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Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al. | ||
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| The vascular pedicle is usually easily visualized once the latissimus is elevated. The blood supply to the upper portion of the serratus from the lateral thoracic artery or long thoracic artery can often be mistaken for the blood supply to the lower slips. In almost every instance, however, the major blood supply to the lower three slips comes from a continuation of the subscapular-thoracodorsal vascular axis. l0-12 This can be visualized on the undersurface of the latissimus or lying on the serratus muscle as these vessels come out of the axilla. They are usually covered by a fatty areolar tissue and must be carefully separated from the surrounding multiple branches that enter the adjacent muscles. 13
The long thoracic nerve is anterior to the vessels and densely adherent to the fascia over the serratus, joining the blood supply to the posterior three slips at about the sixth rib. This nerve must be carefully isolated, and one can usually discern a definite, separate, definable bundle of fascicles that descend with the artery and vein to the seventh, eighth, and ninth slips.11 These can be separated proximally from the sixth, fifth, and possibly fourth slips, but denervation of these important remaining slips is possible. If a long nerve pedicle is needed, it is probably wiser to insert a segmental graft than to risk the possibility of denervating the proximal slips of the serratus, producing winging of the scapula. |
Once the vascular pedicle has been isolated, the branch to the latissimus can be tied and the dissection carried up into the axilla to gain an extremely long vascular pedicle, if needed.2,3,5 Ordinarily, for use in facial paralysis, a relatively short pedicle is all that is needed; therefore the blood supply to the latissimus can be left intact and the nerve pedicle kept short so that the cross-facial nerve can be anastomosed as near the muscle as possible, permitting rapid reinnervation.2 |
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| Ch. 21 Page 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | |||