A horizontal skin incision is marked midway between the cricoid cartilage and the sternal notch. The skin is infiltrated with Xylocaine-Epinephrine to decrease the bleeding.
The skin incision is made with a Colorado Needle mounted on an electric knife (Bovie). A steel blade scalpel is as good and is preferred by many surgeons.
After incising the subcutaneous tissue and platysma, the strap muscles are separated in the midline.
The strap muscles is a name given to the four infrahyoid muscles that lie in front of the larynx. They are the sternohyoid, sternothyroid, thyrohyoid and the omohyoid.
The isthmus of the thyroid gland is either retracted or divided in the midline. (In this picture, the isthmus has been divided and retracted laterally, along with the strap muscles.) The anterior tracheal wall is divided between the third and fourth tracheal rings. A clamp is used to widen the tracheal opening. The endotracheal tube is seen inside the tracheal lumen.
The tracheal wall incision is extended downward, bilaterally to form a "trapdoor" flap. The flap is everted with an Allis clamp.
A silk suture is used to retract the trapdoor flap, making it easier to insert the tracheostomy cannula, and preventing it from going through a false passage into the mediastinum.