ANATOMICAL STUDY OF THE NEUROVASCULAR PEDICLE OF

Alexandria Bulletin
Safwat et al.
845
ANATOMICAL STUDY OF THE NEUROVASCULAR PEDICLE OF THE SERRATUS
ANTERIOR MUSCLE
Safwat M.D, Abdel Rahman W.A
Department of Anatomy, Faculty of Medicine, Alexandria University
ABSTRACT
Introduction: The serratus anterior flap become a favorite option for small wounds of the distal limb or composite
and large defects in association with flaps of the subscapular system based on the subscapular-thoracodorsal
vascular pedicle. The lower serratus anterior flap is ideal for reconstruction of small to moderate-sized defects
because of its flat and broad dimensions. The serratus anterior flap can be used with varying composition of tissue
ranging from fascia only, to adiposofascial, to muscle, to muscle with bone in the form of either underlying rib, or
in conjunction with a scapular bone flap. There are some variations in the branching patterns of the axillary
artery. Such variations are significant in the diagnostic or therapeutic invasive procedures carried out on the
axillary artery.
Aim of the work: The aim of this anatomic study was to examine the neurovascular supply of the serratus anterior
muscle in cadaveric specimens, describe their typical anatomy and possible variations, and to identify their
different measurements.
Materials& methods: Fourteen axillary regions of seven formalin-fixed cadavers were dissected. Specimens were
measured for the origin, lengths, and external diameters of the subscapular, thoracodorsal arteries, and their
serratus anterior branches. All branches of the serratus artery were documented for location, diameter and which
slips they served. Also, nerve dimensions (length, diameter and which slips they served) were measured. Inaddition, muscle slip length, muscle slip width and thickness at its origin were measured.
Results: In all dissected specimens at least one serratus anterior branch was observed. Four branching patterns
were observed. In five specimens (35.7 %), it was a unique branch; in six specimens (42.9%), there were two
branches; in two specimens (14.3%), there were three branches and in one specimen four branches were observed
(7.1%).
Conclusion: The results of this study provide an anatomic framework to improve current reconstructive
procedures on the serratus anterior neurovascular structures.
Key words: Amatomy, serratus anterior, neurovascular pedicle.
Abbreviations:
• LT: Lateral Thoracic Vessels
• T: Thoracodorsal Vessels
• N: Long Thoracic Nerve
• AV: Axillary Vein
• SM: Serratus Aanterior Muscle
• S: Subscapular Artery
• AA: Axillary Artery
• C: Circumflex Scapular Artery
• PM: Pectoralis Minor Muscle
• L: Latissimus Dorsi Muscle
• AC: Anterior Circumflex Humeral Artery
• PC: Posterior Circumflex Humeral Artery
• AN: Axillary Nerve
• LA: Nerve To Latissimus Dorsi Muscle
INTRODUCTION
The Serratus anterior muscle is a thin muscular
sheet, situated between the ribs and the scapula at
the upper lateral part of the chest. It arises by fleshy
digitations from the outer surfaces and superior
borders of the upper eight, nine or even ten ribs, and
from the aponeuroses covering the intervening
intercostals. Its fibers pass backward, closely applied
to the chest-wall, and are inserted into the ventral
surface of the vertebral border of the scapula.(1)
The Serratus anterior muscle is supplied by the
long thoracic nerve, which is derived from the fifth,
sixth, and seventh cervical nerves. This muscle
carries the scapula forward, and at the same time
raises the vertebral border of the bone. It is therefore
concerned in the action of pushing. Its lower and
stronger fibers move forward the lower angle and
assist the trapezius in rotating the bone at the
sternoclavicular joint. The serratus anterior muscle
may assist in raising and everting the ribs; but it is
Bull. Alex. Fac. Med. 43 No.4, 2007.
not the important inspiratory muscle as it was
formerly believed to be.(2)
The serratus anterior muscle is a type III muscle
(has 2 dominant pedicles). The first dominant
pedicle is lateral thoracic artery which supplies the
upper three or four slips. The second dominant
pedicle is thoracodorsal artery which sends two to
four branches to the muscle. The lateral thoracic
artery arises directly from the second part of the
axillary artery. It also supplies the pectoral muscles
and the subscapularis muscle. The subscapular artery
is the largest branch of the axillary artery which
ends as the circumflex scapular and thoracodorsal
arteries. The thoracodorsal artery follows the lateral
border of the scapula between the latissimus dorsi
and serratus anterior muscles supplying them. It also
supplies the teres major, and intercostals muscles.(3)
The serratus anterior free muscle flap was first
introduced by Buncke et al.(4) Because of its
thinness, and the length and diameter of the vascular
ISSN 1110-0834
852
Serratus Anterior Neurovascular Pedicle.
pedicle, the serratus anterior flap become a favorite
option for small wounds of the distal limb or
composite and large defects in association with flaps
of the subscapular system based on the subscapularthoracodorsal vascular pedicle.(5)
The lower serratus anterior flap is ideal for
reconstruction of small to moderate-sized defects
because of its flat and broad dimensions. The
dominant vascular pedicle of slips six through
nine (or ten) is consistent and of a relatively
large diameter. Also, its long arc of rotation
allows the utilization of the serratus anterior
muscle flap in head and neck, and mediastinal
surgery without microvascular anastomoses.(6) The
branches to serratus anterior were of sufficient
dimensions to support either a latissimus dorsi
flap or a serratus anterior flap. These facts, in
combination with the ease of harvest, acceptable
donor-site morbidity, and well concealed location of
the donor site scar all make it an ideal candidate for
muscle transfer. Also, the divisibility of the flap into
multiple force vectors makes the serratus a versatile
muscle flap.(7) The flap is known for its low rate of
operative, perioperative, and long term morbidity.(8)
Complication rates for seroma, hematoma, and
neuropraxia have been reported to be less than that
for the gracilis muscle donor site.(9)
The entire muscle can be used as flap but this will
result in severe winging of scapula, to prevent this
condition and to maintain function it is very
important to preserve at least the upper five
digitations and their innervations and, only the lower
three or four slips should be harvested as a flap. No
evidences of shoulder dysfunction or decreased
shoulder strength were observed with the harvest of
this flap. Vu et al.(10) and Gordon et al.(11) have
reported mild winging but no differences in the push
or abduction strength. Fassio et al. (12) have noted no
correlation between the degree of scapular winging
and the number of slips harvested (up to four). Also,
Pittet et al.(13) have not observed any functional
deficit in patients. A recent study has also shown
that there is no impairment of shoulder function on
removal of the three distal slips of the muscle.(14)
The serratus anterior flap can be used with varying
composition of tissue ranging from fascia only,(15)
to adiposofascial,(16) to muscle,(17) to muscle with
bone in the form of either underlying rib(18,19)
or in conjunction with a scapular bone flap.(15) The
serratus anterior muscle has often been transferred
along with the latissimus dosi muscle to reconstruct
larger defects.(20) Duteille et al.(21) have used muscle
flaps, myocutaneous, osteomuscular flap or osteomyocutaneous flaps with a good functional outcome.
The serratus anterior muscle is used for flap
reconstruction of lower limbs,(22) dorsal surface hand
defects,(23) head, neck, and extremity injuries,(24)
bony and soft tissue defects in the face,(25)
the mandible,(26) chest wall(27) and vascular
Bull. Alex. Fac. Med. 43 No.4, 2007.
Safwat et al.
reconstruction and revascularization of extensive
ischemic areas such as cerebral hemispheres.(28) The
serratus anterior muscle has recently been suggested
as a versatile and reliable flap for reconstruction of
complex craniofacial and neck lesions, sacroiliac
region injuries, as well as intrathoracic and
extrathoracic reconstruction procedures.(29)
The ideal flap for reconstruction of the face should
bring with it tissue similar in consistency, quantity,
and appearance, with minimal donor – site
morbidity. Pittet et al.(13) have used serratus anterior
muscuocutaneous flap and have found it to meet
most of the criteria. Donor muscles commonly used
today for facial reanimation, such as the gracilis(30) is
limited by bulkiness and the number of force vectors
they can provide. Other muscles such as the extensor
digitorum brevis, rectus abdominis, and pectoralis
major and minor, have been used but are often too
forceful and produce a single or at best two reliable
vectors of force.(31)
There are some variations in the branching
patterns of the axillary artery.(32) Such variations are
significant in the diagnostic or therapeutic invasive
procedures carried out on the axillary artery (such as
ligation of injured arteries, angiographic studies of
the axillary vessels, and axillary aneurysms). It is
also considerable to avoid the possibility of arterial
damages during surgical interventions of the serratus
anterior flap surgery.(33) More recent cadaveric
studies have attempted to characterize the serratus
muscle and its neurovascular supply to aid in its
usage as a flap, but various aspects remain to be
determined precisely for its clinical use.(32) Thus the
goal of this anatomic study was to examine the
neurovascular supply of the serratus anterior muscle
in cadaveric specimens, describe their typical
anatomy and possible variations, and to identify
their different measurements.
METHODS
Fourteen axillary regions of seven formalin-fixed
cadavers from the Anatomy Department, Faculty of
Medicine, Alexandria University, were used for this
descriptive study. They were injected by red latex
via the subclavian arteries using manual pressure.
The cadavers were then positioned in the supine
position with the ipsilateral arm abducted 90 degrees
at the shoulder and with the elbow in 90 degrees of
flexion.
The long thoracic nerve and the vascular
pedicle from the subscapular artery were followed
distally until the circumflex scapular, thoracodorsal,
latissimus, and serratus arteries were identified.
Serratus anterior slips were exposed. The serratus
artery was followed to its branching points on the
muscle. The long thoracic nerve was followed
distally to its divisions; the slips innervated by each
of the divisions were documented. The overlying fat
and fascia were removed, and selected specimens
Safwat et al.
Alexandria Bulletin
were preliminary photographed. After confirming
the presence of paired venae comitantes
accompanying the artery to its most distal extent,
veins were removed to allow better visualization of
the artery and the nerve. Additional photographs
were taken at this time.
Specimens were measured for the origin, lengths,
and external diameters of the subscapular,
thoracodorsal arteries, and their serratus anterior
branches. All branches of the serratus artery were
documented for location, diameter and which slips
they served. Nerve dimensions (length, diameter and
which slips they served) were measured. Attention
was then turned to the arterial pattern supplying the
serratus anterior muscle. The arterial length was
measured with a scale 0.5 mm ruler. The external
diameter of the arteries was measured with a scale
of 0.1 mm. The external diameter of the arteries
was measured after removal of the perivascular
tissues untiles the superficial layers of the adventitia.
The serratus anterior muscles were freed from the
ribs and their insertion on the scapula. The scapular
insertion of the muscle was divided with a scalpel.
Attention was then turned to the neurovascular
pedicle. The long thoracic nerve was divided distal
to its origin, and dissected from the surrounding
tissues. A 2-cm section of the axillary artery
containing the subscapular artery was divided. The
circumflex scapular and the latissimus dorsi
branches were divided, isolating the muscle on the
serratus branch. Muscle slip length (origin to
insertion), muscle slip width at its origin from the
superior to the inferior edge, and slip thickness near
the slip origin were measured.
RESULTS
The serratus anterior muscle and fascia were
found to have a dual blood supply, with the upper
part supplied by the lateral thoracic artery and the
lower part by terminal branches of the thoracodorsal
artery. The lateral thoracic artery was noted to
supply the upper four slips. In all specimens,
branches of the thoracodorsal artery to the serratus
anterior muscle (the serratus arteries) were providing
the dominant blood supply to the lower serratus
anterior slips (Fig. 1).
The axillary artery and its branch, the subscapular
artery, were patent in all cases. The subscapular
artery was present in all cases. It originated from
the third part of the axillary artery in 11 of 14
specimens (78.6%) (Fig. 2), and from the second
part in the remaining 3 specimens (21.4 %)
(Fig.3).The circumflex humeral arteries arose from
the circumflex scapular artery in 1 of these three
specimens (Fig.4). Also, the lateral thoracic artery
was seen arising from the subscapular artery in
these 3 specimens and in one of the normal 11
subscapular origin specimens (Fig. 5).The mean
Bull. Alex. Fac. Med. 43 No.4, 2007.
845
external diameter of the subscapular artery at its
origin was 6.0 ± 0.1 mm. Its mean length till
its division into the circumflex scapular and
thoracodorsal arteries was 2.7 ± 1.2 cm.
The thoracodorsal artery was extending directly
from the subscapular artery. It was found in all
dissected cases. Its mean external diameter was 3.0 ±
0.06 mm at its origin. The mean length from the
beginning of the circumflex scapular artery until
its division into its two terminal branches (the
serratus anterior and latissimus dorsi arteries) was
5.2 ± 1.06 cm. (Table I)
The diameter and lengths of the serratus arteries
were measured. The mean external diameter at its
origin was 2.1 ± 0.05 mm, and the mean length till
its division in the muscle slips was 4.8 ± 2.5 cm .In
all dissected specimens at least one serratus anterior
branch was observed. Four branching patterns were
observed. In 5 specimens (35.7 %) it was a unique
branch (Fig. 4); in 6 specimens (42.9%) two
branches (Fig. 2, 5); in 2 specimens three branches
(14.3%) (Fig. 6), and in 1 specimen four branches
were observed (7.1%) (Fig.7). In the case of multiple
branches the distal branch always presented the
largest diameter. The site of penetration of the first
serratus artery branch to the serratus muscle varied
from the 4th intercostals space to the sixth rib.
In all specimens, paired venae comitantes
accompanied the serratus artery and its branches to
their distal-most extent. After confirming this for
each specimen, we removed the veins to allow better
visualization of the artery and nerve. In one
specimen, the origins of the lateral thoracic vein and
lateral thoracic artery were 2.5 cm apart from each
other (Fig.8).
The long thoracic nerve was consistently present
inferior to the clavicle and lateral to the serratus
muscle. The nerve branching pattern mimicked the
arterial branching pattern, but the nerve consistently
branched proximal to the artery by one intercostal
space (Fig. 4, 7). The nerve was consistently deep to
the artery, which was deep to the venae comitantes,
all of which ran superficial to the serratus anterior
muscle. The nerve divisions mirrored those of the
artery. The mean diameter of the nerve at its
beginning was 2.00 ± 0.09 mm, and at the beginning
of each muscular branch was 1.5 ± 0.7 mm. The
mean length of the nerve from the contribution of
C7 to the beginning of its first division was 11.9 ±
0.9 cm. (Table I)
The serratus anterior muscle was separated from
the cadever (Fig. 6, 9). Dimensions of the muscle
slips were measured. They were varied minimally.
Their mean length (from origin to insertion) was
16.1 ± 1.7 cm, mean width (at its origin) was 2.5 ±
0.09 cm, and mean thickness at its origin was 4.4 ±
0.7 mm.
852
Serratus Anterior Neurovascular Pedicle.
Safwat et al.
Table I: Values of length and external diameters of the arteries and long
thoracic nerve to the serratus anterior muscle
Name
Subscapular artery
Length
External diameter (at origin)
2.7 ± 1.2 cm
6.0 ± 0.1 mm
Thoracodorsal artery
5.2 ± 1.06 cm
3.0 ± 0.06 mm
Serratus arteries
4.8 ± 2.5 cm
2.1 ± 0.05 mm
Long thoracic nerve
11.9 ± 0.9 cm
2.00 ± 0.09 mm
Values are presented as mean + standard deviation.
Fig 1: A photograph of the right serratus anterior muscle
(SM) showing its dual blood supply from the lateral
thoracic (LT), and thoracodorsal (T) vessels. N: long
thoracic nerve, (→): serratus branches, AV: axillary vein.
Fig 3: A photograph of left serratus anterior muscle (SM)
showing the origin of the subscapular artery (S) from the
second part of axillary artery (AA). serratus branches are
seen (→). N: Long thoracic nerve, T: thoracodorsal artery,
L; latissimus dorsi muscle. AV: axillary vein, LT: lateral
thoracic artery.
Bull. Alex. Fac. Med. 43 No.4, 2007.
Fig 2: A photograph of the left serratus anterior muscle
(SM) showing the origin of the subscapular artery (S) from
the third part of axillary arter (AA). Two serratus branches
are seen (→). N: Long thoracic nerve, T: thoracodorsal
artery, C: circumflex scapular artery, PM: pectoralis minor
muscle, L: latissimus dorsi muscle.
Fig 4: A photograph of the left serratus anterior muscle
(SM) showing the origin of the subscapular artery (S) from
the second part of axillary artery (AA). The anterior (AC)
and posterior circumflex arteries (PC) are arising from
circumflex humeral artery (C). One serratus branch is seen
(→). N: Long thoracic nerve, T: thoracodorsal artery, L;
latissimus dorsi muscle. AN: axillary nerve.
Safwat et al.
Alexandria Bulletin
845
Fig.5: A photograph of right serratus anterior muscle (SM)
showing the origin of lateral thoracic (LT) from
subscapular artery (S). Two serratus arteries are seen (→).
N: Long thoracic nerve, T:thoracodorsal artery, C:
circumflex humeral artery.
Fig. 6: A photograph of separate serratus anterior muscle
(SM), with three serratus branches (→) from thoracodorsal
artery (T). AA: Axillary artery, S: subscapular artery, C:
circumflex scapular artery, N: long thoracic nerve, LT:
lateral thoracic artery, LA: artery to latissimus dorsi
muscle.
Fig 7: A photograph of right serratus anterior muscle (SM)
showing four serratus branches (→) from thoracodorsal
artery (T). N: Long thoracic nerve, L; latissimus dorsi
muscle.
Fig 8: A photograph of right serratus anterior muscle (SM)
showing separate origin of lateral thoracic artery (LTA)
and vein (LTV). N: long thoracic nerve.
Fig 9: A photograph of separate serratus anterior muscle (SM), with two serratus branches (→) from thoracodorsal artery
(T). AA: Axillary artery, S: subscapular artery, C: circumflex scapular artery, N: long thoracic nerve, LA: artery to
latissimus dorsi muscle, LT: lateral thoracic arising from subscapular artery.
Bull. Alex. Fac. Med. 43 No.4, 2007.
852
Serratus Anterior Neurovascular Pedicle.
DISCUSSION
The subscapular vascular system has a lot to offer
to the reconstructive surgery. Serratus anterior
muscle has been suggested as a versatile and reliable
flap for reconstruction of head, neck, and extremity
injuries. In the present study, the serratus muscle
was found to have a dual blood supply, with the
upper part supplied by the lateral thoracic artery and
the lower part by terminal branches of the
thoracodorsal artery. This finding was in agreement
with Moore and Dalley(3) and Magden et al.(1)
They have concluded that the pedicle of choice
for elevation of either a standard flap or
for microvascular transplant is the thoracodorsal
pedicle. However, Erdogmus and Govsa(29) have
found that the lateral thoracic artery was extending
into the lower serratus anterior muscle in two
out of 15 specimens. Also, Lipa and Chang(34) have
mentioned that the main blood supply to the serratus
anterior comes from the lateral thoracic artery. Also,
Magden et al.(1) and Rabi et al.(35) have observed
unusual vascular pedicles of the serratus anterior
muscle. The serratus anterior branch originated
directly from the first part of the axillary artery as
the first branch. However, they found that the
branches which supplied the serratus anterior muscle
were of satisfactory size (diameter of more than 1.0
mm) for using the muscle as a muscle flap. The
serratus branch has also been reported to arise from
the first intercostal artery,(36) or directly from the
subscapular artery.(37) In the present study, the
circumflex humeral artery arose from circumflex
scapular artery in one out of 14 specimens. This
finding was in agreement with Aizawa et al.(38)
The subscapular artery is the largest branch of the
axillary artery. In the present study, the subscapular
artery was found in all specimens. It was
arising from the third part of axillary artery in 11 of
14 specimens (78.6%), and from the second part
in the remaining 3 specimens (21.4 %). However,
Malikov et al.(39) have found that its origin was
located in the third part of the axillary artery in 35
of 40 cases (87 %) and in the second part in 5
cases (13%). Also, its origin from the second part
of the axillary artery was reported in 8% by
Bartlett et al.,(40) 13% by Rowsell et al.,(41) and 10%
by Vu et al.(10)
In the present work the mean external diameter of
the subscapular artery at its origin was 6.0 ± 0.1 mm,
and its mean length was 2.7 ± 1.2 cm. These
findings were in agreement with Malikov et al.(39)
They have found that the external diameter of the
subscapular artery at its origin was 5.5 mm, and the
mean length was 2.4 cm. Also, Rowsell et al.(41)
have found the mean external diameter was 6.0 mm
and the mean subscapular artery length was 2.2 cm.
The thoracodorsal artery was found in all the
dissected specimens arising from the subscapular
artery. In the present work, the mean length was 5.2
Bull. Alex. Fac. Med. 43 No.4, 2007.
Safwat et al.
± 1.06 cm, and the mean external diameter at its
origin was 3.0 ± 0.06 mm. Also, Malikov et al.(39)
have found that its mean external diameter was 3.00
(1.9-4.2) mm at the origin, and Godat et al.(42) have
measured it to be 3.3 ± 1.0 mm.
The diameter and lengths of the serratus arteries
were measured. Godat et al.(42) have measured the
mean diameter of the serratus artery at the take-off
of the latissimus artery was 2.1 ± 0.5 mm, but they
did not measure the length of serratus branches
alone. In the present work, the mean lengths of the
serratus branches were 4.8 ± 2.5 cm, and the mean
external diameters at their beginning were 2.1 ± 0.05
mm. By adding the mean length of the thoracodorsal
and serratus arteries, it was found that the mean
length from the beginning of the circumflex scapular
artery until its penetration into the muscle was
measured 10 cm in this study. Similar results were
observed by Godat et al.(42) who found that the
mean ± SD length of the vascular pedicle from its
origin from the circumflex scapular artery to the
junction of slips 5 and 6 was 9.2 ± 2.3 cm. Also,
Malikov et al.(39) have observed that the mean length
from the beginning of the circumflex scapular artery
until its penetration into the muscle was measured at
8.7 cm. However, Cuadros et al.(43) have mentioned
that the mean pedicle length was 11.3 ± 2.8 cm.
In the present study, the vascular pattern of the
serratus anterior muscle were four types: type I with
one branch (35.7%), type II with two branches
(42.9%), type III with three branches (14.3%), and
type IV with four branches (7.1%). In all specimens
dissected at least one serratus anterior branch was
observed. In the case of multiple branches the distal
branch always presented the largest diameter. These
findings were in agreement with other studies, but
with varying percentages. Three vascular patterns
were identified by Cuadros et al.(43): type I with
one branch (40 %), type II with two branches
(50 %), and type III with three branches (10%).
Godat et al.(42) have found a different distribution of
blood supply to the lower portion of the serratus
muscle. They found three branching patterns: (38٪)
no branch points (type 0); all common slip arteries
branched off the main serratus artery, (60 ٪) had one
arterial branch point (type 1); several common slip
arteries divided from each branch, and (2٪) had two
branch points (type II). Only, Rowsell et al.(41) have
mentioned four vascular patterns as that found in
the present study. In contrast, Malikov et al.(39) and
Vu et al.(10) have found that type I was more than
type II in the distribution of branches from the
thoracodorsal to the lower serratus muscle.
In this study all the dissected specimens showed
paired venae comitantes that accompanied the
serratus artery and its branches to their distalmost extent. This finding was in agreement with
Godat et al.(42) In the present study, only in one
Safwat et al.
Alexandria Bulletin
specimen, the lateral thoracic artery was away
from its accompanying veins by 2.5 cm. Also,
Malikov et al.(39) have noticed that in one out of 40
specimens, the origins of the thoracodorsal vein and
thoracodorsal artery was located 3.5 cm from each
other.
In the present work, the long thoracic nerve was
consistently present inferior to the clavicle and
lateral to the serratus muscle. The nerve branching
pattern mimicked the arterial branching pattern, but
at a proximal level by one intercostal space. The
same findings were reported by Godat et al.(42) and
Cuadros et al.(43) Godat et al.(42) have found that the
branching pattern of the nerve was proximal to the
artery by an average of 7 mm (ranging from 0 to 22
mm). They have mentioned that this finding
was useful for the surgeon in isolating a single
muscle slip.
In the present study, the mean length of the long
thoracic nerve from its beginning to its first branch
to the serratus muscle was 11.9 ± 0.9 cm, its mean
diameter at its beginning was 2.00 ± 0.09 mm, and at
the beginning of each muscular branch was 1.5 ± 0.7
mm. Also, Godat et al.(42) have found that the mean
length of the nerve from the contribution of C7 to
the junction of slips 5 and 6 was 12.7 ± 2.1cm, its
diameter after C7 contribution was 2.0 ± 0.4 mm,
and its diameter at the slip 5/6 was 1.6 ± 0.4 mm.
In the present study, the mean dimensions of the
serratus muscle slip were 16.1 ± 1.7 in length, 2.5 ±
0.09 cm in width, and 4.4 ± 0.7 mm in thickness.
These findings were nearly similar to Godat et al.(42)
They have found that the mean length of the slip was
17.2 ± 2.0 cm, the mean width was 2.4 ± 0.5 cm, and
the mean thickness at its origin was 5.4 ± 1.5 mm.
The results of this study provide an anatomic
framework to improve current reconstructive or
aesthetic procedures on the serratus anterior
neurovascular structures. The vascular pedicle to the
serratus anterior muscle flap is a reliable one,
permits the flap to be used in diversity of ways
and in combinations with the overlying skin or
ribs. The serratus anterior flap can be dissected
with ease, but data about the axillary vascular
tree and pedicle of the serratus anterior muscle and
their anatomical variations will provide a valuable
anatomical knowledge for non complicated medical
interventions and surgical approaches on this region
especially in case of reconstructive surgery.
REFERENCES
1. Magden O, Gocmen-Mas N, Caglar B. Multiple
variations in the axillary arterial tree relevant to
plastic surgery: A case report. Int J MorphoL
2007; 25(2): 357- 61.
2. Standring S, Ellis H, Healy JC, Collins P,
Johnson D, Williams A, Wigley C. Gray’s
Anatomy. 39th ed. Churchill Livingstone:
Edinburgh, London, New York 2005; 837- 8.
Bull. Alex. Fac. Med. 43 No.4, 2007.
3.
845
Moore KL, Dalley AF. Clinically oriented
anatomy. 5th ed. Lippincott Williams & Wilkins:
Philadelphia, Baltimore 2006; 750- 2.
4. Buncke H, Alpert B, Gordon L. Microvascular
serratus anterior transplantation. In proceedings of
the 51st annual convention of the American society
of plastic and reconstructive surgeons. Plastic
surgery education foundation, and American
society of maxillofacial surgeons, Honolulu,
Hawaii, 1982; October 10-15.
5. Halim AS, Wan Z. Anomalous arterial supply to
the muscles in a combined latissimus dorsi and
serratus anterior flap. Clin Anat 2004; 17 (4):
358-9.
6. Vu P, Guedon C,Gehanno P, Andreassian B .
Anatomic basis of serratus anterior muscle flap
transposition. Surg and Radiol Anat 1988; 10 (3):
173-85.
7. Lifchez SD, Sanger JR, Godat DM, Recinos RF,
LoGiudice JA, Yan JG. The serratus anterior
subslip: anatomy and implications for facial and
hand reanimation. Plast Reconstr Surg 2004; 114
(5): 1068-76.
8. Derby LD, Bartlett SP, Low DW. Serratus
anterior free-tissue transfer: Harvest-related
morbidity in 34 consecutive cases and a review of
the literature. J Reconstr Microsurg 1997; 13: 397403.
9. Carr MM, Manktelow RT, Zuker RM. Gracilis
donor morbidity. Microsurg 1995; 16: 598-600.
10. Vu P, Guedon C, Gehanno P, Andreassian B.
Anatomical basis of the transposition of the
serratus anterior muscle. Study of 40 dissections. J
Chir 1989; 126 (1): 45-53.
11. Gordon L, Levinsohn DG, Finkemeier C,
Angeles A, Deutch H. The serratus anterior freemuscle transplant for reconstruction of the injured
hand: An analysis of the donor and recipient sites.
Plast Reconstr Surg 1993; 92 (1): 97- 101.
12. Fassio E, de Mortillet S, Laulan J, Laurent B,
Fouquet B, Goga D, Ballon G. Serratus anterior
muscle flap: indications and sequelae. 26 cases
and review of the literature. Ann Chir Plast Esthet
1999; 44 (2): 175-82.
13. Pittet B, Mahajan AL, Alizadeh N,
Schlaudraff KU, Fasel J, Montandon D. The free
serratus anterior flap and its cutaneous component
for reconstruction of the face: a series of 27 cases.
Plast Reconstr Surg 2006; 117(4):1277-88.
14. Dumont CE, Domenghini C, Kessler J. Donor
site morbidity after serratus anterior free muscular
flap: A prospective clinical study. Ann Plast Surg
2004; 52: 195-8.
15. Buehler MJ, Pacelli L, Wilson KM. Serratus
fascia “sandwich” free-tissue transfer for complex
dorsal hand and wrist avulsion injuries. J Reconstr
Microsurg 1999; 15; 315-20.
16. Kim Y, Chung Y, Kwon T, Lee D, Cha J.
Reconstruction of soft-tissue defects using serratus
852
Serratus Anterior Neurovascular Pedicle.
anterior adipofascial free flap. Plast Reconstr Surg
1999; 103 (3) :925-9.
17. Duteille F, Lim A, Dautel G. Free flap coverage
of upper and lower limb tissue defects in chidren:
A series of 22 patients. Ann Plast Surg 2003; 50:
344-9.
18. Georgescu AV, Ivan O. Serratus anterior-rib
free flap on limb born reconstruction. Microsurg
2003; 23: 217-25.
19. Brenner P, Zwipp H, Rammelt S. Vascularized
double barrel ribs combined with free serratus
anterior muscle transfere for homologous
restoration of the hindfoot after calcanectomy. J
Truama 2000; 49: 331-5.
20. Fairbanks
GA,
Hallock
GG.
Facial
reconstruction using a combined flap of the
subscapular axis simultaneously including
separate medial and lateral scapular vascularized
bone grafts. Ann Plast Surg 2002; 49: 104-8.
21. Duteille F, Waast D, Perrot P, Cronier P,
Hubert L, Pannier M. The serratus anterior free
flap in limb reconstruction. About 30 cases. Ann
Chir Plast Esthet 2005; 50 (1):71-5.
22. Saeed M, Rufal AA, ELsayed SE, Sadiq MS.
Variations in the subclavian-axillary arterial
system. Saudi Med J 2002; 23: 206- 12.
23. Fassio E, Laulan J, Aboumoussa J, Senyuva C,
Goga D, Ballon G. Serratus anterior free fascial
flap for dorsal hand coverage. Ann Plast Surg
1999; 43: 77-82.
24. Hui KC, Zhang F, Lineaweaver WC, Moon W,
Buncke GM, Buncke HJ. Serratus anterior-rib
composite flap: anatomic studies and clinical
application to hand reconstruction. Ann Plast Surg
1999; 42(2): 132-6.
25. Tian W, Wang D, Liu L, Huang F, Xie Q,
Yan Z, Li Y, Li S. Clinical study on
reconstruction of hemifacial atrophy with serratus
anterior free-muscle flap. Zhongguo Xiu Fu
Chong Jian Wai Ke Za Zhi 2005; 19 (10): 799802.
26. Ioannides C. Free composite myo-osseous flap
with serratus anterior and rib: Indications in head
and neck reconstruction. Head Neck 1998; 20:
660-1.
27. Chapelier A, Macchiarini P, Rietjens M,
Lenot B, Margulis A, Petit JY, Dartevelle P. Chest
wall reconstruction following resection of large
primary malignant tumours. Eur J Cardiothorac
Surg 1994; 8 (7): 351- 7.
28. Yoshioka N, Tominaga S, Inui T. Cerebral
revascularization using omentum and serratus
anterior muscle free flap transfer for adult
moyamoya disease: case report. Surg Neurol
1996; 46: 430- 5.
29. Erdogmus S, Govsa F. Distal variations of the
neurovascular pedicle of the serratus anterior
muscle as a flap. Surg Radiol Anat 2005; 27 (2):
Bull. Alex. Fac. Med. 43 No.4, 2007.
Safwat et al.
100- 7.
30. Zuker RM, Goldberg CS, Manktelow RT. Facial
animation in chidren with Mỏbius syndrome after
segmental gracilis muscle transplant. Plast
Reconstr Surg 2000; 106 (1): 1-9.
31. Terzis JK, Noah ME. Analysis of 100 cases of
free-muscle transplantation for facial paralysis.
Plast Reconstr Surg 1997; 99: 1905-21.
32. Pandey SK, Shukla VK. Anatomical variation in
origin and course of the thoracoacromial trunk and
its branches. J Nepal Med Coll 2004; 6:88-91.
33. Valnicek, S. M. The subscapular arterial tree as
a source of microvascular arterial grafts. Plast.
Reconst. Surg 2004; 113: 2001-5.
34. Lipa JE, Chang DW. Lateral thoracic artery as a
vascular variant in the supply to the free serratus
anterior flap. J Reconstr Microsurg 2001; 17:
413- 5.
35. Rabi S, Indrasingh I, Koshy S, Vettivel S. An
aberrant independent origin of the serratus anterior
pedicle: Case report. Eur. J Anat 2003; 7 (1):
63- 5.
36. De Fontaine S, Decker G, Goldschmidt D.
Anomalous blood supply to the serratus anterior
muscle flap. Br J Plast Surg 1994; 47: 505-6.
37. Goldberg JA, Lineaweaver WC, Buncke HJ. An
aberrant independent origin of the serratus anterior
pedicle. Ann Plast Surg 1990; 25: 487-90.
38. Aizawa Y, Ohtsuka K, Kumaki K. Examination
on the courses of the arteries in the axillary
region I. The course of the subscapular artery
system, especially the relationships between the
arteries and the posterior cord of the brachial
plexus. Kaibogaku Zasshi 1995; 70 (6):554-68.
39. Malikov S, Casanova D, Magnan PE,
Branchereau A, Champsaur P. Anatomical bases
of the bypass-flap: study of the thoracodorsal axis.
Surg. Radiol Anat 2005; 27 (2): 86-93.
40. Bartlett SP, May JW, Yaremchuk MJ. The
latissimus dorsi musle: a fresh adaver study of the
primary neurovascular pedicle. Plast Reconstr
Surg 1981; 67: 631-6.
41. Rowsell AR, Davies DM, Eiesenberg N,
Taylor GI. The anatomy of the subscapularthoracodorsal arterial system: study of 100
cadaver dissections. Br J Plast Surg 1984; 37:
574-6.
42. Godat DM, Sanger JR, Lifchez SD, Recinos RF,
Yan, J, Godat MR, Ramirez CE, Matloub HS.
Detailed Neurovascular Anatomy of the Serratus
Anterior Muscle: Implications for a Functional
Muscle Flap with Multiple Independent Force
Vectors. Plast Reconstr Surg 2004; 114 (1):21-29.
43. Cuadros CL, Driscoll CL, Rothkopf DM. The
anatomy of the lower serratus anterior muscle: a
fresh cadaver study. Plast Reconstr Surg 1995; 95
(1): 93-9.