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 A. The skin island is depicted here paralleling the central fibers of the latissimus in an oblique fashion down toward the posterior iliac spine. This island can be placed transversely, obliquely downward as shown. Its width may be up to 8 cm and still permit primary closure of the defect, depending on the size of the patient and the amount of subcutaneous tissue. The end of the incision is brought into the axilla just anterior to the posterior axillary fold to permit access to the apex of the axilla and the base of the pedicle. A Z-plasty is placed in the axilla if the dissection is carried to the apex.
 B. The elevation of the skin flaps from the underlying muscle. The skin island, if taken with the muscle, should be secured with tacking sutures to prevent it from being sheared from the underlying muscle. The dissection of the surrounding skin flaps can be accomplished by cutting just superficial to the thin fascia over the muscle. One should not see the muscle fibers. The area of the cutting and coagulating "Bovie" cautery speeds up dissection and conserves blood. Once the muscle has been isolated, however, bipolar coagulation or instrument dissection should be used to protect the isolated vascular pedicle.
 C. The anterior border of the latissimus has been elevated from the underlying serratus. This cleavage plane is easily developed superiorly but becomes increasingly more intimately attached to the serratus as one proceeds inferiorly. Sharp dissection is necessary in the lower portion to free the anterior border of the latissimus. As one exposes the under- surface of the latissimus muscle, the combined vascular anatomy of the serratus and latissimus can be visualized. The subscapular vessels end by dividing into an anterior branch, which goes to the lower serratus fibers, and a posterior branch, the thoracodorsal, which supplies the latissimus. The nerve to the latissimus follows the subscapular and thoracodorsal vessels, whereas the nerve to the serratus is more anterior and fixed to the chest wall. The subscapular artery can be freed up to the axillary artery, providing a long vascular pedicle. The venae comitantes are often joined to form a single vein in the upper axilla.
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PLATE XIX-3
 A. The posterior-superior margin of the latissimus is separated from the teres major at the angle of the scapula. These two muscles are closely adherent as they approach their insertion on the medial surface of the humerus. If the upper border is mobilized, the dissection can be carried downward anteriorly above the serratus. It is often better to complete this dissection before the anterior dissection so that one does not dissect deep to the serratus in the anterior dissection. Large perforators are encountered to the intercostal vessels in the posterior axillary line, entering the deep surface of the muscle. These should be carefully tied or clipped.
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