Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 21:
Free Serratus Anterior Static and Dynamic Muscle Transplantation
  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

A. The anatomic territory of the serratus is closely associated with that of the latissimus dorsi and its dissection is familiar to anyone working with the latissimus. The key to the entire area is the subscapular artery, which comes off the third part of the axillary artery and is the largest branch of the axillary artery. It runs down the subscapularis muscle to reach the latissimus dorsi muscle, which it supplies. It continues to supply the lower serratus anterior muscle or the lower four slips, 6, 7, 8, and 9. The upper portion of the serratus is supplied by the lateral thoracic artery, which is located more anteriorly because it comes off the second part of the axillary artery under the pectoralis minor. The nerve to the serratus, the long thoracic nerve, runs down on the middle surface of the serratus beneath the fascia and reaches the lower three slips anterior to the vessels. The third part of the serratus, or the lower three slips, has a definable nerve and blood supply, which lends it to isolation as a separate transplant. The lower three slips are also supplied by branches from C6 and C7, which make them, as a unit, worthwhile as a muscle transfer in upper brachial plexus lesions.

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