PECTORAL REGION 9 



point demands the attention of the student before the dis- 

 section is commenced, and that is the position of the nipple. 

 As a rule it lies superficial to the interspace between the 

 fourth and fifth ribs, and it is situated rather more than four 

 inches from the median line. 



The student should examine these various landmarks, not 

 only upon the dead body but also upon himself and his 

 friends, until he is perfectly familiar with them, both by touch 

 and sight, and can at once put his finger on any given point, 

 whatever the position of the limb may be. 



Dissection. Reflection of the Skin. Incisions: (i) Along 

 the middle line of the body from the upper margin of the manu- 

 brium sterni to the tip of the xiphoid process. (2) Upwards 

 and laterally from the tip of the xiphoid process to the nipple. 

 At the nipple the incision must bifurcate, to encircle the dark 

 patch of skin around the nipple which is called the areola, 

 then it must be continued along the anterior fold of the axilla 

 to the arm. As soon as it reaches the arm it must be carried 

 downwards for about 63 mm. (two inches and a half), and then 

 transversely to the lateral border of the arm. (3) From the tip 

 of the xiphoid process transversely across the front and side of 

 the chest to the plane of the posterior fold of the axilla (Fig. 5). 



To make a clean incision in the skin place the point of the 

 scalpel on one end of the line of incision, and, holding the scalpel 

 at right angles to the surface to be incised, force the point 

 through the skin till it enters the soft superficial fascia which 

 lies beneath. Then incline the blade to an angle of 45 to 

 the surface of the skin, and, pressing firmly on the back of the 

 blade with the forefinger, carry it steadily to the opposite end 

 of the line of incision, but as the end of the line is approached 

 bring the blade again to a right angle with the surface, and so 

 withdraw it from the incision. 



To reflect the skin take hold of one of the angles of the flap 

 marked out by the incisions with the forceps ; in the case of 

 the upper flap (i, Fig. 5), which should be dealt with first, the 

 superior medial angle on the right side and the inferior medial 

 angle on the left side, and with the edge of the scalpel detach it 

 from the soft fat beneath. 



As soon as the angle selected is sufficiently detached discard 

 the forceps, and, holding the detached angle of skin between 

 the thumb and forefinger of the left hand, keep it tense and 

 draw the edge of the scalpel across the skin at its junction with 

 the fat from one edge of the flap to the other, always keeping 

 the edge of the knife against the skin. Be careful not to take 

 any fat away with the skin. Continue the reflection until the 

 lateral border of the shoulder region is reached. Leave the 

 flap hanging along that border and turn to flap 2, Fig. 5. Com- 

 mence at the medial angle, proceed as with flap i, and con- 

 tinue the reflection until the posterior fold of the axilla is reached. 



As the skin flaps are reflected towards the arm and the side 

 of the chest the small patch around the nipple must be left 

 untouched. 



