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 FIG. 21-02. The ipsilateral 7th, 8th, and 9th slips of the serratus anterior muscle have been isolated (Penrose drain). The dominant pedicle from the thoracodorsal vessels has been looped, and enters the lower third of the muscle at the junction of the middle and posterior thirds. The latissimus muscle has been retracted to expose the scapular insertion.
 FIG. 21-03. The flap has been divided after careful isolation of the long thoracic nerve branch to the lowest three slips, preserving the proximal nerve to allow muscle function and prevent scapular winging. The muscle has been inverted (9th slip superior, 7th inferior) to place the vascular pedicle deep to the muscle bulk to permit later debulking without injuring the vascular supply, which was performed to the facial vessels.
 FIG. 21-04. The postoperative follow-up at 3 years shows excellent contour.
 FIG. 21-05. The longitudinal midaxillary scar is well hidden beneath the arm, and there is no compromise to shoulder elevation or scapular winging. Side view.
 FIG. 21-06. Dorsal view.
CASE 2
A 30-year-old woman with Romberg's disease had noted facial atrophy in retrospect over 18 years.
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 FIG. 21-07. The atrophy was worse in the 2 years before reconstruction.
 FIG. 21-08. The surgical landmarks for the lowest three serratus slips (scapular angle, ribs) are marked on the chest wall.
 FIG. 21-09. The flap has been isolated on its vascular pedicle.
 FIG. 21-10. With its posterior neurovascular supply, the serratus muscle is ideally suited for splitting of the anterior insertions to reconstruct complex defects.
 FIG. 21-11. Six-month follow-up shows excellent contour and restoration of facial symmetry. Front view.
 FIG. 21-12. Lateral view.
 FIG. 21-13. Inferior view.
CASE 3
A 45-year-old woman underwent resection of a scalp sarcoma 13 years before referral. The skin graft on the left forehead and scalp was unstable.
 FIG. 21-14. Front view.
 FIG. 21-15. Side view.
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