I don't like cruciate incisions because when you push the trach in, you push cartilaginous flaps into the airway, and if you get a chondritis, it can be a problem for the patient after decannulation in terms of stenosis.
I don't like cutting out windows because you have no security if the trach falls out later (i.e., the immediate post-op period before epithelialization). In addition to my own trachs, I've had to evaluate a lot of other trachs and be called to replace trachs that other services have placed. If you get a thick neck, all that tissue can collapse over the tracheotomy, and you can lose that little window you've made pretty easily. After you divide all the fascia and straps, you lose those tracheal attachments that draw the trachea anteriorly -- you can get a deep hole real fast. I just find that creating flaps -- whether Bjork, T-flaps, I-flaps, or whatever -- gives you more security.
Now there are some people that say Bjork flaps disrupt the blood supply to the midline since it's a circumferential blood supply, and that leads to A-frame stenosis of the trachea -- I don't see it, and I've done a lot of trachs and taken care of a lot of post ops. I won't hesitate to do a Bjork flap, except in a kid. Nevertheless, I still secure a pedi trach with stay sutures.
Always for me. But it's usually Tycron or Silk. Braided sutures are better in my opinion since they don't slide.
No. I don't see the point. It's a contaminated wound. You can't clean it, and I wouldn't want to get betadine in the trachea. Of all the trachs I've done, and my colleagues have done, we've had only a few cases of tracheitis or stomal infections.
Furthermore, unless there's some huge skin incision, which is rare, I don't close the skin either. Let's face it: If you need a trach, your concern isn't cosmesis.
Lastly: post-op CXRs? Never. Doesn't change your management. Pneumothorax -- very, very rare.
