Figure 10

In the extended approach, the brachial plexus is exposed through a standard L-shaped incision with a deltopectoral extension (dashed line). Extending the horizontal limb of the L-incision posteriorly, the trapezius muscle is disinserted from the clavicle and acromion process. Extending the vertical limb of the L-incision horizontally along the superior nuchal line, the origin of the trapezius muscle from the superior nuchal line and the external occipital protuberance is cut and the spinal accessory nerve followed to its motor point into the trapezius muscle. Next, the muscle itself is reflected posteriorly to expose the levator scapulae muscle anteriorly and the splenius capitis muscle posteriorly. This done, the splenius capitis and semispinalis capitis musles is disinserted from the occiput and reflected posteriorly as well.