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 B. The muscle has been completely mobilized from the posterior superior margin to the anterior margin. It can then be detached from the lumbodorsal fascia just off the midline and down over the inferior insertion. If the dissection is carried inferiorly to the iliac crest, fascia can be carried with the muscle. The blood supply to the tip of this thin muscle is precarious, however, and should not be depended on to support an overlying skin graft. If it is carried with the transplant and buried under the wound margin of the recipient area, it can survive as a free graft, or rolled onto itself to form a tendinous insertion.
PLATE XIX-4
 A. The muscle has now been detached from its chest wall and rotated upward on its humeral insertion. The neurovascular pedicle is completely isolated, but it is not transected until the muscle is ready for transfer. It is wise to keep the humeral insertion of the muscle intact until transfer to prevent traction on the vascular pedicle. The branch to the serratus has been tied, as have the circumflex scapular vessels. It is wise to tie these branches long if there is a possibility that internal shunts may be needed for multiple transplants, or flow-through interpositional anastomoses.
PLATE XIX-5. Application
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 A. A large unstable wound with an underlying fracture is stabilized with a medullary plate, which is exposed.
 B. The contaminated medullary plate has been removed, the unstable scar excised, and the entire area exposed with superior, anterior, and inferior flaps. The posterior tibial neurovascular bundle has been isolated in the posterior compartment. One of the venae comitantes has been isolated and turned out for an end-to-end repair to the latissimus vein. The artery to the latissimus has been repaired in an end-to-side fashion to the posterior tibial artery, preserving distal circulation. The latissimus muscle has been folded backward and secured in place while this repair is performed. At the completion of the artery and venous repair, the entire muscle is folded forward, covering the bony and soft-tissue defect and providing the blood supply to the underlying structures.
C,
D.
The skin flaps have been rotated back in place and the entire muscle has
been covered with a mesh skin graft.
Clinical Cases
CASE 1
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