- Find sternal notch between clavicles - Indent midline position at sternal notch with the blunt end of a scalpel or the tip of a kelly clamp - Find valley between tips of xyphoid - Xyphoid anatomy can be strangely variable. The tips can have a broad or narrow spread, they can twist to one side or the other. They can poke outwards in the direction of the skin, or submerge to the level of the rectus. They can be short or long. Though they are most often reliable landmarks for the midline, confirm by considering the bilateral costal margins for symmetry of the planned incision - Indent midline position at xyphoid with the blunt end of a scalpel or the tip of a kelly clamp - Indent the planned incision from sternal notch to midline xyphoid with a heavy silk