|The incision is a transverse sub-mammary incision. It is useful to mark with ink the mid line, the upper and lower limits of the defect and the incision itself half way between these limits. As ink is frequently smudged during the operation I scratch two or three lines across the incision for later alignment. The defect is rarely fully symmetrical so the incision should be carefully marked with the eventual alignment in mind.
|Subcutaneous flaps are fashioned to allow full movement of the later muscle flaps. Stay outside the muscle fascia to avoid bleeding.They do not need to be quite as extensive as the muscle flaps. Keep in mind that you do not want to de-vascularise the skin completely. Avoid button holing the skin. Placement of retractors superiorly and inferiorly in the corners of the incision will allow the skin to be undermined laterally to allow full rectus incisions.
|A corner of the pectoralis is raised being careful to cauterise each perforating branch of the IMA before it bleeds. (They can be a nuisance to stop if you miss one!) The flaps are continued superiorly to at least the level of the second rib and laterally to the costo-chondral junctions.
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