The SALTT is described in the beach-chair position, although it could also be performed in the lateral decubitus position. The arm is prepped in the standard sterile fashion, and care is taken to ensure the entirety of the scapula is visualized and the medial border is
accessible. A dynamic arm holder is utilized on the ipsilateral side to facilitate transition between slight flexion during harvest and abduction and external rotation during tendon fixation.

The scapula is landmarked including the scapular spine, superomedial border, and medial border. The lower trapezius tendon is expected to insert approximately 3 to 5 cm from the medial palpable scapular border at the level of the scapular spine and will cross obliquely through the surgical field²⁰ (Figure 19-1). In larger patients, pressing backward on the anterior shoulder and retracting the scapula can help with palpation of the medial border. Both horizontal and vertical incisions have been described. We prefer a horizontal incision just inferior to the scapular spine adjacent to the medial scapular border of approximately 3 to 5 cm in length. Dissection is carried down through subcutaneous tissues until the overlying fascia of the lower trapezius tendon is encountered. The lower trapezius tendon inserts on a bony tubercle on the undersurface of the scapular spine, immediately adjacent to the more lateral fascial attachment of the posterior deltoid. Inferior to this will be a fat pad that we routinely excise. Deep to this fat pad, the infraspinatus fascia is encountered. The lower trapezius tendon and muscle is found crossing obliquely through the surgical field and is most readily found by blunt dissection medially along the infraspinatus fascia. The muscle may also be found and stimulated more medially to determine the correct depth of dissection (Figure 19-2A). Beginning laterally, the tendon is released from the scapular spine. The raphe between the lower and middle trapezius can be found and utilized to ensure that only the lower trapezius muscle and tendon are harvested. Once detached, the tendon and muscle can be flipped and the undersurface will show a definite, clearly defined tendinous structure (Figure 19-2B). Medial dissection is limited to approximately 2 cm from the scapular border by the spinal accessory nerve. Dissection in this area, if performed, should be carefully done through superficial to deep dissection to avoid iatrogenic injury. The lower trapezius muscle should be freed of adhesions to the more superficial medial fascia, as well as distal, deep fascial attachments to the infraspinatus fascia. This can be achieved with blunt dissection. The lower trapezius has small excursion, although releasing adhesions provides improved visualization during later tendon attachment (Figure 19-2C).