• Pectoralis major m.

• Serratus anterior m.

• Long thoracic n.

• Cephalic v.

• Deltopectoral triangle

• Clavipectoral fascia

5.) Remove any remaining subcutaneous tissue and investing fascia from the pectoralis major mm. and the visible portion of the serratus anterior mm. Remove the investing fascia from the muscle via sharp dissection at right angles to the muscle fascicles. This will allow the visualization of basic features of a muscle: fiber directions and attachments (origins and insertions).

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.

Photo 8. Investing fascia

Photo 9. Procedural: investing fascia and subcutaneous tissue removal

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.

Photo 10: Procedural: how to reflect a muscle

6.) Observe attachments of pectoralis major mm. and serratus anterior mm. Identify long thoracic n. superficial to the serratus anterior m.

Pectoralis major m.:

*[ ] indicate source of the nerve or artery*

Serratus anterior m.:

Photo 11. Pectoralis major and serratus anterior mm.

7.) Locate the cephalic v. in the deltopectoral triangle. Keep this vein intact during reflection of the pectoralis major m.

Note: The cephalic v. drains lateral components of the superficial upper limb into the axillary v.

Photo 12. Cephalic vein and deltopectoral triangle

Reflect pectoralis major mm., and identify pectoralis minor mm. and associated neurovasculature.

Find these structures:

• Pectoralis minor m.

• Lateral pectoral n.

• Medial pectoral n.

• Thoraco-acromial a. (pectoral brs.)

• Thoraco-acromial v.

8.) Reflect the pectoralis major mm. from their proximal attachments (clavicle and sternum/costal cartilages). Use blunt dissection to reflect the muscle laterally to protect the deep neurovasculature.

Photo 13. Procedural: pectoralis major m. incision

Photo 14. Procedural: pectoralis major m., reflected  

Note: Neurovasculature lies immediately deep to the clavicular head of pectoralis major m.

9.) Bilaterally identify and clean the pectoralis minor m., lateral pectoral n., medial pectoral n., and branches of the thoraco-acromial a and v.

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.

Photo 15. Medial and lateral pectoral nn.  

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.

Photo 16. Thoracoacromial a. and v., pectoral branches and lateral pectoral n.

Reflect pectoralis minor mm. to identify neurovasculature

Find these structures:

• Medial pectoral n.

• Thoraco-acromial a. (pectoral brs.)

• Clavipectoral fascia

10.) Reflect the pectoralis minor mm. from their proximal attachments (3rd-5th ribs). Reflect the muscles superolateral (toward the coracoid process of the scapula). Locate any remaining 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.

11.) Observe pectoral branches of the thoraco-acromial a. and the medial pectoral n.

Photo 17. Pectoralis minor muscle, reflected

Place donor into a prone position

12.) The donor will need to be moved into a prone (face downward) position to dissect the superficial back.

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.

Remove skin from the back

13.) Make a midsagittal incision, beginning at the external occipital protuberance of the occipital bone and continuing inferiorly to the tip of the coccyx.

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.

Photo 18. Procedural: midsagittal incision on the back

14.) Create paired transverse incisions perpendicular to the length of the midsagittal incision. This should create “skin flaps” with subcutaneous tissue that are approximately 3-4 inches wide and extend laterally to either the posterior axillary, or the midaxillary lines.

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.

Photo 19. Procedural: transverse incisions of the back

Photo 20. Procedural: superior longitudinal and transverse incisions

15.) Using toothed forceps or hemostats, lift the edge of skin at the corner of two incisions. Remove skin flaps and subcutaneous tissue to reveal the underlying muscle and thoracolumbar aponeurosis. The accessory nerve (CN XI) is superficial in the neck region. In the superior-most sections of this dissection, use sharp dissection to remove skin only. Blunt dissection should be used to clean and investigate areas deep to the skin.

Photo 21. Trapezius m., latissimus dorsi m., and thoracolumbar aponeurosis

Identify and reflect the trapezius m. Identify the neurovasculature associated with this muscle.

Find these structures:

• Thoracolumbar aponeurosis (fascia)

• Trapezius m.

• Accessory n. (CN XI)

• Transverse cervical a.

• Transverse cervical v.

16.) Clean and define the attachments and borders of the trapezius m. Locate the posterior layer of the thoracolumbar aponeurosis (fascia).

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.

17.) Reflect the trapezius m.

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.

Photo 22. Procedural: trapezius m. incisions

Photo 23: Procedural: trapezius reflected

18.) Locate and clean the neurovasculature associated with the trapezius m. Accessory n. (CN XI) is often difficult to locate. Try to find the nerve between the trapezius m. and sternocleidomastoid m.

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.

Photo 24. Accessory n. (CN XI)

Photo 25. Transverse cervical a. and v. and subtrapezial plexus

Identify and reflect the latissimus dorsi mm. Locate neurovasculature associated with this muscle.

Find these structures:

• Latissimus dorsi m.

• Thoracodorsal n.

• Thoracodorsal a.

• Thoracodorsal v.

19.) Clean and define the proximal attachments and borders of the latissimus dorsi mm.

Latissimus dorsi m.:

20.) Bilaterally reflect the latissimus dorsi mm. The incision of the latissimus dorsi mm. should separate the muscle fibers at the thoracolumbar aponeurosis, and reflect the belly of the muscle toward the axilla.

Photo 26. Procedural: latissimus dorsi incision

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.

21.) Identify thoracodorsal neurovasculature deep to the latissimus dorsi mm.

Note: The thoracodorsal neurovascular bundle is visible near the axilla and deep to the latissimus dorsi m.

Photo 27. Latissimus dorsi and thoracodorsal neurovasculature

Identify muscles deep to the trapezius m.

Find these structures:

• Levator scapulae m.

• Rhomboid minor m.

• Rhomboid major m.

22.) On each side, locate levator scapulae m., rhomboid minor m., and rhomboid major m. This musculature has distal attachments along the medial border of the scapula, sequentially from superior to inferior.

Photo 28. Levator scapulae m., rhomboid minor and minor mm.

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.: