The anatomic landmarks to be identified are jugulum, xiphoid, sternal midline, and the IV intercostal space. The skin incision extends for about 5 cm, the subcutaneous tissue and the pectoral fascia are divided and the periosteum is marked in the midline. The III (younger patients) or IV (older, osteoporotic patients) right intercostal space is then dissected. The sternotomy is the performed from the jugulum following the midline up to the desired intercostal space, where the sternum is divided horizontally. Usually the saw is kept on the operating field in the rare event of an emergency conversion into a full sternotomy. Bone wax and cautery can be used to assure the hemostasis and a small retractor is placed, the fatty tissue is divided and the pericardium is opened and suspended.