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Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al. |
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The elevation and separation of the muscle can proceed from the chest wall and the angle of the scapula. This is best achieved by defining the lower border of the ninth slip and opening this area with sharp dissection to reach the undersurface of the muscle, which is an easily defined plane that can be swept clear with blunt digital dissection. The separation between the seventh and sixth slips can then be performed from the deep surface anteriorly, taking care to preserve the neurovascular bundles as they enter the seventh slip. Once the upper and lower borders of the three slips have been separated, the muscle can be detached from the rib cage with sharp dissection. Multiple perforators from the intercostal system in this area must be tied or clipped. Separation of the muscle from the angle of the scapula should be done with care, trying to preserve the cleft between the seventh and sixth slips, which spiral around as they approach the angle of the scapula.
Because of the profuse blood supply between the intercostal vessels and the origin of the serratus on the chest wall and the blood supply from the thoracodorsal artery, compound flaps of the serratus and one or two of the underlying ribs can be mobilized.6,14,15 The rib survives on the blood supply coming through the muscles proximally or the intercostal vessels can be isolated, separated, and reanastomosed in the recipient area. 14,16 An overlying skin island supplied by the large perforators can be carried with the underlying muscle.7 |
Operative Sequence PLATE XXI-1. Anatomy
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Ch. 21 Page 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |