Part II. Main elements of operational technique

2.1. Dissection of the skin, subcutaneous fat and superficial fascia

Surgical instruments: scalpel with a removable disposable blade with blade No. 23, used for long incisions.

Before starting the incision, it is necessary to determine the thickness of the subcutaneous tissue in the patient. To do this, you need to take the skin in a fold. The angle of inclination of the scalpel will depend the fold’s thickness. The surgeon and assistant should take a comfortable position in relation to the operating field. The incision is usually made from left to right and towards the surgeon. The incision must be started from the most distant point of the incision, otherwise the surgeon’s hand will not have support and the movements will be uncertain, which may cause the incision line to be uneven. The scalpel is held in the right hand (for right-handed) in the position of a table knife (Fig. 1).

Fig. 2.1. The position of the scalpel in the surgeon’s hand and the fixation of the skin while performing the incision

In order for the skin not to move, it is necessary to fix it with the thumb and forefinger of the left hand on opposite sides of the proposed incision, as shown in Fig. 2.1. If a sufficiently long incision is needed, then you can move the left hand along the way.

If the incision is made correctly, the depth of the wound is the same throughout it, the deeper located formations (own fascia, etc.) are not damaged. The incision of the skin, subcutaneous tissue and superficial fascia is performed in one step to ensure smooth edges of the incision. With repeated dissections of the skin, uneven edges and small flaps are formed, in which elements of inflammation and tissue necrosis may appear.

To achieve a uniform depth of dissection of a thick layer of subcutaneous adipose tissue (more than 2 cm), a scalpel is placed at the beginning of the incision at an angle of 90° to the skin surface and the skin, subcutaneous adipose tissue and superficial fascia are pierced. Without removing the scalpel, move it to a position at an angle of 45° and continue the incision at the same depth. At the end of the incision, the scalpel is again returned to the position at an angle of 90° and removed from the surgical wound.

In the case of poorly developed subcutaneous tissue, it is safer to hold the scalpel at an angle of 45° from the very beginning, and then additionally dissect the tissue at the beginning and end of the incision.