1. Anterior Upper Arm Thorax, Shoulder & Upper Limb
Christina Duncan
Stacey Fain

2. Anatomical Landmarks Palpations - Thoracic Jugular Notch Manubrium
Body and Xiphoid Process of Sternum
Sternal Angle
Acromion
Nipple

3. Anatomical Landmarks Palpations – Brachial Median epicondyle
Lateral epicondyle
Cubital fossa

4. Incision Lines - Thoracic
First Incision: Midline cut from jugular notch to xiphoid process
Three lateral incisions will originate from first incision.
Upper border of the manubrium to the acromion along the clavicle (A-D). Extend this incision down the arm 5 inches (D-G) and then around the arm. (G,H)
From the midline laterally (encircling the pigmented areola) to the midaxillary line about 3 inches below the anterior axillary fold. (B-E)
From the xiphisternal junction to the midaxilllary line following the 6th rib. (C-F)
Midaxillary Line

5. Incision Lines - Brachial
From first brachial circumferential incision (G,H), continue down arm approximately four inches and make another circumferential cut immediately superior to the cubital fossa (I,J). I J

6. Reflection of Skin - Thoracic
Start at jugular notch. Hold scalpel edge at a slight angle to underlying superficial fascia and proceed laterally.
Make an incision in reflected skin for index finger of free hand for purpose of providing traction.
GOAL: To have little or no fat adhering to deep surface of the skin, which will show many small pock marks/pits called dermal papillae.
Keep 2 skin flaps attached laterally so they can be replaced over chest to prevent drying out.
Leave nipple and areola attached to underlying tissue. In males, the nipple is directly attached to anterior thoracic wall. In females, the nipple is completely within the superficial fascia.

7. Reflection of Skin - Brachial
Starting from midline incision, reflect skin medially and distally, respectively. I
Distal
Medial J

8. Watch Out! Medial Supraclavicular Nerves
Intermediate Supraclavicular Nerves
Lateral Supraclavicular Nerves

9. Watch Out! – Vascular

10. Cautionary Tales - Nerves
Medial Brachial Cutaneous Nerves
Intercostobrachial Nerves