Daliakopoulos et al. Journal of Medical Case Reports 2010, 4:75 http://www.jmedicalcasereports.com/content/4/1/75 Page 3 of 8 Figure 2 Magnetic resonance imaging of the sagittal plan of the large adenocarcinoma. Whole thickness invasion of the sternum, surrounding fat tissues, and the anterior mediastinum is shown. used to expose the serratus anterior muscle (SAM). The SAM was identified and mobilized by separating it from the chest wall and then carefully dividing its attach- ments to the first 4 to 5 ribs, with a periosteal elevator at first and then with a cautery. As dissection proceeded upward toward her axilla, the contribution of the lateral thoracic artery was seen entering the muscle on its ante- rior cephalic border. The blood supply to the serratus anterior may come from the thoracodorsal pedicle, from the subscapular pedicle, or directly from the axillary artery. In our case, our patient’s blood supply came from the serratus anterior branch from the thoracodor- sal artery, which originates as the largest branch from the subscapular artery. During the procedure these branches were identified and preserved. The harvested SAM was advanced and transposed within its arc of rotation towards the midsternal line to cover the defect. The sternal incision started at the level of our patient’s manubriosternal joint and extended inferiorly to her xiphisternum. The surgical resection was a vertical elliptical incision of the visible mass. Total sternectomy was performed at all layers encompassing our patient’s skin, subcutaneous tissues, right pectoralis major muscle, all her costal cartilages of the first five ribs (Figure 3), and the anterior part of her pericardium. Mobilization began first on one side of her sternum with exposure and section of the ribs. The ribs were divided laterally. Her right internal thoracic artery and the intercostals neurovascular bundle were ligated with absorbable suture. Lastly, the critical point of mass attachment to the heart was approached. Immediate clo- sure of the defect was performed without cement but with a single 0.6-mm Gore-Tex cardiovascular mesh (W. L. Gore and Associates, Flagstaff, Arizona) which was cut to a size smaller than that of the defect. The mesh was thus effectively stretched when it was sutured to her chest wall so that any laxity in the reconstruction was alleviated (Figures 4 and 5). The serratus anterior