The skin incision is made from the jugular notch to just below the xiphoid process. The subcutaneous tissues and presternal fascia are incised to expose the periostium of the sternum. The sternum is divided longitudinally in the midline. After placement of a sternal retractor, the thymic fat pad is divided up to the level of the brachiocephalic vein. An avascular midline plane is identified easily but is crossed by a few thymic veins that are divided between fine silk ties or hemoclips. The pericardium is opened anteriorly to expose the heart. With 2-0 Ethibond sutures the pericardium is suspended.