A median sternotomy involves making a vertical incision in the sternum from just below the sternal notch to the distal end of the xiphoid process. Care must be taken not to cause injury to the vessels, in particular to the brachiocephalic veins. Bleeding from the branches of the internal thoracic artery can occur and needs to be controlled. Opening the sternum causes traction on the upper ribs and may lead to rib fractures. Sometimes partial sternotomy is performed with the incision involving only the upper part of the sternum and ending at the level of manubriosternal junction or just below. A median sternotomy allows access to the heart, including coronary arteries and valves, pericardium, great vessels, anterior mediastinum, and thymus, as well as to the lower trachea. It can also be used for removal of retrosternal goiter or during esophagectomy. The incision can be extended laterally into the supraclavicular region, giving access to the subclavian and carotid arteries.