Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

LATISSIMUS DORSI MUSCLE FLAP
579
LATISSIMUS DORSI MUSCLE FLAP
Incision (Fig. 11–7)
The patient is placed on the side, with the donor side
upward and the shoulder joint abducted. An incision is
m ade from the posterior axillary fold, running pos-
teroinferiorly toward the loin, 3 to 5 cm posterior to the
lateral margin of the muscle. The length of the incision
accords with the size of the m uscle ap required. At
times, a small skin island is designed, remaining on the
muscle as a monitor for the integrity of the circulation.
Figure 11–7
Incision.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Teres major m.
4. Rhomboid major m.
5. Infraspinatus m.
6. Axillary a. and v.
7. Subscapular a. and v.
8. Thoracodorsal a., v., and n.
9. Circum ex scapular a. and v.
10. Branch to serratus anterior
11. Serratus posterior inferior m.
12. Intercostalis externus m.
13. Pectoralis major m.

Exposure of the Latissimus Dorsi
Muscle (Fig. 11–8)
The skin and subcutaneous layers are incised. Anterior
and posterior aps are raised with undermining to ex-
pose the super cial surface of the latissim us dorsi mus-
cle (1). Then the lateral and superior borders of the
muscle are identi ed.
580
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Figure 11–8
Exposure of the latissimus dorsi muscle.
1. Latissimus dorsi m.
3. Teres major m.
2. Serratus anterior m.
4. Rhomboid major m.

Dissection at the Lateral Border
(Fig. 11–9)
At its lateral border, dissection proceeds between the
latissimus dorsi (1) and serratus anterior (2) muscles.
The middle portion of the latissimus dorsi is separated
from the chest wall.
LATISSIMUS DORSI MUSCLE FLAP
581
Figure 11–9
Dissection at the lateral border.
1. Latissimus dorsi m.
2. Serratus anterior m.
10. Branch to serratus anterior

Dissection of the Neurovascular
Bundle (Fig. 11–10)
In the axillary dissection, the thoracodorsal neurovas-
cular pedicle (8) is identi ed under the latissimus dorsi
(1), ~2 to 3 cm medial to the lateral border of the mus-
cle. Its entrance to the muscle can be de ned ~9 cm be-
low the apex of the axilla.
One or two branches (10) to the serratus anterior
are ligated, and the thoracodorsal neurovascular pedi-
cle (8) is then isolated and marked with a vascular loop.
The proxim al part of the m uscle is isolated and re-
tracted with a Penrose drain. After identi cation of the
circum ex scapular artery (9), the pedicle can be dis-
sected up to the origins of the subscapular vessels (7).
582
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Figure 11–10
Dissection of the
neurovascular bundle.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Teres major m.
6. Axillary a. and v.
7. Subscapular a. and v.
8. Thoracodorsal a., v., and n.
9. Circum ex scapular a. and v.
10. Branch to serratus anterior
13. Pectoralis major m.

Elevation of the Distal Portion
(Fig. 11–11)
After dissecting between the muscle and the chest wall
toward the back midline and the iliac crest, and ligating
the branches from the intercostals and lumbar arteries,
the distal portion of the muscle is divided at a level de-
pending on the amount of tissue required at the recipient
site. As the muscle ap is elevated from the chest wall
proximally, some perforating branches from the chest
wall to the deep surface are encountered and ligated.
LATISSIMUS DORSI MUSCLE FLAP
583
Figure 11–11
Elevation of the distal
portion.
2. Serratus anterior m.
3. Teres major m.
4. Rhomboid major m.
5. Infraspinatus m.
11. Serratus posterior inferior m.
12. Intercostalis externus m.

Completion of Harvesting (Fig. 11–12)
The proximal portion of the muscle (1) is divided near
its insertion, with protection of the neurovascular pedi-
cle (8). Tethered only by the neurovascular bundle, the
latissimus dorsi (1) is almost freed.
584
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Figure 11–12
Completion of harvesting.
1. Latissimus dorsi m.
6. Axillary a. and v.
7. Subscapular a. and v.
8. Thoracodorsal a., v., and n.

LATISSIMUS DORSI
MYOCUTANEOUS FLAP
Flap Design (Fig. 11–13)
The lateral and upper borders of the muscle should be
identi ed by palpation. A skin paddle of the required
size is outlined at the proper location on the muscle.
Generally, the myocutaneous perforators from the latis-
simus dorsi are more numerous over the proximal two-
thirds of the muscle.
If the skin paddle is larger than 10 cm in width,
donor-site closure m ay require a split-thickness skin
graft. The maximum dimensions are ~40
20 cm.
LATISSIMUS DORSI MYOCUTANEOUS FLAP
585
Figure 11–13
Flap design.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Thoracodorsal a., v., and n.
4. Axillary a. and v.
5. Subscapular a.
6. Teres major m.

Flap Incision and Exposure of the
Muscle (Fig. 11–14)
A circumferential incision of the skin ap is performed
and extended proximally to the axillary fossa. The ante-
rior and posterior skin over the rest of the latissimus
dorsi (1) is raised to expose the lateral and upper bor-
ders of the latissimus dorsi muscle. The skin margin of
the ap is sutured to the m uscle fascia with several
tacking sutures to avoid shearing injury to the myocu-
taneous perforators.
586
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Figure 11–14
Flap incision and exposure of the muscle.
1. Latissimus dorsi m.
2. Serratus anterior m.
6. Teres major m.

Elevation of the Musculocutaneous
Flap (Fig. 11–15)
The latissimus dorsi (1) with its skin paddle is elevated,
and its neurovascular pedicle (3) dissected, as de-
scribed in the section on muscle ap harvesting.
LATISSIMUS DORSI MYOCUTANEOUS FLAP
587
Figure 11–15
Elevation of the musculocutaneous ap.
1. Latissimus dorsi m.
3. Thoracodorsal a., v., and n.
4. Axillary a. and v.
5. Subscapular a.

BILOBED SPLIT LATISSIMUS DORSI FLAP
Marking between the Lateral and
Medial Branches (Fig. 11–16)
The muscle or myocutaneous ap based on the thora-
codorsal neurovascular pedicle (3) is raised, as has
already been described. On the deep surface, the en-
trance of the neurovascular pedicle is identi ed, and
the lateral and medial neurovascular branches (4,5) are
traced from it. The neurovascular pattern may be de-
ned by transillumination and with the use of a stimu-
lator. It can be m arked with several needles passed
through the ap.
588
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Figure 11–16
Marking between the lateral
and medial branches.
1. Latissimus dorsi m.
3. Thoracodorsal a. and v.
4. Lateral branch
5. Medial branch
6. Axillary a. and v.
7. Thoracodorsal n.

Separating the Muscle (Fig. 11–17)
The skin paddle is incised and the muscle is split along
the previously marked neurovascular pattern.
BILOBED SPLIT LATISSIMUS DORSI FLAP
589
Figure 11–17
Separating the muscle.
4. Lateral branch
5. Medial branch

LATERAL SPLIT LATISSIMUS DORSI FLAP
Incision (Fig. 11–18)
An incision is m ade from the posterior axillary fold,
running along the lateral border of the latissimus dorsi
m uscle. (If a myocutaneous ap is required, the skin
paddle is designed on the lateral part of the muscle.)
590
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Figure 11–18
Incision.
1. Latissimus dorsi m.
2. Teres major m.
3. Thoracodorsal a. and v.
4. Lateral branch
5. Medial branch
6. Axillary a. and v.
7. Thoracodorsal n.
8. Serratus anterior m.

Identi cation of the Lateral Branch
(Fig. 11–19)
The m uscle is elevated to expose the thoracodorsal
neurovascular bundle (3), and its entrance and lateral
branches (4) are then identi ed.
LATERAL SPLIT LATISSIMUS DORSI FLAP
591
Figure 11–19
Identi cation of the lateral branch.
1. Latissimus dorsi m.
5. Medial branch
2. Teres major m.
6. Axillary a. and v.
3. Thoracodorsal a. and v.
7. Thoracodorsal n.
4. Lateral branch
8. Serratus anterior m.

Separating the Muscle (Fig. 11–20)
Taking care that the lateral branch (4) is included, the
lateral part of the muscle is split, and the medial vascu-
lar branch (5) is ligated. The lateral nerve branch is sep-
arated from the m edial branch in the thoracodorsal
nerve (7) and divided to be as long as possible, leaving
the medial nerve branch intact. The lateral split latis-
sim us dorsi ap, based on the thoracodorsal-lateral
branch neurovascular bundle, is isolated.
592
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Figure 11–20
Separating the
muscle.
1. Latissimus dorsi m.
3. Thoracodorsal a. and v.
4. Lateral branch
5. Medial branch
7. Thoracodorsal n.

RIB–LATISSIMUS DORSI
OSTEOMYOCUTANEOUS FLAP
Flap Design and Proposed Rib
(Fig. 11–21)
The latissimus dorsi muscle covers the lower ribs from
the back m idline to the posterior axillary line. There are
vascular com m unications between the thoracodorsal
artery and the periosteal vessels of the ribs. The ninth
or 10th ribs may be selected to be combined in the ap.
A bony length of ~12 cm is available.
RIB–LATISSIMUS DORSI OSTEOMYOCUTANEOUS FLAP
593
Figure 11–21
Flap design and proposed rib.
1. Latissimus dorsi m.
2. Intercostalis m.
3. Ninth rib
4. Pleura
5. Thoracodorsal a., v., and n.

Dissection and Osteotomy of the Rib
(Fig. 11–22)
Flap elevation is begun distally and must stop at the in-
tercostal space inferior to the selected ribs. Then the in-
tercostal muscles (2) are incised in the intercostal space,
and the rib is divided at both ends. The rib (3) is sepa-
rated from the pleura (4). The component is then ipped
proximally, keeping it intact with the muscle ap.
594
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Figure 11–22
Dissection and osteotomy of the rib.
1. Latissimus dorsi m.
3. Ninth rib
2. Intercostalis m.
4. Pleura

Completion of Flap Elevation
(Fig. 11–23)
Intercostal muscles proximal to the selected ribs are in-
cised, and the osteomyocutaneous ap is isolated on
the thoracodorsal neurovascular pedicle (5), as was al-
ready described.
RIB–LATISSIMUS DORSI OSTEOMYOCUTANEOUS FLAP
595
Figure 11–23
Completion of ap elevation.
1. Latissimus dorsi m.
3. Ninth rib
5. Thoracodorsal a., v., and n.
Note: Refer to Chapter 9 for additional details on harvesting a vascularized rib.

SCAPULAR BONE–LATISSIMUS DORSI
OSTEOMUSCULAR FLAP
With the angular artery, the latissimus dorsi ap can
combine with the lateral portion of the scapular bone.
The technique, as reported, can be utilized in cases of
loss of both soft tissue and a segment of tibia bone due
to trauma.
Identi cation of the Angular Artery
(Fig. 11–24)
An incision is m ade as for a regular latissim us dorsi
muscle ap (described earlier). Once the lateral margin
of the muscle is reached, a careful dissection proceeds
to search for the serratus branch, while the latissim us
dorsi muscle is elevated. As soon as the serratus branch
is identi ed, it is traced in a retrograde fashion to the
thoracodorsal artery, continuously attempting to iden-
tify the angular artery. The angular artery may originate
from the thoracodorsal artery or from the serratus
branch, and it runs posteriorly toward the lateral border
of the scapula.
596
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Figure 11–24
Identi cation of the angular artery.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Thoracodorsal a., v., and n.
4. Serratus branch
5. Angular a.
6. Circum ex scapular a.
7. Subscapular a.

Dividing Muscles and Visualizing the
Angular Artery (Fig. 11–25)
The serratus branch and the circum ex scapular artery
are ligated, keeping the angular artery intact with the
thoracodorsal artery. The latissim us dorsi m uscle (1)
ap is raised from its caudal and medial ends (which
are proposed for the muscle ap), and the scapular ori-
gin of the teres major muscle (8) is detached. At this
time, the lateral edge of the scapula is clearly exposed,
and it can easily be visualized that the angular artery
(5) enters the soft tissue on the lateral border of the
scapula.
SCAPULAR BONE–LATISSIMUS DORSI OSTEOMUSCULAR FLAP
597
Figure 11–25
Dividing muscles and visualizing the
angular artery.
1. Latissimus dorsi m.
2. Serratus anterior m.
5. Angular a.
8. Teres major m.
9. Infraspinatus m.

Exposure of Scapular Bone
(Fig. 11–26)
The infraspinatus (9) and subscapularis m uscles are di-
vided along the line proposed for the ap on the scapu-
lar bone. The average bony size is 5
2 cm, and the
inferior angle of the scapula is reserved for prevention
of a winging scapula.
598
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Figure 11–26
Exposure of scapular bone.
1. Latissimus dorsi m.
2. Serratus anterior m.
5. Angular a.
8. Teres major m.
9. Infraspinatus m.

Osteotomy (Fig. 11–27)
Osteotomy is perform ed on the scapula, with care to
protect the angular artery and vascular pedicle of the
thoracodorsal vessels (3). After the proximal end of the
latissimus dorsi muscle (1) near its insertion is divided,
the latissimus dorsi osteomuscular ap with scapular
bone is ready for transfer.
SCAPULAR BONE–LATISSIMUS DORSI OSTEOMUSCULAR FLAP
599
Figure 11–27
Osteotomy.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Thoracodorsal a., v., and n.
5. Angular a.
8. Teres major m.
9. Infraspinatus m.

THORACODORSAL ARTERY
PERFORATOR (TAP) FLAP
To overcome the problem of bulkiness, the TAP ap has
been developed since the last decade of the previous cen-
tury. Some authors have named it “the latissimus dorsi
perforator-based ap.” According to classic terminology,
the skin ap would be named after its location or its sup-
plying vessels, despite the muscle underneath—such as
the deep inferior epigastric artery, gluteal artery perfora-
tor, or anterolateral thigh aps. The nomenclature of “tho-
racodorsal artery perforator (TAP) ap” would be proper.
Doppler Detection and Flap Design
(Fig. 11–28)
First, the anterior border of the latissimus dorsi muscle
is marked on the skin surface. If possible, it would be
useful to use ultrasound preoperatively to identify the
exact lateral boundary, especially in obese patients.
A point is marked 8 cm below the posterior axillary
fold and 2 cm posterior to the lateral border of the mus-
cle, where it represents approximately the hilus for the
thoracodorsal neurovascular bundle into the m uscle.
From this point, Doppler detection proceeds distally to
search for the cutaneous perforator in a band 2 to 3 cm
in width parallel to the lateral border of the muscle. In
m ost cases, there may be two to three cutaneous perfo-
rators found. The proximal one is usually larger and lo-
cated a little below the point m arked. The second
perforator may be ~3 cm distal to the proximal one.
The ap is designed on the basis of the most reli-
able perforator found by Doppler owmeter. The ante-
rior border of the ap should be placed ~1 cm over the
lateral boundary of the muscle, at the level of the hilus,
so that it can include the direct cutaneous branch,
which is given off from the thoracodorsal or subscapu-
lar artery. It runs around the lateral edge of the m uscle.
The size of the ap can be up to 25 cm in length and
14 cm in width.
600
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Figure 11–28
Doppler detection and ap design.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Musculocutaneous perforator
4. Thoracodorsal a., v., and n.
5. Branch to serratus anterior m.
6. Circum ex scapular a.
7. Subscapular a.

Anterior Elevation and Perforator
Identi cation (Fig. 11–29)
The anterior border of the ap is incised down to the
suprafascial plane on the serratus anterior muscle (2),
and the incision is extended into the axilla. A dissection
is performed medially toward the lateral border of the
latissim us dorsi m uscle (1). As soon as the border is
reached, attention should be paid to identifying the di-
rect cutaneous branch at the level of the hilus of the
thoracodorsal artery, even though it rarely exists. If it is
present, the rest of the procedure is m ore convenient
and simple. If not, dissection is continued to search out
the cutaneous perforator(s) (3) in the plane between
the fascia and the latissim us dorsi muscle beyond its
lateral borders.
THORACODORSAL ARTERY PERFORATOR (TAP) FLAP
601
Figure 11–29
Anterior elevation and perforator identi cation.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Musculocutaneous perforator

Perforator Veri cation (Fig. 11–30)
Usually, one or two larger cutaneous perforators may
be found during the dissection beyond the lateral bor-
der of the latissim us dorsi m uscle. Subsequently, the
lateral edge of the muscle is elevated to look for the
thoracodorsal vessels on the ventral surface, and to ver-
ify that the cutaneous perforators originate from the
lateral branch through the muscle.
602
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Figure 11–30
Perforator veri cation.
1. Latissimus dorsi m.
2. Serratus anterior m.
4. Thoracodorsal a., v., and n.
5. Branch to serratus anterior m.

Intramuscular Dissection of
Perforator (Fig. 11–31)
Once the cutaneous perforator(s) (3) is (are) veri ed,
the rest of the ap is raised as an island ap on the per-
forator(s). As the muscle (1) is gradually split longitudi-
nally, an intram uscular dissection proceeds to isolate
the perforator bundle (3) and lateral branch of the tho-
racodorsal artery (4) from the m uscle by ligating all
muscular branches until the main trunk of the thora-
codorsal artery (4) is reached.
Some authors take a m uscle cuff with a diameter of
2 to 3 cm around the perforator bundle. This lessens the
amount of intramuscular dissection necessary.
THORACODORSAL ARTERY PERFORATOR (TAP) FLAP
603
Figure 11–31
Intramuscular dissection of perforator.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Musculocutaneous perforator
4. Thoracodorsal a., v., and n.

Completion of Harvesting (Fig. 11–32)
Dissection is continued in the axilla to ligate the lateral
branch of the thoracodorsal artery (4) distal to the take-
off of the perforator (3) and the medial branch of the
thoracodorsal artery at its bifurcation. For more length
of vascular pedicle, the circum ex scapular artery is lig-
ated, and the subscapular artery can be reached. During
the dissection of the vascular pedicle, care should be
taken to preserve intact the thoracodorsal nerve and its
branches in the muscle (1), as far as possible.
At this stage, the TAP ap is ready for transfer. For a
free ap, the pedicle is divided and pulled through the
cleavage of the muscle. If used for a local island transfer
as, for exam ple, in reconstruction of the breast, the
muscle cleavage is enlarged to allow the ap to pass
through.
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Figure 11–32
Completion of harvesting.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Musculocutaneous perforator
4. Thoracodorsal a., v., and n.
5. Branch to serratus anterior m.
6. Circum ex scapular a.
7. Subscapular a.

SCAPULAR AND PARASCAPULAR FLAPS
Anatomy (Fig. 11–33)
The circum ex scapular artery (7) arises from the sub-
scapular artery (6) ~3 to 4 cm from its origin at the axil-
lary artery (5). (For variations in its origin, see section
on the latissimus dorsi.) The artery (7) passes posteri-
orly through the triangular space bordered by the teres
minor (4) above, the teres major (3) below, and the long
head of the triceps (2) laterally, and in this space it usu-
ally gives off the following branches:
1. The infrascapular branch (9) enters the subscapular
fossa deep to the subscapularis.
2. One or two muscular branches run to the teres major
and teres m inor.
3. The descending branch (10) goes back as its continua-
tion and emerges posteriorly from the triangular space;
it then divides into two main cutaneous branches (11, 1)
right at the edge of the lateral border of the scapula.
4. The cutaneous scapular branch (11) runs horizon-
tally over the posterior aspect of the scapula.
5. The cutaneous parascapular branch (1) proceeds to
the inferior angle of the scapula.
6. Before dividing into the two m ain cutaneous
branches, the circum ex scapular artery (7) gives off
several sm all branches that penetrate the lateral
border of the scapula.
Measurements of Arteriovenous Scapular System
Diameter (mm) Length (cm)
Subscapular
Artery
3–4
3–4
Vein
3.5–4.5
Circum ex scapular
Artery
2.5–3.5
3–4
Vein
2.5–4.0
Descending
Artery
1.5–2.0
4–6
Vein
2.0–2.5
Cutaneous scapular
Artery
0.8–1.5
Vein
1.0–2.0
Cutaneous parascapular
Artery
0.8–1.5
Vein
1.0–2.0
SCAPULAR AND PARASCAPULAR FLAPS
605
Figure 11–33
Anatomy of the scapular
ap.
1. Cutaneous parascapular branch
2. Long head of triceps m.
3. Teres major m.
4. Teres minor m.
5. Axillary a.
6. Subscapular a.
7. Circum ex scapular a.
8. Thoracodorsal a.
9. Infrascapular branch
10. Descending branch
11. Cutaneous scapular branch

606
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Clinically, this scapular area supplied by the circum ex
scapular artery has becom e one of the most frequently
used donor sites in reconstructive m icrosurgery be-
cause of consistent vascular anatomy, easily accessible
vascular pedicle, desirable vessel diameter and length,
and ap safety and reliability.
There is a moderate amount of subcutaneous tissue
and generally hairless skin. Flap size can reach 10
25
cm in the scapular ap and 15
30 cm in the para-
scapular ap. There is, however, no large single nerve
that can be used to innervate these aps.
The lateral border of the scapula can provide vascu-
larized bone, especially useful for face and hand recon-
struction.
Generally, the donor site defect can be closed di-
rectly, with acceptable scarring and little postoperative
m orbidity.
Based on the subscapular arterial system, scapular
or parascapular osteocutaneous aps can be combined
with the latissimus dorsi and serratus anterior or their
myocutaneous aps.
COMMENT AND INSIGHTS
Figure 11–34
Flap design.
1. Deltoid m.
2. Teres major m.
3. Teres minor m.
4. Long head of triceps m.
5. Descending branch of circum ex scapular a.
6. Infraspinatus m.
7. Trapezius m.
8. Rhomboideus major m.
9. Latissimus dorsi m.
10. Axillary a.
11. Subscapular a.
12. Circum ex scapular a.
13. Thoracodorsal a. and n.
14. Subscapularis m.
Scapular Flap
Flap Design (Fig. 11–34)
The location of the triangular space is marked using the
following method. The distance from the midpoint of
the scapular spine can be derived from the form ula:
D1
(D 1)/2, where D is the distance between the
midpoint of the spine and the tip of the scapula. The
location of the triangular space can be con rmed with
bi-digital palpation.
The ap is outlined according to the following pa-
rameters. Its axis corresponds to the cutaneous scapu-
lar artery that runs from the marked triangular space
medially and parallel to the scapular spine. Flap design
may vary, although an elliptical shape is preferred for
easy closure, with the lateral end of the ellipse positioned

just over the triangular space. The medial end can ex-
tend all the way to the midline of the back; the superior
limit is the spine of the scapula and the inferior limit is
the tip of the scapula. A ap can be harvested larger
than 10 cm in width and 20 cm in length.
The patient can be positioned in either lateral de-
cubitus, prone, or three-quarter position, depending on
whether the recipient site is posterior or anterior.
There are two options for exposing the emergence
of the cutaneous branches.
Lateral Exposure of Vascular Emergence
(Fig. 11–35)
The rst incision is started on the upper lateral portion of
the ellipse described previously. The posterior margin of
the deltoid (1) is identi ed and the muscle is retracted
superiorly revealing the teres minor (3). Dissection pro-
ceeds along the surface of the teres minor, a brofatty
tissue through which the cutaneous branches (5) of the
circum ex scapular vessel’s course can be exposed.
SCAPULAR AND PARASCAPULAR FLAPS
607
Figure 11–35
Lateral exposure of vascular emergence.
1. Deltoid m.
4. Long head of triceps m.
2. Teres major m.
5. Descending branch of circum ex scapular a.
3. Teres minor m.
6. Infraspinatus m.

Medial Exposure of Vascular Emergence
(Fig. 11–36)
Elevation of the ap begins m edially in an avascular
plane, just above the super cial fascia of the infraspina-
tus (6) and teres major (2) muscles. Once the triangular
space is reached near the lateral border of the scapula,
the vessels can be seen emerging in a brofatty tissue
between the teres minor and major muscles.
608
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Figure 11–36
Medial exposure of vascular emergence.
2. Teres major m.
6. Infraspinatus m.
3. Teres minor m.
7. Trapezius m.
5. Descending branch of circum ex scapular a.
8. Rhomboideus major m.

Flap Elevation (Fig. 11–37)
The vascular pedicle (5) and triangular space should be
further identi ed while raising the rem ainder of the
ap. It is not necessary to dissect the vessels in the -
brofatty tissue; the optimal way to isolate the pedicle is
to stay close to the muscular walls, freeing the bro-
fatty tissue toward the center of the space.
SCAPULAR AND PARASCAPULAR FLAPS
609
Figure 11–37
Flap elevation.
2. Teres major m.
6. Infraspinatus m.
3. Teres minor m.
7. Trapezius m.
5. Descending branch of circum ex scapular a.
8. Rhomboideus major m.

Dissection in the Scapular Triangular Space
(Fig. 11–38)
For further dissection, the long head of the triceps and
the teres major and minor (2,3) should be retracted in
their respective directions to gain better exposure. The
branches to the teres m ajor and m inor, infraspinatus
and infrascapular branches, are ligated successively. In
this manner, a vascular pedicle length of 6 to 9 cm can
be obtained.
610
III.11 TRUNK: BACK
Figure 11–38
Dissection in the scapular triangular space.
2. Teres major m.
3. Teres minor m.
4. Long head of triceps m.
5. Descending branch of circum ex scapular a.
6. Infraspinatus m.
7. Trapezius m.
8. Rhomboideus major m.

Pedicle Dissection in the Axilla
(Fig. 11–39)
When a longer pedicle or further and better exposure
are necessary, a 5 cm incision is made in the midaxilla.
The subscapular artery (11) is identi ed and a tunnel is
bluntly dissected under the teres minor to connect the
triangular and axillary spaces. Once the thoracodorsal
vessels (13) are ligated, a maximum pedicle length can
reach 11 to 14 cm.
SCAPULAR AND PARASCAPULAR FLAPS
611
Figure 11–39
Pedicle dissection in the axilla.
2. Teres major m.
12. Circum ex scapular a.
9. Latissimus dorsi m.
13. Thoracodorsal a. and n.
10. Axillary a.
14. Subscapularis m.
11. Subscapular a.
Note: In 4% of cases the circum ex scapular artery originates independently
from the axillary artery.

Parascapular Flap
Flap Design (Fig. 11–40)
Once the triangular space is located, as in the scapular
ap described previously, the m ain axis of the para-
scapular ap is drawn along the lateral border of the
scapula. The upper edge of the ap is at or above the
level of em ergence of the cutaneous vessels; the lower
edge can be situated as far as 25 to 30 cm from the up-
per edge. The maximum width of this ap is ~15 cm and
the donor site can be closed directly.
612
III.11 TRUNK: BACK
Figure 11–40
Flap design.
1. Teres major m.
2. Teres minor m.
3. Latissimus dorsi m.
4. Infraspinatus m.
5. Long head of triceps
6. Descending branch of circum ex scapular a.
7. Cutaneous parascapular branch
8. Cutaneous scapular branch

Completion of Flap Harvesting
(Fig. 11–41)
Procedures for raising the ap, dissection, and isolation
of the vascular pedicle (6) are similar to the scapular
ap.
SCAPULAR AND PARASCAPULAR FLAPS
613
Figure 11–41
Completion of ap harvesting.
1. Teres major m.
2. Teres minor m.
3. Latissimus dorsi m.
4. Infraspinatus m.
5. Long head of triceps
6. Descending branch of circum ex scapular a.
7. Cutaneous parascapular branch
8. Cutaneous scapular branch

SCAPULAR OSTEOCUTANEOUS FLAP
The length of the lateral scapular border (from the gle-
noid fossa to the inferior angle) ranges from 10 to 14 cm
and the thickness of the lateral border is between 0.7
and 1.2 cm. The midportion of the scapula is quite thin,
~0.2 cm , making it ideal for palatal or orbital oor re-
construction.
Flap Design and Bony Segment
Proposed (Fig. 11–42)
The skin ap can be designed and elevated following
the procedures and techniques for either scapular or
parascapular ap (or both) as previously described.
614
III.11 TRUNK: BACK
Figure 11–42
Flap design and bony segment proposed.
1. Teres major m.
2. Teres minor m.
3. Latissimus dorsi m.
4. Infraspinatus m.
5. Trapezius m.
6. Rhomboideus major m.
7. Descending branch of circum ex scapular a.
8. Scapula bone
9. Nutrient branch to scapula
10. Subscapular m.
11. Serratus anterior m.

Flap Elevation and Exposure of
Scapular Bone (Fig. 11–43)
The emergence of the vascular bundle (7) in the bro-
fatty tissue is identi ed, with care taken not to divide
the small, easily observed branches (9) to the bone over
the lateral scapular border (8). The circum ex scapular
artery is dissected in its lateral aspect, preserving these
bone branches in its medial aspect.
An incision is made directly through the muscles
(4) overlying the scapula (8) and, using a periosteal ele-
vator, the periosteum is stripped suf ciently to perform
osteotomies.
SCAPULAR OSTEOCUTANEOUS FLAP
615
Figure 11–43
Flap elevation and exposure of scapular bone.
1. Teres major m.
6. Rohmboideus major m.
2. Teres minor m.
7. Descending branch of circum ex scapular a.
3. Latissimus dorsi m.
8. Scapula bone
4. Infraspinatus m.
9. Nutrient branch to scapula
5. Trapezius m.

Osteotomy (Fig. 11–44)
The bone (8) is divided vertically with an oscillating
saw along the transition between the thick lateral bor-
der and thin blade and transversely just below the gle-
noid fossa.
The muscular origins of the serratus anterior (11),
subscapularis (10), and teres major and minor (2) are
616
III.11 TRUNK: BACK
Figure 11–44
Osteotomy.
2. Teres minor m.
8.
Scapula bone
4. Infraspinatus m.
9.
Nutrient branch to scapula
5. Trapezius m.
10. Subscapular m.
6. Rhomboideus major m.
11. Serratus anterior m.
7. Descending branch of circum ex scapular a.
Note for Donor Closure: All muscle origins at the donor site are reattached to the scapula through drill holes while closing
the donor site.
detached sharply from the remnants of the lateral bor-
der and inferior angle of the scapula (8), leaving a 0.5-cm
muscular sleeve. The vascular pedicle (7) is further dis-
sected to its proxim al lim its either at the junction of
the thoracodorsal artery or to the axillary artery, if
necessary.

SCAPULAR AND PARASCAPULAR
COMBINED FLAP
Flap Design (Fig. 11–45)
After determining the emergence point of the circum-
ex scapular artery, both scapular and parascapular
aps are designed according to the courses of the cuta-
neous scapular and parascapular arteries as axes of
both aps. Thus, an inverted L-shaped ap (Pacm an
ap)—a scapular and parascapular com bined ap—is
form ed to meet the requirements of shape and size for
the recipient site.
SCAPULAR AND PARASCAPULAR COMBINED FLAP
617
Figure 11–45
Flap design.
1. Teres major m.
2. Teres minor m.
3. Latissimus dorsi m.
4. Infraspinatus m.
5. Trapezius m.
6. Descending branch of circum ex scapular a.
7. Cutaneous scapular branch
8. Cutaneous parascapular branch

Completion of Flap Harvesting
(Fig. 11–46)
The ap is raised following the procedure described for
the scapular ap.
618
III.11 TRUNK: BACK
Figure 11–46
Completion of ap harvesting.
1. Teres major m.
2. Teres minor m.
3. Latissimus dorsi m.
4. Infraspinatus m.
5. Trapezius m.
6. Descending branch of circum ex scapular a.
7. Cutaneous scapular branch
8. Cutaneous parascapular branch

SCAPULAR AND LATISSIMUS DORSI
COMBINED FLAP
Flap Design (Fig. 11–47)
The scapular ap is initially designed as described pre-
viously. From its lateral border, an incision is made to
the axillary fossa and another incision runs downward
from the inferior border of the ap.
SCAPULAR AND LATISSIMUS DORSI COMBINED FLAP
619
Figure 11–47
Flap design.
1. Latissimus dorsi m.
2. Teres major m.
3. Teres minor m.
4. Trapezius m.
5. Rhomboideus major m.
6. Circum ex scapular a.
7. Thoracodorsal a. and n.
8. Subscapular a.
9. Serratus anterior m.

Elevation of the Scapular Flap and
Exposure of the Latissimus Dorsi
Muscle (Fig. 11–48)
First, the circum ex scapular artery (6) is identi ed in
the triangular space. The scapular ap is raised. Then
the lateral and inferior aps are turned laterally and in-
feriorly, respectively. The outer surface and the anterior
border of the latissimus dorsi (1) are exposed.
620
III.11 TRUNK: BACK
Figure 11–48
Elevation of the scapular ap and exposure of the latissimus dorsi muscle.
1. Latissimus dorsi m.
4. Trapezius m.
2. Teres major m.
5. Rhomboideus major m.
3. Teres minor m.
6. Circum ex scapular a.

Elevation of Latissimus Dorsi Muscle
Flap and Dissection of Circum ex
Scapular Vessels (Fig. 11–49)
The latissimus dorsi muscle ap (1) is isolated (see sec-
tion on latissimus dorsi) with care to keep the bifurca-
tion of the circum ex scapular (6) and thoracodorsal
arteries (7) intact. The teres major muscle (2) is identi-
ed and the circum ex scapular artery is dissected un-
der the muscle.
SCAPULAR AND LATISSIMUS DORSI COMBINED FLAP
621
Figure 11–49
Elevation of latissimus dorsi muscle ap and dissection of circum ex
scapular vessels.
1. Latissimus dorsi m.
6. Circum ex scapular a.
2. Teres major m.
7. Thoracodorsal a. and n.
3. Teres minor m.
8. Subscapular a.
4. Trapezius m.
9. Serratus anterior m.
5. Rhomboideus major m.

Releasing the Conjoined Pedicle by
Dividing the Teres Major (Fig. 11–50)
If the scapular ap is not very large, it can be passed
through to the axillary fossa under the teres major mus-
cle (2). If necessary, the teres major muscle (2) can be
divided so that the scapular ap is delivered safely.
622
III.11 TRUNK: BACK
Figure 11–50
Releasing the conjoined pedicle by dividing the teres major.
1. Latissimus dorsi m.
6. Circum ex scapular a.
2. Teres major m.
7. Thoracodorsal a. and n.
3. Teres minor m.
8. Subscapular a.
4. Trapezius m.
9. Serratus anterior m.
5. Rhomboideus major m.

BIBLIOGRAPHY
Latissimus Dorsi Flap
Allen RJ, Dupin CL, Dreschnack PA, et al. The latissimus
dorsi/scapular bone ap (the “latissim us/bone ap”).
Plast Reconstr Surg 1994;94:988
Anderl H, Kerschbaum er S. Early correction of the tho-
racic deformity of Poland’s syndrome in children with
the latissimus dorsi muscle ap: long term follow-up
of two cases. Br J Plast Surg 1986;39:167
Angrigiani C, Grilli D, Siebert J. Latissimus dorsi mus-
culocutaneous ap without m uscle. Plast Reconstr
Surg 1995;96:1608
Barton RM. Microneurovascular transfer of the latis-
simus dorsi muscle and musculocutaneous aps to the
forearm . In: Strauch B, Vasconez LO, Hall-Findlay E,
eds. Grabb’s Encyclopedia of Flaps. Vol 2. Boston: Little,
Brown; 1990:1205–1206
Barton RM, Vasconez LO. Microvascular free transfer of
a latissimus dorsi muscle and musculocutaneous ap.
In: Strauch B, Vasconez LO, Hall-Findlay E, eds. Grabb’s
Encyclopedia of Flaps. Vol 3. Boston: Little, Brown;
1990:1773–1777
Bostwick J III, Nahai F, Wallace JG, Vasconez LO. Sixty
latissimus dorsi aps. Plast Reconstr Surg 1979;63:31
Brenner P, Reichert B, Schaefers H-J, et al. Chest wall re-
construction by free latissimus dorsi ap 25 years after
accidental exposure to a source of industrial irradia-
tion. Br J Plast Surg 1995;48:431
Chang DW, Youssef A, Cha S, Reece GP. Autologous
breast reconstruction with the extended latissim us
dorsi ap. Plast Reconstr Surg 2002;110:751
Chiang Y-C, Wei F-C. Sim ultaneous coverage of two
separate defects w ith two free hem i aps harvested
from one latissimus dorsi muscle. Plast Reconstr Surg
1995;95:385
Chowdary RP, Murphy RX. Delayed debulking of free
muscle aps for aesthetic contouring debulking of free
muscle aps. Br J Plast Surg 1992;45:38
Classen DA. Free ap coverage of bilateral frostbite of
the feet. Plast Reconstr Surg 2000;106:1316
Cohen BE. Shoulder defect correction with the island
latissimus dorsi ap. Plast Reconstr Surg 1984;74:650
Commins DJ, Hancock K, Breach NM. Reconstruction of
the cervico-thoracic oesophagus with a tubed latis-
simus dorsi myocutaneous pedicled ap. Br J Plast Surg
1994;47:199
D’Aniello C, Grimaldi L, Bosi B, Brandi C. Shoulder re-
construction by latissim us dorsi myocutaneous ap
BIBLIOGRAPHY
623
based on the serratus branch after advanced soft-
tissue sarcom a excision. Plast Reconstr Surg 2000;
105:2082
de la Torre JI, Grif n DW, Vasconez LO. Harvesting the
latissimus dorsimuscle for cardidomyoplasty. Plast Re-
constr Surg 2000;105:83
Delay E, Gounot N, Bouillot A, et al. Autologous latis-
simus breast reconstruction: a 3-year clinical experience
with 100 patients. Plast Reconstr Surg 1998;102:1461
Delay E, Jorquera F, Lucas R, Lopez R. Sensitivity of
breasts reconstructed with the autologous latissim us
dorsi ap. Plast Reconstr Surg 2000;106:302
Dellon AL, Mackinnon SE. Segm entally innervated
latissimus dorsi muscle: microsurgical transfer for fa-
cial reanimation. J Reconstr Microsurg 1985;2:7
Fisher J, Bostwick J III, Powell RW. Latissim us dorsi
blood supply after thoracodorsal vessel division: the
serratus collateral. Plast Reconstr Surg 1983;72:502
Freedlander E. Brachial plexus cord compression by the
tendon of a pedicled latissim us dorsi ap. Br J Plast
Surg 1986;39:514
Gerber B, Krause A, Reim er T, et al. Breast reconstruc-
tion with latissimus dorsi ap: improved aesthetic re-
sults after transection of its hum eral insertion. Plast
Reconstr Surg 1999;103:1876
Germann G, Steinau H-U. Functional soft-tissue cover-
age in skeletonizing injuries of the upper extrem ity
using the ipsilateral latissim us dorsi myocutaneous
ap. Plast Reconstr Surg 1995;96:1130
Germ ann G, Steinau H-U. Breast reconstruction with
the extended latissimus dorsi ap. Plast Reconstr Surg
1996;97:519
Giesswein P, Constance C, Mackay DR, Manders EK. Su-
percharged latissimus dorsi m uscle ap for coverage of
the problem wound in the lower back. Plast Reconstr
Surg 1994;94:1060
Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi
muscle ap with split-thickness skin graft cover: a re-
port of 16 cases. Plast Reconstr Surg 1982;70:173
Guerra AB, Metzinger SE, Lund KM, et al. The thora-
codorsal artery perforator ap: clinical experience and
anatom ic study with emphasis on harvest techniques.
Plast Reconstr Surg 2004;114:32
Harii K, Asato H, Yoshimura K, et al. One-stage transfer
of the latissimus dorsi muscle for reanimation of a par-
alyzed face: a new alternative. Plast Reconstr Surg
1998;102:941
Hirase Y, Kojima T, Kinoshita Y, et al. Composite recon-
struction for chest wall and scalp using multiple ribs:

latissimus dorsi osteomyocutaneous aps as pedicled
and free aps. Plast Reconstr Surg 1991;87:555
Hui KCW, Zhang F, Sutkin H, et al. Functional assess-
ment of the shoulder following latissimus dorsi muscle
donation in the handicapped. J Reconstr Microsurg
1999;15:101
Kakibuchi M, Fujikawa M, Hosokawa K, et al. Func-
tional reconstruction of m axilla with free latissim us
dorsi-scapular osteom usulocutaneous ap. Plast Re-
constr Surg 2002;109:1238
Karp NS, Bass LS, Kasabian AK, et al. Balloon assisted
endoscopic harvest of the latissim us dorsi m uscle.
Plast Reconstr Surg 1997;100:1161
Kat CC, Darcy CM, O’Donoghue JM, et al. The use of the
latissimus dorsi musculocutaneous ap for immediate
correction of the deformity resulting from breast con-
servation surgery. Br J Plast Surg 1999;52:99
Kelly EJ, O’Sullivan ST, Kay SPJ. Microneurovascular
transfer of contralateral latissim us dorsi in Poland’s
syndrome. Br J Plast Surg 1999;52:503
Kim JT, Koo BS, Kim SK. The thin latissimus dorsi per-
forator-based free ap for resurfacing. Plast Reconstr
Surg 2001;107:374
Kimata Y, Tsukada S, Iwamoto T, Harii K. Free combined
parascapular ap and latissimus dorsi muscle ap for
facial palsy and neck reconstruction. Br J Plast Surg
1995;48:515
Koshima I, Saisho H, Kawada S, et al. Flow-through thin
latissimus dorsi perforator ap for repair of soft-tissue
defects in the legs. Plast Reconstr Surg 1999;103:1483.
Laitung JK, Peck F. Shoulder function following the loss
of the latissim us dorsi m uscle. Br J Plast Surg 1985;
38:375
Lee H-B, Lew D-H, Oh S-H, et al. Simultaneous recon-
struction of the Achilles tendon and soft-tissue defect
using only a latissimus dorsi m uscle free ap. Plast Re-
constr Surg 1999;104:111
Lee J-W, Chang T-W. Extended latissimus dorsi muscu-
locutaneous ap for breast reconstruction: experience
in Oriental patients. Br J Plast Surg 1999;52:365
Lin C-H, Wei F-C, Levin LS, Chen MC. Donor-site mor-
bidity com parison between endoscopically assisted
and traditional harvest of free latissimus dorsi muscle
ap. Plast Reconstr Surg 1999;104:1070
Logan AM, Black MJM. Injury to the brachial plexus re-
sulting from shoulder positioning during latissim us
dorsi ap pedicle dissection. Br J Plast Surg 1985;
38:380
Maruyama Y, Onishi K, Iwahira Y, et al. Free compound
rib-latissimus dorsi osteomusculocutaneous ap in re-
construction of the leg. J Reconstr Microsurg 1986;3:13
Maruyam a Y, Urita Y, Ohnishi K. Rib-latissim us dorsi
osteomyocutaneous ap in reconstruction of a mandi-
bular defect. Br J Plast Surg 1985;38:234
Maxwell GP, Manson PN, Hoopes JE. Experience with
thirteen latissimus dorsi myocutaneous free aps. Plast
Reconstr Surg 1979;64:1
Maxwell GP, McGibbon BM, Hoopes JE. Vascular con-
siderations in the use of a latissim us dorsi myocuta-
neous ap after a m astectomy with an axillary dissec-
tion. Plast Reconstr Surg 1979;64:771
Maxwell GP, Stueber K, Hoopes JE. A free latissim us
dorsi myocutaneous ap. Plast Reconstr Surg 1978;
62:462
May JW Jr, Gallico GG III, Jupiter J, Savage RC. Free latis-
simus dorsi muscle ap with skin graft for treatment of
traum atic chronic bony wounds. Plast Reconstr Surg
1984;73:641
McCraw JB, Penix JO, Baker JW. Repair of major defects
of the chest wall and spine with the latissim us dorsi
myocutaneous ap. Plast Reconstr Surg 1978;62:197
Mickel TJ, Barton FE Jr, Rohrich RJ, et al. Management
and prevention of lum bar herniation following a latis-
simus dorsi ap. Plast Reconstr Surg 1999;103:1473
Moore TS, Farrell LD. Latissim us dorsi myocutaneous
ap for breast reconstruction: long-term results. Plast
Reconstr Surg 1992;89:666
Ninkovic M, Kronberger P, Harpf C, et al. Free inner-
vated latissimus dorsi muscle ap for reconstruction of
full-thickness abdom inal wall defects. Plast Reconstr
Surg 1998;101:971
Ninkovic MM, Schwabegger AH, Hausler JW, et al. Lim b
salvage after fulm inant septicem ia using a free latis-
simus dorsi cross-leg ap. J Reconstr Microsurg 2000;
16:603
Ninkovic M, Stenzl A, Hess M, et al. Functional urinary
bladder wall substitute using a free innervated latis-
sim us dorsi m uscle ap. Plast Reconstr Surg 1997;
100:402
Noever G, Brueser P, Koehler L. Reconstruction of heel
and sole defects by free aps. Plast Reconstr Surg 1986;
78:345
Ohsumi N, Shimamoto R, Tsukagoshi T. Free composite
latissimus dorsi muscle-rib ap not containing the in-
tercostals artery and vein for reconstruction of bone and
soft-tissue defects. Plast Reconstr Surg 1994;94:372
624
III.11 TRUNK: BACK

Olivari N. Use of thirty latissim us dorsi aps. Plast
Reconstr Surg 1979;64:654
Olvera-Caballero C, Victoria-Morales G. Neurovascular
latissimus dorsi free- ap transfer for the reconstruction
of a m ajor abdom inal-wall defect in a 13-m onth-old
child: case report. J Reconstr Microsurg 1998;14:341
Pelissier P, Pistre V, Casoli V, et al. Reconstruction of
short lower leg stum ps with the osteom usculocuta-
neous latissim us dorsi-rib ap. Plast Reconstr Surg
2002;109:1013
Prakash PJ, Gupta AK. The subscapular approach in
head and neck reconstruction with the pedicled latis-
simus dorsi myocutaneous ap. Br J Plast Surg 2001;
54:680
Quillen CG, Shearin JC Jr, Georgiade NG. Use of the
latissim us dorsi myocutaneous island ap for recon-
struction in the head and neck area. Plast Reconstr
Surg 1978;62:113
Rosen HM. Double island latissimus dorsi muscle-skin
ap for through-and-through defects of the forefoot.
Plast Reconstr Surg 1985;76:461
Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The
anatomy of the subscapular-thoracodorsal arterial sys-
tem: study of 100 cadaver dissections. Br J Plast Surg
1984;37:574
Rowsell AR, Eisenberg N, Davies DM, Taylor GI. The
anatomy of the thoracodorsal artery within the latis-
simus dorsi muscle. Br J Plast Surg 1986;39:206
Rowsell AR, Godfrey AM, Richards MA. The thinned
latissimus dorsi free ap: a case report. Br J Plast Surg
1986;39:210
Salibian AH, Tesoro VR, Wood DL. Staged transfer of a
free microvascular latissimus dorsi myocutaneous ap
using saphenous vein grafts. Plast Reconstr Surg 1983;
71:543
Schultes G, Gaggl A, Kaercher H. Reestablishm ent of
sensitivity in the latissim us dorsi transplant through
anastomosis of the thoracodorsal nerve with sensitive
nerves. Plast Reconstr Surg 1999;103:857
Schultes G, Kaercher H, Gaggl A. Sensate myocutaneous
latissimus dorsi ap. J Reconstr Microsurg 1998;14:541
Schultes G, Kaercher H, Gaggl A. Histologic and clinical
results of reinnervation of the latissimus dorsi transfer
with the thoracodorsal nerve. J Reconstr Microsurg
1999;15:567
Senyuva C, Yucel A, Aydin Y, et al. Coverage of knee-
tumor-resection prostheses with free aps. J Reconstr
Microsurg 1997;13:277
Sera n D, Goodkind DJ. Microsurgical free transfer of a
latissimus dorsi musculocutaneous ap. In: Strauch B,
Vasconez LO, Hall-Findlay E, eds. Grabb’s Encyclopedia
of Flaps. Vol 3. Boston: Little, Brown; 1990:1314–1318
Serletti JM, Higgins J, Carras AJ. Free latissimus dorsi
myocutaneous ap for secondary breast reconstruction
after partial loss of a TRAM ap. Plast Reconstr Surg
1997;100:690
Shrotria S. Single axillary incision for quadrantectomy,
axillary clearance and imm ediate reconstruction with
latissimus dorsi. Br J Plast Surg 2001;54:128
Smith BK, Cohen BE, Biggs TM, Suber J. Sim ultaneous
bilateral breast reconstruction using latissim us dorsi
myocutaneous aps: a retrospective review of an insti-
tutional experience. Plast Reconstr Surg 2001;108:1174
Snobl D, Binaghi LE, Zenker LE. Microarchitecture and
innervation of the human latissimus dorsi muscle. J Re-
constr Microsurg 1998;14:171
Spinelli HM, Fink JA, Muzaffar AR. The latissimus dorsi
perforator-based fasciocutaneous ap. Ann Plast Surg
1996;37:500
Stevenson T, Rohrich RJ, Pollack RA, et al. More experi-
ence with the “reverse” latissimus dorsi musculocuta-
neous ap: precise location of blood supply. Plast Re-
constr Surg 1984;74:237
Taniguchi Y, Tam aki T. Reconstruction of intractable
ulcer of the knee joint in Werner’s syndrome with free
latissimus dorsi myocutaneous ap. J Reconstr Micro-
surg 1998;14:555
Theile RJW, Lanigan MW, McDermant GR. Reconstruc-
tion of aplasia cutis congenital of the scalp by split rib
cranioplasty and a free latissim us dorsi muscle ap in
a nine-month-old infant. Br J Plast Surg 1995;48:507
Titley OG, Spyrou GE, Fatah MFT. Preventing seroma in
the latissim us dorsi ap donor site. Br J Plast Surg
1997;50:106
Tobin GR, Moberg AW, DuBou RH, et al. The split latis-
simus dorsi myocutaneous ap. Ann Plast Surg 1981;
7:272
Tobin GR, Schusterman M, Peterson GH, et al. The in-
tramuscular neurovascular anatomy of the latissim us
dorsi muscle: the basis for splitting the ap. Plast Re-
constr Surg 1981;67:637
Watson JS, Craig RDP, Orton CI. The free latissimus dorsi
myocutaneous ap. Plast Reconstr Surg 1979;64:299
Wei W, Qi Z, Lin X, et al. Free split and segmental latis-
simus dorsi muscle transfer in one stage for facial re-
animation. Plast Reconstr Surg 1999;103:473
BIBLIOGRAPHY
625

Wilson IF, Lokeh A, Schubert W, Benjam in CI. Latis-
simus dorsi myocutaneous ap reconstruction of neck
and axillary burn contractures. Plast Reconstr Surg
2000;105:27
Yam am oto N, Igota S, Izaki H, Arai K. “Reverse turn-
over” transfer of a latissim us dorsi m uscle ap to a
large lumbar defect. Plast Reconstr Surg 2001;107:1496
Yano K, Kosokawa K, Takagi S, et al. Breast reconstruc-
tion using the sensate latissim us dorsi m usculocuta-
neous ap. Plast Reconstr Surg 2002;109:1897
Scapular and Parascapular Flaps
Aharinejad S, Dunn RM, Fudem GM, et al. The m i-
crovenous valvular anatomy of the human dorsal tho-
racic fascia. Plast Reconstr Surg 1997;99:78
Angrigiani C, Grilli D. Total face reconstruction with
one free ap. Plast Reconstr Surg 1997;99:1566
Arnez ZM, Scamp T, Planinsek F, Ahcan U. Lateral ex-
tension of the free scapular ap. Br J Plast Surg 1994;
47:268
Bakhach J, Peres JM, Scalise A, et al. The quadrifoliate
ap: a com bination of scapular, parascapular, latis-
sim us dorsi and scapula bone aps. Br J Plast Surg
1996;49:477
Barwick WJ, Goodkind DJ, Sera n D. The free scapular
ap. Plast Reconstr Surg 1982;69:779
Caffee HH. Transfer of the scapular ap on a reverse latis-
simus muscle pedicle. Plast Reconstr Surg 1998; 101:85
Cerkes N, Erer M, Sirin F. The combined scapular/para-
scapular ap for the treatm ent of extensive electrical
burns of the upper extrem ity. Br J Plast Surg 1997;
50:501
Chiu DT, Sherman E, Edgerton MT. Coverage of the cal-
varium with a free parascapular ap. Ann Plast Surg
1984;12:60
Colen LB, Pessa JE, Potparic Z, Reus WF. Reconstruction
of the extrem ity with the dorsal thoracic fascia free
ap. Plast Reconstr Surg 1998;101:738
Datiashvili RO, Shibaev EY, Chichkin VG, Oganesian AR.
Reconstruction of a complex defect of the hand with
two distinct segm ents of the scapula and a scapular
fascial ap transferred as a single transplant. Plast Re-
constr Surg 1992;90:687
De Lorenzi F, van der Hulst RRWJ, Boeckx WD. Horse-
shoe expanded scapular free ap shows no venous
congestion. Br J Plast Surg 2001;54:604
Fonesca dos Santos L, Gilbert A. The free scapular ap.
In: Strauch B, Vasconez LO, Hall-Findlay eds. Grabb’s
Encyclopedia of Flaps. Vol 3. Boston: Little Brown;
1990:412ff
Gahhos FN, Tross RB, Salomon JC. Scapular free- ap dis-
section made easier. Plast Reconstr Surg 1985;75:115
Germann G, Bickert B, Steinau U, et al. Versatility and
reliability of combined aps of the subscapular system.
Plast Reconstr Surg 1999;103:1386
Gilbert A, Teot L. The free scapular ap. Plast Reconstr
Surg 1982;69:601
Gopinath KS, Chandrashekar M, Kumar MV, Bhargava
A. The scapular fasciocutaneous ap: a new ap for re-
construction of the posterior neck. Br J Plast Surg
1993;46:508
Gucer T, Oge K, Ozgur F. Is it necessary to use the an-
gular artery to feed the scapular tip when preparing a
latissimus dorsi osteomyocutaneous ap? Case report.
J Reconstr Microsurg 2000;16:197
Hallock GG. Permutations of combined free aps using
the subscapular system. J Reconstr Microsurg 1997;13:47
Hamdi M, Weiler-Mithoff EM, Webster MHC. Cross-leg
pedicled free scapular ap for neuropathic foot ulcer:
case report. J Reconstr Microsurg 2000;16:597
Hamilton SGL, Morrison WA. The scapular free ap. Br
J Plast Surg 1982;35:2
Im anishi N, Nakajim a H, Aiso S. Anatomical relation-
ship between arteries and veins in the scapular region.
Br J Plast Surg 2001;54:419
Imanishi N, Nakajima H, Aiso S. Anatomical study of the
venous drainage architecture of the scapular skin and
subcutaneous tissue. Plast Reconstr Surg 2001;108:656
Kim PS, Gottlieb JR, Harris GD, et al. The dorsal thoracic
fascia: anatomic signi cance with clinical applications
in reconstructive m icrosurgery. Plast Reconstr Surg
1987;79:72
Kim PS, Lewis VL Jr. Use of a pedicled parascapular ap
for anterior shoulder and arm reconstruction. Plast Re-
constr Surg 1985;76:942
Kimata Y, Sekido M, Ebihara S, et al. Free adipofascial
ap for scalp reconstruction: case report. J Reconstr
Microsurg 1999;15:109
Koshim a I, Soeda S. Repair of a wide defect of the lower
leg with the combined scapular and parascapular ap.
Br J Plast Surg 1985;38:518
Kunstfeld R, Petzelbauer P, Wickenhauser G, et al. The
prefabricated scapula ap consists of syngeneic bone,
connective tissue, and a self-assem bled epithelial coat-
ing. Plast Reconstr Surg 2001;108:1908
626
III.11 TRUNK: BACK

Masaki F, Takehiro D, Ryuuichi M, Kumi M. Late recon-
struction of two total metacarpal bone defects using
lengthening devices and a double-barrel osteocuta-
neous free parascapular ap. Plast Reconstr Surg
2000;106:102
Mayou BJ, Whitby D, Jones BM. The scapular ap: an
anatom ical and clinical study. Br J Plast Surg
1982;35:8
Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular
ap: a new cutaneous microsurgical free ap. Plast Re-
constr Surg 1982;69:591
Rautio J, Asko-Seljavaara S, Laasonen L, Harma M. Suit-
ability of the scapular ap for reconstructions of the
foot. Plast Reconstr Surg 1990;85:922
Russell RC, Khouri RK, Upton J, et al. The expanded
scapular ap. Plast Reconstr Surg 1995;96:884
Sawaizumi M, Maruyama Y, Kawaguchi N. Vertical dou-
ble ap design for repair of wide defects of the lower
lim b, using com bined ascending scapular and latis-
simus dorsi aps. J Reconstr Microsurg 1995;11:407
Schlenz I, Korak KJ, Kunstfeld R, et al. The derm is-
prelam inated scapular ap for reconstructions of the
hard palate and the alveolar ridge: a clinical and histo-
logic evaluation. Plast Reconstr Surg 2001;108:1519
Sekiguchi J, Kobayashi S, Ohmori K. Use of the osteo-
cutaneous free scapular ap on the lower extremities.
Plast Reconstr Surg 1993;91:103
Seneviratne S, Duong C, Taylor GI. The angular branch
of the thoracododrsal artery and its blood supply to the
inferior angle of the scapula: an anatomical study. Plast
Reconstr Surg 1999;104:85
Serra JM, Muirragui A, Tadjalli H. The circum ex scapu-
lar ap for reconstruction of mandibulofacial atrophy. J
Reconstr Microsurg 1985;1:263
Shimizu T, Ohno K, Michi K, et al. Morphom etric ex-
amination of the free scapular ap. Plast Reconstr Surg
1997;99:1947
Siebert JW, Longaker MT, Angrigiani C. The inframam-
mary extended circum ex scapular ap: an aesthetic
improvem ent of the parascapular ap. Plast Reconstr
Surg 1997;99:70
Sundine MJ, Sharobaro VI, Ljubic I, et al. Inferior angle
of the scapula as a vascularized bone graft: an
anatomic study. J Reconstr Microsurg 2000;16:207
Swartz WM, Banis JC, Newton ED, et al. The osteocuta-
neous scapular ap for mandibular and maxillary re-
construction. Plast Reconstr Surg 1986;77:530
Teot L, Bosse JP. The use of scapular skin island aps in
the treatment of axillary postburn scar contractures. Br
J Plast Surg 1994;47:108
Upton J, Albin Re, Mulliken JB, Murray JE. The use of
scapular and parascapular aps for cheek reconstruc-
tion. Plast Reconstr Surg 1992;90:959
Urbaniak JR, Koman LA, Goldner RD, et al. The vascu-
larized cutaneous scapular ap. Plast Reconstr Surg
1982;69:772
Wu WC, Chang YP, So YC, et al. The combined use of
aps based on the subscapular vascular system for
limb reconstruction. Br J Plast Surg 1997;50:73
Xu J, Li SK, Li YQ, et al. Superior extension of the para-
scapular free ap for cervical burn scar contracture.
Plast Reconstr Surg 1995;96:58
Yadav P, Rajput R. Pedicled transfer of vascularized
scapular bone graft to the humerus. Plast Reconstr Surg
2001;107:140
Yam am oto Y, Sugihara T, Kawashim a K, Qi F. An
anatomic study of the latissimus dorsi-rib ap: an ex-
tension of the subscapular combined ap. Plast Recon-
str Surg 1996;98:811
Yanai A, Nagata S, Hirabayashi S, Nakam ura N. In-
verted-U parascapular ap for the treatm ent of axil-
lary burn scar contracture. Plast Reconstr Surg
1985;76:126
Yang LM, Shi WY, Zhong SZ, et al. Clinical application
and anatom ical studies of the parascapular ap. Med J
PLA China 1983;8:326
Yu LT. The scapular island ap: a new application for
breast reconstruction. Plast Reconstr Surg 1995;96:878
BIBLIOGRAPHY
627