By using the serratus as the source of rib blood supply and the thoracodorsal vessels as the pedicle, the serratus anterior-rib composite flap avoids the disadvantages of the short internal mammary or the posterior intercostal pedicles of microvascular rib osseous or osteocutaneous flaps (1, 2). Based on its cross-sectional area and curved shape, the rib is an excellent source of vascularized bone to reconstruct defects of the facial bones, particularly the mandible. The serratus anterior-rib composite flap is suitable for repair of mandibular defects with soft-tissue loss, either of the floor of the mouth or of the chin or neck (3). The circumferential thickness of rib and its general shape are also similar to what is found in metacarpal and metatarsal bones. The serratus-rib composite flap can provide an excellent resource for reconstruction of metacarpal and metatarsal defects with associated soft-tissue defects (4, 5).

In reconstruction of segmental long-bone defects of the lower extremity, vascularized fibular osteoseptocutaneous flaps are generally recommended as the first choice, because the fibular flap has several advantages (6, 7, 8). However, when the fibular flap is not available and the bone defects are greater than 10 cm, serratus anterior-rib flaps become useful alternative flaps. Because the rib flap is curved, rather than straight, and has a limited cross-sectional area to withstand body
weight-load, indications in lower-extremity reconstruction at this point are (a) bilateral tibial fibular defects greater than 10 to 12 cm; (b) extensive composite defects of bone and soft tissue; and (c) contralateral fibula damage, making the vascular anatomy and dissection unreliable and difficult. The flap may need to be extended to include two or three ribs, to provide more strength and to support axial weight-bearing (9, 10).