- an incision is made following the line of the deltopectoral groove
- In obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable
- a 10-15 cm incision is usually utilized, but is sized according to surgical need and size of patient
- Superficial dissection
- attention must be paid to superficial skin vessels, as these can bleed significantly
- the deltopectoral fascia is encountered first ; the cephalic vein is surrounded in a layer of fat and is used to identify the interval
- the cephalic vein can be mobilized either medially or laterally, depending on patient factors and surgeon preference.
- fibers of the deltoid are retracted laterally and the pectoralis major is retracted medially
- Deep dissection
- the short head of the biceps and coracobrachialis arise from the coracoid process and are retracted medially.
- The musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process; retraction of the conjoint tendon must be done with care.
- the fascia on the lateral side of the conjoint tendon is incised to reveal the subscapularis
- External rotation puts the subscapularis fibers on stretch
- the subscapularis may be released from its insertion on the lesser tuberosity through the tendon or via an osteotomy
- the capsule is then incised (as needed) to enter the joint