The principle of fascial dissection is more easily achieved when the surgeon uses the knife through fascial planes. For some steps of the operation the scalpel is the best surgical tool whereas for others the scissor is preferred. Elevation of the skin flaps and dissection of the sternocleidomastoid muscle, submandibular fossa, deep cervical muscles, carotid sheath, and strap muscles are best performed using knife dissection. On the other hand, dissection of the area around the spinal accessory nerve, posterior triangle, and paratracheal space is more easily accomplished with the scissor. The main difference between these two groups is the type of tissue that is being dissected. Knife dissection requires firm tissue like muscle or vessels (Fig. 5-1), whereas fibrofatty tissue is more easily dissected with the scissors (Fig. 5-2).
Knife dissection requires precise handling of the knife, careful surgical technique, and adequate help from the assistants. The blade of the scalpel must be directed oblique to the tissue that is being dissected and away from the muscle or vessel whose fascia is being removed. This protects the structures, especially the veins, from being injured by the knife blade. To be appropriate, knife dissection must be carried all the way up and down the surgical field, avoiding the creation of holes along the dissected structure. The knife blade is much more efficient when cutting over tense tissue. Thus, the assistants must apply adequate tension to the surgical field to increase the effectiveness of knife dissection.
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