Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 21:
Free Serratus Anterior Static and Dynamic Muscle Transplantation
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  A. Once the entire superior outer surface of the serratus has been cleared, one then proceeds to develop the lower border of the last slip to the ninth rib. This cleavage plane can be developed quickly once the lower border of the ninth rib has been identified and the entire undersurface of the serratus has been freed from the origin of the muscle and the chest wall laterally to the angle of the scapula. The interval between slips 7 and 6 can be developed with the tip of the finger on the undersurface of the muscle. Once this interval cleavage plane has been established, the dissection can proceed from the chest wall to the angle of the scapula, separating the lower three slips completely. Great care must be taken as one approaches the neurovascular pedicle. Every effort should be made to preserve the nerve supply to the higher slips. This is usually fairly easy to do because a definite branch of the nerve splits off to supply slips 7, 8, and 9. The vascular pedicle can be traced proximally and the branch to the latissimus can be tied off if a long pedicle is needed. This can be carried all the way to the axillary artery, if necessary, for an extremely long vascular pedicle. The nerve cannot be developed above the level of C7 without damaging the nerve supply to the higher slips. Under magnification, the nerve can be split off from the higher slips, but this is increasingly difficult as one proceeds proximally. If a long nerve pedicle is needed, it is probably wiser to insert a nerve graft rather than unnecessarily denervate the proximal muscle slips, which results in winging of the scapula.


  B. Slips 7, 8, and 9 have been detached from their costal origin. They interdigitate with the external oblique muscle and must be separated sharply. Multiple perforators from the intercostal vessels come through the muscles at this junction and must be carefully tied and ligated. This rich collateral blood supply between the intercostal system and the subscapular system permits vascularized ribs to be carried with the serratus muscle. The attachment of the muscle to the angle of the scapula is then separated sharply. The fibers of slips 6 and 7 form a spiral and must be separated with careful dissection.


C. The serratus has now been isolated entirely on its neurovascular pedicle and is ready for transfer.


Clinical Cases

CASE 1

A 36-year-old man developed Romberg's disease, having initially noted facial atrophy as a teenager.

FIG. 21-01. The patient has had multiple collagen injections that brought moderate improvement, but have disappeared completely.


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